Part 1: Self­care for Diabetes 
Patients
Publish date: June 29, 2020
Author(s): 
Courtney Bennett Wilke, MPAS, PA­C
Author and Disclosure Information

Diabetes Complications: Prevention and Screening (1 of 2)

Diabetes mellitus is prevalent in our society; 1 in 10 Americans has the
condition and > 1 in 3 has prediabetes.1 Due to the widespread comorbidities
and complications of this disease, the American Diabetes Association (ADA)
recommends that diabetes management focus on evaluation and treatment
of complications.2 Diabetes-related complications can be life-altering and
challenging for patients because their quality of life suffers.
For providers, there are several evidence-based screening tools and
preventive practices (in and beyond glycemic control) that reduce diabetes
complications such as congestive heart failure, kidney failure, lower
extremity amputation, and stroke.3 We as providers can treat patients by
implementing appropriate goal-directed therapy.4-6
In this 5-part series, I will explore the evidence and recommendations for a
multimodal approach in a patient with type 2 diabetes. Here—in Part 1—I
explore the self-care behaviors our patients can adopt to improve their
symptoms of diabetes.

Case Report
Mr. W is an overweight 64-year-old man with hypertension, hyperlipidemia,
and type 2 diabetes mellitus. He visits the clinic for his yearly physical exam.
He is concerned because his father, who had diabetes, developed renal
failure and had multiple amputations near the end of his life. He is worried
that he might face the same outcomes and asks you what he can do to avoid

his father’s fate.


Advising Your Patient on Self­care
The cornerstone of diabetes management is appropriate self-care. Both the
ADA and the American Association of Clinical Endocrinologists (AACE)
recommend that treatment plans should encourage the patient to adopt
healthy lifestyle behaviors, including a healthy diet, regular exercise, weight
control, and avoidance of tobacco.2,7,8 These interventions have positive
effects on blood pressure, glucose control, and lipid levels. They can also
reduce the risk for diabetic complications, including atherosclerotic
cardiovascular disease (ASCVD), which is the foremost cause of death among
patients with diabetes. During a patient visit, clinicians can suggest the
following self-care interventions for improving long-term outcomes.
Education sessions. The ADA recommends that individuals with diabetes
participate in diabetes self-management education and support (DSMES)
sessions.2 In these sessions, patients with diabetes are instructed on a
variety of self-care behaviors, including lifestyle interventions, medication
management, self-monitoring, and problem-solving.9 These programs—often
paid for in part by health insurance—are taught by health care professionals
such as registered dieticians, nutritionists, or certified diabetes
educators.9,10 Evidence suggests DSMES increases patients’ sense of selfefficacy and may improve blood sugar management.10 Clinicians can help
guide their patients through the Association of Diabetes Care & Education
Specialists’ online database to identify a DSMES program near them
(see www.diabeteseducator.org/living-with-diabetes/find-an-educationprogram).11
Diet. The AACE recommends a plant-based diet high in polyunsaturated and
monounsaturated fatty acids and limited in trans fatty acids and saturated
fats.7 Evidence strongly suggests that a Mediterranean diet with high
vegetable intake and decreased saturated fats helps to reduce the risk for
major cardiovascular events (myocardial infarction and stroke).12

Exercise. Both the ADA and AACE recommend that most adults with
diabetes engage in at least 150 min/week of moderate-to-vigorous aerobic
and strength-training exercises.2,7 Clinicians should evaluate patients with
sedentary lifestyles prior to them engaging in vigorous physical activity
beyond simple walking.2 The ADA also recommends that patients should
avoid sitting for long periods of time by engaging in physical activity at least
every 30 minutes.2 For adults who may not be able to participate in
moderate-to-vigorous exercise, recommend alternative flexibility and
balance-training activities, such as yoga or tai chi, 2 to 3 times per week.2
Weight management—a combined effort of diet, exercise, and behavioral
therapy—is pivotal in the management of type 2 diabetes due to the
potential benefits in insulin resistance, blood pressure, hyperlipidemia, and


other factors.2 Weight loss may also improve glycemic control and reduce the
need for glucose-lowering medications.2 For patients who struggle with
weight loss, consider prescribing FDA-approved weight-loss medications
(phentermine, orlistat, lorcaserin, naltrexone/bupropion, liraglutide) or, in
some cases, referring for bariatric surgery.2,7
Sleep hygiene is an important element in any preventive treatment plan.
This includes interventions as simple as going to bed at the same time every
night, sleeping in a dark room, sleeping for at least 7 hours, and removing
electronic devices from the bedroom.13 Patients should avoid alcohol,
caffeine, and large meals before bedtime.13
Additionally, obstructive sleep apnea (OSA) is often underdiagnosed in
patients with diabetes and contributes to insulin resistance, inflammation,
and elevated blood pressure.7,14 For early identification of OSA, order a sleep
study when appropriate and refer patients to sleep specialists if needed.
Patients who are recommended for treatment should be monitored for
increasing compliance with care and to ensure benefit from treatment.


Part 2: Controlling BP in Diabetes 
Patients
Publish date: July 2, 2020
Author(s): 
Courtney Bennett Wilke, MPAS, PA­C
Author and Disclosure Information

Diabetes Complications: Prevention and Screening (2 of 2)

Previously, I introduced the topic of self-care for patients with diabetes to
prevent complications. Now let’s explore how to help reduce risk for
cardiovascular conditions in these patients, starting with blood pressure
control.

CASE CONTINUED


Mr. W’s vitals include a heart rate of 82; BP, 150/86 mm Hg; and O2
saturation, 98%. He is afebrile. You consider how to best manage glucose
control and reduce the risk for cardiovascular conditions.

Reducing the Risk for Cardiovascular Conditions
The ADA recommends at least annual systematic assessment of
cardiovascular risk factors, including weight, hypertension, dyslipidemia,
chronic kidney disease (CKD), and presence of albuminuria.2 Managing these
conditions to the standards supported by currently available evidence should
reduce the risk for ASCVD in patients such as Mr. W. Two newer medication
classes—glucagon-like peptide-1 receptor agonists and sodium-glucose
cotransporter-2 inhibitors—offer potential benefit in reducing cardiovascular

risk.15,16 Consider these medications for patients with diabetes or known
ASCVD or for those who are at high risk for ASCVD and/or CKD.2,7
Furthermore, the ADA recommends using a risk calculator, such as the
ASCVD Risk Estimator Plus created by the American College of
Cardiology/American Heart Association (see to stratify the 10-year risk for a first ASCVD event.2 This
calculator can produce results that can help guide an individualized riskreduction treatment plan for each patient. Also, consider low-dose aspirin for
primary prevention in those at high risk for ASCVD (10-year risk > 10%) and
for secondary prevention of ASCVD in those who have already had a
cardiovascular event.2,7

Setting and Meeting BP Goals
Hypertension is common in patients with diabetes, with a recent study
suggesting that ≥ 67% of these patients have elevated BP.17 Significant
evidence demonstrates that BP control reduces morbidity and mortality in
diabetes.18 Although the importance of BP control in this setting is widely
known, recent studies have demonstrated that only 30% to 42% of affected
patients meet their BP goals.19,20
How to make a BP goal. Guideline recommendations for setting specific BP
goals have varied slightly over the past several years and are influenced by
known comorbidities such as ASCVD and CKD. Patients should be part of the
decision-making process to individualize goals based on their circumstances
and safety. A BP goal of < 130/80 mm Hg is generally acceptable for patients
who are known to have ASCVD or who are at high risk (≥ 15% risk) for
ASCVD in the next 10 years.7 A goal of < 140/90 mm Hg is considered
appropriate in those with a lower risk for ASCVD.7,8,21,22


Medications. Selecting an appropriate antihypertensive medication relies
on multiple factors. Evidence supports the use of angiotensin-converting
enzyme inhibitors and angiotensin II receptor blockers for diabetes, and both

the AACE and ADA recommend these medications as an initial treatment
option.2,7 They help reduce the progression of kidney disease in patients with
albuminuria and may improve cardiovascular outcomes.23-27 When additional
agents are needed to meet BP goals, the ADA recommends thiazide-like
diuretics (chlorthalidone and indapamide) or calcium channel blockers
(dihydropyridine).2 Although some hyperglycemic adverse effects have been
observed with use of thiazide-like diuretics, these might be outweighed by
the benefit of BP control.24
Monitor the patient’s BP at every visit, and advise the patient to regularly
measure his or her BP at home with a BP cuff. Patients who may need
assistance with at-home monitoring can be directed to an online guide on
how to accurately measure their BP (see www.heart.org/en/healthtopics/high-blood-pressure/understanding-blood-pressurereadings/monitoring-your-blood-pressure-at-home). For those who report
consistently above-goal measurements at home, advise them to check their
BP cuff, because an ill-fitting cuff is a well-known cause of inaccurate
measurement. Patients also should be assessed for medication
nonadherence, white coat hypertension, and secondary hypertension.7,8 If a
patient’s BP is truly above goal, a step-up in therapy may be appropriate
because without adequate BP control, the benefit in mortality and morbidity
may not be fully realized.28

Part 4: Monitoring for CKD in 
Diabetes Patients
Publish date: July 21, 2020
Author(s): 
Courtney Bennett Wilke, MPAS, PA­C
Author and Disclosure Information

Diabetes Complications: Prevention and Screening (4 of 4)



Previously, we discussed assessment and treatment for dyslipidemia in
patients with diabetes. Now we’ll explore how to monitor for kidney disease
in this population.

CASE CONTINUED
Mr. W’s basic metabolic panel includes an estimated glomerular filtration rate
(eGFR) of 55 ml/min/1.73 m2 (reference range, > 60 ml/min/1.73 m2). In the
absence of any other markers of kidney disease, you obtain a spot urinary
albumin-to-creatinine ratio (UACR). The UACR results show a ratio of 64
mg/g, confirming stage 3 chronic kidney disease (CKD).

Monitoring for Chronic Kidney Disease
CKD is characterized by persistent albuminuria, low eGFR, and
manifestations of kidney damage, and it increases cardiovascular
risk.2 According to the ADA, clinicians should obtain a UACR and eGFR at
least annually in patients who have had type 1 diabetes for at least 5 years
and in all patients with type 2 diabetes.2 Monitoring is needed twice a year
for those who begin to show signs of albuminuria or a reduced eGFR. This
helps define the presence or stage of CKD and allows for further treatment
planning.
Notably, patients with an eGFR < 30 ml/min/1.73m2, an unclear cause of
kidney disease, or signs of rapidly progressive disease (eg, decline in GFR
category plus ≥ 25% decline in eGFR from baseline) should be seen by
nephrology for further evaluation and treatment recommendations.2,36
Diabetes medications for kidney health. Sodium-glucose cotransporter-2
(SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists may
be good candidates to promote kidney health in patients such as Mr. W.
Recent trials show that SGLT2 inhibitors reduce the risk for progressive
diabetic kidney disease, and the ADA recommends these medications for
patients with CKD.2,16,36 GLP-1 receptor agonists also may be associated with a

lower rate of development and progression of diabetic kidney disease, but
this effect appears to be less robust.7,15,16 ADA guidelines recommend SGLT2
inhibitors for patients whose eGFR is adequate.37
ADA and AACE guidelines offer specific treatment recommendations on the
use of SGLT2 inhibitors and GLP-1 receptor agonists in the management of
diabetes.10,37 Note that neither SGLT2 inhibitors nor GLP-1 agonists are strictly
under the purview of endocrinologists. Rather, multiple guidelines state that
they can be utilized safely by a variety of practitioners.6,38,39


In the concluding part of this series, we will explore how to screen for
peripheral neuropathy and diabetic retinopathy—identification of which can
improve the patient’s quality of life.