diabetes mellitus, education, hypoglycemia, primary care, self-care, self-management, type 2 diabetes mellitus



  1. Palmer, Carrie DNP, RN, ANP-BC, CDE


Abstract: NPs and other primary care providers will continue to encounter a growing population of patients with type 2 diabetes mellitus. Helping patients engage in self-care behaviors is essential to achieve blood glucose control and prevent diabetes-related complications. This article explores opportunities to provide education to patients with diabetes mellitus on the important self-care topics of nutrition and hypoglycemia during a primary care visit.


Article Content

Diabetes mellitus and its complications have become a major health concern nationwide. An estimated 30.3 million individuals in the United States have diabetes mellitus (representing over 9% of the country's population), and the vast majority of individuals have type 2 diabetes mellitus (T2DM).1 The healthcare costs associated with direct diabetes treatment, management of complications, and lost productivity exceeded $245 billion in 2012.2 Now, more than ever, NPs and other healthcare providers must provide patients with the self-care skills necessary to prevent diabetes complications and maintain or improve their quality of life.

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Background and significance

Diabetes mellitus is a chronic illness requiring self-care and daily decision-making to incorporate self-care activities.3 Management is complex, focusing on not only blood glucose control but also cardiovascular risk reduction and complication prevention. It is not unusual for a patient with diabetes to be taking two or more medications for diabetes, along with aspirin, an HMG-coenzyme A reductase inhibitor (statin) drug, multiple antihypertensive medications, and numerous medications for other chronic problems. In addition, patients are often prescribed blood glucose monitoring devices.4 Patients may experience diabetes distress or a consuming worry about the burden of managing a chronic illness, which can lead to poor outcomes.5


The complexity of T2DM care does not just exist for the patient. NPs and other primary care providers (PCPs) who care for patients with diabetes often face multiple demands during clinical encounters. With the skyrocketing rates of chronic illnesses, primary care patients have an average of seven issues per clinic visit. Patients with T2DM generally have multiple comorbid conditions as well as health maintenance needs outside of chronic illness care, requiring significant monitoring of their diabetes through lab evaluation.


The standard for delivery of diabetes self-management education (DSME) is participation in a program focused on diabetes-related self-care, lifestyle modifications, and prevention of complications. Self-management education supports the knowledge and skills for patients to engage in daily self-care activities related to their diabetes. These programs are often lead by certified diabetes educators and can include nurses, dietitians, and pharmacists.5


Engaging in DSME can reduce the costs associated with hospitalizations, reduce complications, and improve outcomes.3-5 Although these programs are beneficial, the vast majority of diabetes-related encounters with patients will occur in the primary care setting. Less than 7% of individuals with a new diagnosis of T2DM receive formal DSME, meaning NPs and other PCPs have the opportunity and obligation to at least partially meet this need in primary care.3


Despite the demands placed upon both patient and NP, T2DM management is more successful when patients can manage their diabetes through education, partnership, anticipatory guidance, and self-management training. Recognizing the patient as central to the process of education-that the patient is the one who carries out the activities of self-management-is paramount in the relationship between patient and provider.6


Providing basic diet information

The days of advising patients to "eat less, move more" are long gone along with standardized, calorie-limited diets for patients with T2DM.7 These recommendations do not provide any substantive direction for patients; there is no focus on healthful foods and physical activity, and they do not represent personalized guidance. Medical nutrition therapy (MNT) can be an effective strategy in diabetes management, reducing hemoglobin A1C (A1C) up to 1%.4


Patients with T2DM can lack even basic diabetes-related nutrition knowledge.8 Although trained diabetes educators and registered dietitians most effectively deliver MNT, NPs in primary care can provide basic dietary education to their patients with diabetes to bridge this knowledge gap.9


There are no universally recommended allowances of major nutrients for patients with diabetes. Each individual will present with unique requirements, based on the need for weight loss, gain, or maintenance; food preferences; ability to procure and/or prepare food; and motivation. The American Diabetes Association (ADA) recommends self-management instruction founded on meal planning, healthful nutrient sources, and balancing energy intake with physical activity.4


Several dietary pitfalls are common in patients with T2DM:


* Not taking the time to plan meals


* Meal skipping


* Consumption of sugar-sweetened beverages


* Poor understanding of carbohydrate foods


* Eating too few fruits and vegetables.



For each of these pitfalls, opportunities to provide high-impact education are explored.


Not taking the time to plan meals. For most patients with T2DM, dietary education focuses on basic meal planning and healthy food choices. Meal planning can help patients choose foods for meals and snacks in the proper portion and macronutrient balance. It is most effective when the patient's preferences, schedule, and habits are considered.4


Asking patients what they have eaten in the past 24 hours or what they eat in a typical day can reveal patterns that are harmful to glycemic control, such as meal skipping or nutrient imbalance.10 Along with asking about meal content, asking specifically about snacks, beverages, and timing of meals can help patients make behavioral changes. Ask about barriers to successful meal planning and assist patients in overcoming these barriers. Have some handouts prepared with meal ideas to provide after the clinic visit.


Several plate-based meal-planning methods are available. The U.S. Department of Agriculture has done away with the Food Guide Pyramid in favor of the MyPlate method for all Americans. In this method, a plate of food should contain about 40% vegetables, 30% grains, 20% protein, and 10% fruit along with a small serving of dairy.11 The MyPlate method and Create Your Plate are endorsed by the ADA, which recommend about 50% of the plate include nonstarchy (less than 5 g/serving of carbohydrate) vegetables, about 25% grains, and 25% protein (see Protein sources).4


Prescribe packed lunches for work or school days. Provide easy-to-prepare meal suggestions that can be made ahead, such as cooking a vegetable-based soup or making a salad on weekends and dividing them into containers, with easy protein sources prepped and ready to go (such as eggs, cooked chicken, lunch meats, canned tuna, nuts, or cheese). Suggest preparing snack items ahead of time to decrease the temptation to purchase something unhealthy from a vending machine. Foods such as canned meats and lunch meats can be high in sodium; for patients with comorbid conditions, warranting a lower sodium diet (choosing lower sodium varieties or cooking meat at home to use for lunches) will help control sodium intake and help address hypertension.


Meal skipping. Meal skipping (particularly breakfast) is habitual, and patients need to reset their morning habits. Prescribing breakfast can help patients "push the reset button." Recommend simple foods such as cheese and fruit, nut butter on toast, yogurt, or an egg with a carbohydrate source such as brown rice. Old-fashioned oatmeal prepared without sugar is also a good option for breakfast.


Consumption of sugar-sweetened beverages. One of the most important pieces of advice for patients with diabetes is to stop drinking all sugar-sweetened drinks. Besides soda or sugar-sweetened coffee or tea, juice (even 100% fruit juice), sports drinks, and some alcohol (particularly wine, beer, and mixers) can increase carbohydrate intake (and thus increase weight) significantly. Meta-analyses of randomized controlled trials indicate that calories from liquid fructose, the sugars in sodas and juices, are more readily absorbed than those in whole fruits.12


Patients should be encouraged to consume mostly water, which can be flavored with slices of lemon or other fruits. Coffee and tea can be consumed without sugar for patients who like caffeinated drinks. Nonnutritive sweeteners may decrease overall calorie consumption; however, there is inconclusive evidence to recommend for or against their use. For patients who consume a lot of sugary drinks, recommending a transition to diet drinks can be a useful strategy initially, with an eventual goal to drink mostly water.13 Advise patients to avoid all sugar-sweetened beverages unless they are treating hypoglycemia. Helping patients devise a plan for how they will gradually wean from sugary drinks can increase acceptance of this intervention. Suggest cutting the sugar in tea or coffee by half per week, or reducing soda consumption by half per week, until the habit is broken.


Poor understanding of carbohydrate foods. There is considerable controversy surrounding carbohydrates and fats, accompanied by a cadre of diets that are "low carb," "high protein," "low fat," and many combinations. Although low carbohydrate diets can promote weight loss early, this effect is not sustained and leads to no long-term improvement in the biophysical parameters of T2DM.14,15 Diets with more moderate fat intake can promote satiety and can lead to improved long-term weight management. The healthiest fats to recommend are poly- and monounsaturated fats; trans fats should be avoided. While fats can be healthy, necessary nutrients, small portions of fat are calorie dense, making it easy to upset energy balance (see Fat sources).11


Carbohydrate content and endogenous insulin production have the greatest impact on after-meal glucose levels and should be considered when providing education to patients.7 The ADA recommends limiting refined carbohydrates, such as sweets and processed foods. Carbohydrate intake should come primarily from natural sources, such as whole grains, fruits, vegetables, and legumes. Simple carbohydrates with no nutritional value, such as sugar-sweetened beverages and products described as "low fat" (in which fat has been replaced by sugars) can be replaced by more natural and nutritious sources.4


An assessment of the patient's basic understanding of carbohydrate sources should come prior to making specific recommendations about carbohydrate consumption. NPs should provide information about broader categories to assist in meal planning, such as grains and cereals, higher carbohydrate vegetables, and sweets. Using terms such as "off limits" should be avoided; instead, the use of meal planning can help patients incorporate their food choices in healthy proportions.


Eating too few fruits and vegetables. Eating fruits and vegetables can be a tremendous benefit for heart health, digestive regularity, and weight maintenance, but patients often incorrectly believe that these foods raise glucose and should be avoided. Starchy vegetables such as potatoes and legumes, as well as fruits, pack more of a carbohydrate punch and have significant nutrient benefits, including fiber and vitamins.7


When performing a dietary assessment, ask patients to identify sources of carbohydrates in their diet. Use food models, pictures, or other props to talk about carbohydrates, helping patients identify higher quality sources, and discuss how to incorporate them into their routines. When consumed in proper portions, starchy vegetables and fruits are safe for patients with diabetes. Provide education on healthier means of preparing and consuming these foods, such as avoiding fried foods, adding sugar, or removing peels. Advocate for balance on the plate and include these foods in proper portions (about 25% of the plate).


Along with getting a thorough diet history, asking about any trouble procuring food is essential. Food insecurity exists when individuals lack access to nutritious food or the means to obtain food in an acceptable way. Over 14% of the U.S. population is food insecure and relies on government assistance programs, food banks, or foregoing other necessities, such as healthcare, in order to obtain food. Food insecurity in individuals with diabetes has been associated with poor glycemic control.16 Screening for food insecurity can be accomplished with simple questions in a primary care setting:


* During the past year, did you ever worry whether the food in your house would run out before there was money to get more?


* During the past year, was there ever a time when the food in your house did not last and there was no money to get more?


* Do you have access to stores that sell fresh fruits and vegetables?17



Food-insecure individuals with diabetes can be supported through referrals to government or community assistance programs or through referral to social workers. NPs can prescribe diabetes medications that are based on a meal schedule rather than an assumption of regularity of meals.17 For example, NPs could avoid prescribing insulin that peaks around meal times in patients who may not always have access to food.



Intensive glycemic control, with an A1C of 7% or less, is the gold standard for most patients with diabetes. Tight control of diabetes, often required to achieve this A1C goal, can increase the risk of hypoglycemia. Numerous clinical trials have shown worse cardiovascular outcomes for certain subgroups of patients when glucose levels are normalized, such as those with underlying cardiovascular disease and older adults.18 NPs must carefully weigh the risks and benefits of any level of glycemic control for all patients. Those with limited life expectancy or comorbidities that increase the likelihood of hypoglycemia or complications from hypoglycemia would benefit from less stringent goals, such as an A1C of 8%.19


Hypoglycemia is not caused by diabetes; rather, it is caused by medications used to treat diabetes and the interplay with diet, activity, and overall health. Hypoglycemia can lead to treatment discontinuation, poor control of diabetes, and overall higher healthcare costs.20 NPs have the opportunity to help patients prevent, recognize, and manage hypoglycemia, which can improve outcomes.


The ADA defines hypoglycemia as a blood glucose level less than 70 mg/dL, a value low enough to alert patients and providers to a potential complication, but high enough to not cause severe symptoms.21 Hypoglycemia can be categorized on a spectrum from mild (self-treated) to severe (requiring assistance from another person or emergency medical services). Setting the threshold for acting on low blood glucose to 70 mg/dL can promote self-management and decrease the use of emergency resources.22


Up to 25% of individuals with T2DM treated with insulin have hypoglycemic events every year.18 The timing of hypoglycemia often coincides with the peak of activity of the insulin, particularly in those who skip meals or are on intensive insulin regimens.23 Risk factors that predispose patients to hypoglycemia include older age, intensive regimens, alcohol use, and the presence of comorbidities.22


Insulin and sulfonylureas are the biggest pharmacologic contributors to hypoglycemia. Both agents increase the levels of circulating insulin, independent of food intake or expenditure of energy; therefore, hypoglycemia can occur with skipped meals, alterations in meal composition, increased physical activity, weight loss, or excessive medication use.18 Careful initiation and titration of medications can reduce the likelihood of hypoglycemia, but this is not enough.


Teaching patients to anticipate and be prepared for hypoglycemia, based on the action and peak of medications, food intake, and physical activity, is vitally important. Balancing carbohydrates with protein sources and not skipping meals will help keep blood glucose levels more stable and less likely to drop. Close and careful monitoring of blood glucose levels at home can also aid in prevention, particularly in the setting of a medication adjustment or a new exercise plan.19


NPs must talk to patients about the actions and peaks of their medications so they know when to anticipate hypoglycemia. This information should be provided in the context of dietary information so patients can better plan their meals and activities to ensure lower likelihood of hypoglycemia.


Exercise may induce hypoglycemia by increasing the use of glucose in muscle tissue.24 In individuals with T2DM, glucagon-mediated hepatic glucose release during exercise does not match the decline in blood glucose, leading to hypoglycemia.24 Prolonged or intense exercise, too little carbohydrate intake prior to exercise, or engaging in new routines can cause hypoglycemia.25


It is vital that patients with T2DM test their blood glucose level approximately 30 minutes before exercise. Prior to exercise, it is preferable to have a blood glucose level between 120 to 180 mg/dL to reduce the likelihood of hypoglycemia.24 Patients who take insulin or a sulfonylurea and have a preexercise blood glucose level of less than 100 mg/dL should be treated with 15 g of carbohydrate. Having 15 g of carbohydrate after intense, vigorous exercise can reduce the likelihood of postexercise hypoglycemia.25


NPs should discuss exercise safety with patients. It is recommended to test blood glucose levels prior to exercise; if it is below 100 mg/dL, the patient should eat a snack that includes a carbohydrate and a protein, such as half-sandwich with peanut butter. Medic alert identifications can be recommended for patients who exercise. Should the patient be found unconscious, the responder can have a better idea of what kind of treatment the patient needs.


Chronic kidney disease (CKD) causes multiple aberrations in glucose regulation, but perhaps the most important consideration is it decreases insulin requirements and increases the risk of hypoglycemia with sulfonylureas and insulin.18 Changes associated with aging can increase the likelihood of hypoglycemia or poor outcomes from hypoglycemia, such as a lower threshold to develop hypoglycemic symptoms, natural decline in kidney function, and cognitive impairment. Declining cognition makes it difficult for older adults and their caregivers to recognize the signs and symptoms of hypoglycemia.18


Hypoglycemic unawareness occurs with advanced or long-term diabetes, in which individuals do not experience the usual response to low glucose levels, such as shaking, sweating, dizziness, anxiety, or tachycardia. Besides the well-known problems with hypoglycemia, including falls and alterations in mental status, hypoglycemic events cause a decreased response to subsequent falling blood glucose levels, promoting future hypoglycemia.22


Ask patients about hypoglycemia at each visit. Take the time to review signs and symptoms, prevention, and treatment of hypoglycemia, particularly as patients age and chronic illnesses progress. Adjust medications and treatment goals based on continued assessment of the patient's condition, life expectancy, preferences, and treatment burden. Preventing hypoglycemia, particularly in older adults, is more important than achieving tight glycemic control.


Although avoiding hypoglycemia should be a primary goal, teaching proper management of hypoglycemia can prevent improper treatment, especially in raising blood glucose levels excessively. It is preferable to treat low blood glucose levels in the home as long as the patient is alert and able to consume carbohydrates orally. The first step should be confirming the signs and symptoms of hypoglycemia with a blood glucose test. Signs and symptoms typically include shaking, diaphoresis, anxiety, blurred vision, hunger, and irritability. Once a low blood glucose level is confirmed, treatment should include 15 g of a fast-acting carbohydrate, sufficient to increase the blood glucose level by about 30 mg/dL.


Patients should recheck their blood glucose level approximately 15 minutes after treatment. If the blood glucose level is not above 70 mg/dL, a second dose of 15 g of fast-acting carbohydrate should be consumed.24 Rebound hyperglycemia occurs when a low glucose level is treated with excessive amounts of carbohydrates or with carbohydrates combined with fats and proteins.23,24 The goal of hypoglycemia management is to normalize the blood glucose level without causing a wide swing in the direction of hyperglycemia.


Patients who have risk factors for hypoglycemia should be advised to carry a fast-acting carbohydrate with them at all times. Glucose tablets are simple, stable tools to treat hypoglycemia. NPs should teach patients to consume an adequate amount of tablets, as each tablet generally only contains about 4 g of glucose (see Risk factors for hypoglycemia).


Implementing education in primary care

At each clinic visit, the NP should perform a brief dietary history. This simple line of questions can uncover dietary habits that contribute to poor glucose control and obesity. The NP should also ask simple, pointed questions regarding the ability of patients to obtain food while meeting their other needs. Discovering a need for dietary intervention, whether behavior change or connecting to resources, can promote wellness and decrease overall medication needs.


Providing simple resources to patients, such as a handout illustrating the MyPlate method, nonstarchy vegetables, or low carbohydrates can assist with basic meal planning. Helping patients to set specific, measurable, attainable, realistic, and timely goals, such as limiting fast food to once weekly or discontinuing sugar-sweetened beverages, can promote small successes and empower patients.


Hypoglycemia should be addressed at all visits. A simple question to ask is, "In the past 2 weeks, have you had low blood sugar?" If the patient answers yes, determine what times of day it occurred and if the patient can associate hypoglycemia with a specific event, such as a skipped meal, increased activity, or alteration in medication. Ask how the low blood glucose level was treated and if any emergency services were required (see Fast-acting glucose sources). Often, medication adjustments will be required to reduce hypoglycemia; however, behavioral modification can also prevent lows. Use these opportunities to review proper treatment of hypoglycemia with 15 g of fast-acting carbohydrates.


Provide goals or recommendations to patients as a "prescription." Document these items in the patient's medical record and ask about progress toward goals at each follow-up visit, taking care to examine barriers from the patient's perspective. Addressing lifestyle validates the importance of behavior changes as a means of managing T2DM.



With the prevalence of diabetes increasing annually, NPs will be leaders in helping patients manage their diabetes at home. In order to promote self-management, NPs must not only manage the pharmacotherapeutics and surveillance associated with diabetes, but reinforce behavioral modifications at every visit.


Protein sources7

Best choices of protein for individuals with T2DM


* Plant-based proteins: legumes (beans, peas); lentils; nuts and nut butters; tempeh; tofu; meat substitutes, such as vegetarian "bacon," "chicken nuggets," or "hot dogs"


* Fish and seafood that are not fried


* Fish high in omega-3 fatty acids: salmon, albacore tuna, herring, mackerel, rainbow trout, and sardines, at least 2 servings per week


* Other fish: flounder, catfish, tilapia, cod


* Shellfish: shrimp, crab, oysters


* Poultry: chicken and turkey


* Reduced-fat cheese and cottage cheese


* Eggs and egg whites



Choose less often


* Meats such as beef, pork, and game



Avoid or choose sparingly


* Highly processed food, such as bacon, sausage, and hot dogs



Fat sources7

Healthy fats to choose most often


Monounsaturated fats


* Avocado


* Oils: canola, olive, peanut


* Nuts and nut butters: peanut, pecan, cashew, almond


* Sesame seeds



Polyunsaturated fats


* Oils: corn, cottonseed, safflower, soybean, sunflower


* Nuts: walnuts


* Seeds: pumpkin, sunflower


* Condiments: spreadable margarines, mayonnaise, salad dressings


* Omega-3 fatty acids


* Fish: albacore tuna, salmon, mackerel, herring, rainbow trout, sardines


* Plant sources: tofu, flaxseed and flaxseed oil, canola oil



Fats to choose less often


* Saturated fats: lard, fatback, high-fat meats (bacon, sausage, high-fat ground beef, bologna), full-fat dairy, butter, coconut or coconut oil, gravies and creams, poultry skin, palm oil


* Cholesterol: egg yolks, high-fat dairy, organ meats such as liver, high-fat meats, poultry skins



Fats to avoid


* Trans fats: processed or packaged foods, stick margarines, fast foods



Risk factors for hypoglycemia22


* Aggressive glycemic control or low A1C


* Concomitant use of oral antihyperglycemic drugs and insulin




* Older age


* Cognitive impairment


* Alcohol use


* Autonomic neuropathy with hypoglycemic unawareness


Fast-acting glucose sources23,24


* 4 glucose tablets


* 1 tube glucose gel


* 1 bottle glucose liquid


* 4 oz fruit juice


* 4 oz regular soda


* 5 hard or chewy candies, such as peppermints


* 1 tbsp honey or sugar


All sources listed contain 15 g of fast-acting carbohydrates.




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