**The information contained in this editorial supplement, sponsored by Nipro Diagnostics, Inc., will be conveyed by the author in a podium presentation at the National Nurse Practitioner Symposium, to be held at the Copper Conference Center, Copper Mountain, Colorado, in July.**

One of the most challenging questions that nurse practitioners or other diabetes educators can ask is: “How can I get my patients to do what they are supposed to do?” For NPs, taking care of patients with diabetes mellitus (DM) entails devising treatment plans, providing patient education, and monitoring patients’ responses to treatment. For patients, DM management entails learning a wide variety of new behaviors, including taking medication, implementing lifestyle changes, and self-monitoring of blood glucose levels. Many patients have difficulty adopting these changes and incorporating them into daily life. This article will help NPs guide patients with DM to make behavior changes that will improve their health.

Diabetes mellitus (DM) is a serious and growing public-health concern. This disease affects 25.8 million Americans of all ages, representing 8.3% of the total US population.¹ About 18.8 million persons have been diagnosed with DM and an additional 7 million are undiagnosed—that is, they are not even aware they have DM. In 2010, about 1.9 million Americans aged ≥20 years were newly diagnosed with DM. The prevalence of DM increases with age; in 2010, 26.9% of all US adults aged ≥65 years had DM.

In 2007, the most recent year for which cost data are available, the total cost of DM was $174 billion, which breaks down to $116 billion in direct healthcare costs and $58 billion in indirect costs (eg, those related to disability, work loss, and/or premature death).1 Most of the direct cost is spent on inpatient treatment for the chronic complications of type 2 DM(T2DM). One goal of healthcare reform is to look at how we prioritize payments for DM care so that overall costs can be reduced.

Let us start with the ~$30,000 price tag for a cardiac catheterization for an insured patient who has coronary artery disease (CAD) as a complication of DM; this procedure is fully covered, as it should be. Medications that can help prevent or delay long-term DM complications such as CAD are usually partially, not fully, covered by insurance because they entail a co-pay from the patient. Yet, diabetes education and diabetes counseling— spending increased time teaching patients about their disease and how to care for themselves, and motivating them to institute lifestyle changes—during an office visit, given the amount of time that is spent, is not covered in a commensurate fashion. In fact, education and counseling visits that can help reduce the expensive sequelae of DM are often poorly reimbursed.

Even before you step into the examination room to see patients with newly or recently diagnosed DM, you need to make sure that your attitudes and beliefs are aligned with their best interest. It is important to be nonjudgmental and encouraging. Your interactions with patients will enable you not only to gather information, but also to help patients implement lifestyle changes that will reduce their risk for developing DM-related complications.

When you see patients with DM in the office, remember that this disease may play only a small part in the scheme of their life. Ascertain your patients’ biggest concerns of the day. You may bemore interested in their numbers (eg, their fasting blood glucose [BG] level and their glycosylated hemoglobin [HbA1c] value), whereas they may have family, social, or work obligations on their mind.

Start the visit with an affirmation. Perhaps a patient has lost a little weight or has not gained any weight, or perhaps his or her blood pressure (BP) or lipid levels have improved. Small steps are key, and should be affirmed. The direction toward which patients are moving is more important than the pace of their movement or where they are at a given moment in the process.

After pointing out any positive achievements, I ask the patient, “What is the hardest thing for you right now in dealing with your diabetes?” If the patient says that everything is fine, I pose this follow-up question: “If you could make one change—any change—in your life, what would it be?” The patient’s answers to these two questions will likely give you a context or a direction for that particular visit. Numbers are important, but they exist in a context—the realm of the rest of the patient’s life. Asking these two questions will help you focus your interview and goal-setting.

Long ago, I learned that diet, exercise, and medications are the three essential areas of DM treatment. The key to achieving success in any of these areas is motivation. How do we NPs motivate our patients to do what they need to do to improve their DM? Without providing proper motivation, nothing will work for long. Educating patients, telling them to perform certain acts, and prescribing medications—none of it will work unless you can motivate patients to change their behavior.

Motivational interviewing is a person-centered, directive method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence.² This tool is particularly useful for counseling patients with DM, who will likely need to institute several different types of behavior changes. You can remember the four guiding principles of motivational interviewing by thinking of the acronym RULE:²

R = Resisting the righting reflex;

U = Understanding and exploring the patient’s own motivations;

L = Listening with empathy;

E = Empowering patients, encouraging their hope and optimism.

If you assume the stance of arguing for change—that is, if you act as an authority about the right behavior—patients will be naturally inclined to resist. Rollnick and colleagues² have suggested that if you are arguing with patients for change and they are resisting you, change your approach! According to the tenets of motivational interviewing, you need to suppress your righting reflex and evoke the impetus for change from the patients themselves.²

Instead of imposing your standards and expectations, take a sincere interest in your patients’ concerns, values, and motivations, which are much more likely to lead to behavior change. Ask your patients why they might want to make a change and how they might go about it rather than telling them what they should do.² Try to elicit information about what is important to them.

In contrast to counseling that consists primarily of imparting information to patients, the basis of motivational interviewing is listening. However, this component necessitates more than just asking questions and listening to patients’ answers. Empathetic listening will help you truly understand what patients are saying, including intuiting what they mean.² Part of empathetic listening may even entail performing some of the acts that you are asking patients to perform (eg, exercising daily, checking your BG 4 times/day for several weeks, counting carbohydrates for a week). In this fashion, you may better understand how challenging these tasks are to perform on a regular basis. Not only will engaging in these activities enhance your ability to empathize, they may also help you develop more useful strategies for your patients to adopt.

The fourth guiding principle of motivational interviewing is to help patients explore how they can take an active role and make a difference in their own health care. Although you may recognize the importance of following a healthful diet, patients know how they can best incorporate good dietary principles into daily life. Patients must play an active role in any consultation in order to effectuate change,² which must reflect their expectations, priorities, and attitudes.

Above all, keep in mind that lasting change comes slowly and is achieved in small increments. Many of a person’s responses are automatic, not the result of conscious choice. To become permanent, a new behavior must be practiced repeatedly until it becomes nearly instinctive. Focus on what is being achieved rather than on what is not happening.

Self monitoring of blood glucose (SMBG) is an important tool in both motivation and management of patients with DM. I do not refer to SMBG as a tool to test BG. The concept of testing implies that one can pass or fail, whereas monitoring connotes neither success nor failure.  Monitoring simply means observing or checking one’s progress toward reaching a goal—a guide toward change. Rather than just prescribing a glucose meter for home use, I set the stage so that patients will want both a glucose meter and the information it will provide. Patients and I discuss the effects of high BG levels, and the fact that someone with high BG may be asymptomatic. I liken the glucose meter to a speedometer on a car, an instrument that can provide useful information for patients throughout the day.

At the time of diagnosis, after providing a simple explanation of the pathophysiology of DM, I teach patients how to perform SMBG in the office and they do a check right then and there. I have glucose meters on hand for this purpose; I can teach patients how to check their BG in about 5 minutes. Most patients feel anxious about performing SMBG. However, after they have done it once in the office, they realize that it is not too painful, and much of their anxiety is allayed. I usually give patients a sample meter to take home that day. They leave my office with a new device, as well as with the knowledge about how to use it and the motivation to gather information with it.

I encourage patients to use the glucose meter to help them learn about their DM and start to make incremental behavior changes accordingly. In fact, I tell patients that a BG check should be done only if it provides them with actionable intelligence—information they can use to make changes in their life. So, with regard to SMBG timing, first I encourage patients to check their BG before and 1 hour after finishing each meal for 2 weeks, recording these levels in addition to keeping a diary of what they have eaten and which activities they have performed. I ask them to use a large notebook, not the small log that comes with the glucose meter, to record this information. This way, they can see how various foods and activities affect their BG levels. By reviewing their pre- and postprandial BG levels, they begin to see patterns—which foods and which activities make their BG rise or fall. Then they are better able to make changes in what they eat and do.

This more frequent SMBG need not be done with every meal or for long periods of time, but it does give patients a tool with which to observe the effects of food (or exercise or medications) on BG and then to respond by adjusting their food intake or activity level to try to improve their postprandial BG. These efforts empower patients to use the home glucose meter as a tool to assess and guide treatment for their DM. If patients monitor their BG levels in this way for 2 weeks, levels are nearly always lower at the 2-week follow-up visit.

Healthcare costs are a major concern for many people. A cross-sectional study of 253 people with T2DM showed that cost was the most common barrier to the four self-help behaviors (BG monitoring, medication use, following a meal plan, and regular exercise) and was significantly associated with higher HbA1c values.³ To limit costs associated with DM, NPs need to become familiar with both the glucose meters and the test strips that each patient’s health plan will cover and at what co-pay amount. This information will help ensure that the glucose meter selected offers features and benefits that will meet each patient’s needs, both physically and financially.

I have found that one particular brand of test strips is preferred by every commercial health insurer in my state of Maine. Prescribing test strips that are covered by a formulary will save patients money in terms of their out-of-pocket costs. To further reduce co-payments, many test strip manufacturers provide co-pay assistance programs at the pharmacy check-out that offer additional dollars off a co-pay that may be slightly higher than the “preferred” or Tier 1 product on the formulary.

These co-pay assistance programs provide patients with a broader selection of meters and test strips that may better meet their physical needs. For example, some of your patients may do better with a “no coding” meter than with a coding system because they always forget to code the meter. Others may require larger-sized test strips because they have some peripheral neuropathy and cannot properly use very small test strips. For patients with high copays or for those paying cash for test strips, a store-brand glucose meter and test strips will incur the lowest out-of-pocket cost while providing the same high-quality device and materials.

A comparison study showed that a store-brand meter was as accurate as name-brand meters.^4,5 A cost comparison of BG test strips done in April 2011 showed that, compared with a popular store brand costing $0.70 per strip, three name-brand test strips were 39%-86% more expensive, costing $0.97, $1.25, and $1.30 per strip.⁶ An Internet search conducted by the author shortly before this article went to press has indicated that these same store-brand strips can be purchased online for as little as $.35 a strip.⁷

Once patients have information about the effects of food, exercise, and medications on their BG levels, SMBG frequency depends on their level of glycemic control and their treatment regimen.
Remember, SMBG is used to help patients make a change.

Like instilling motivation, implementing lifestyle changes is a foundation of DM management. When used effectively, lifestyle changes can help patients avoid or reduce the dosage or number of medications they need. The key is to motivate and educate patients to make these changes.

Dietary Changes—My patients with DM are relieved when I tell them not to go on a diet. For most people, a diet represents a drastic attempt at weight loss and is something they hope to go off at some point after they achieve their goal. Many people regain the lost weight when the diet is stopped. I encourage patients not to make any change in their diet that they cannot continue for life.

Small but lasting changes can have a more durable effect than a diet. The nutritional approach to patients with DM focuses on lifestyle changes, not handing out a food plan from a stack of preprinted diets at different calorie levels. A survey identified the six motivational strategies most often used by 395 participating dietitians when counseling patients with DM: (1) tailoring the diet to patients’ lifestyles (99.9%), (2) involving patients in decision making (95.4%), (3) promoting exercise (91.9%), (4)  encouraging SMBG (87.3%), (5) identifying areas that patients are willing to change (86.5%), and (6) using praise and reinforcement (84.3%).⁸

Suggest practical techniques to help patients decrease caloric intake. Many patients need to learn portion control. Using a smaller plate can make smaller food portions more appealing. Patients may have greater ease resisting second helpings if extra food remains out of sight. Confining consumption of meals and snacks to the kitchen or dining room table is one way to reduce distracted eating. Also, food is not consumed while watching television, talking on the phone, reading, or driving. Dining out can be a challenge because most serving sizes at restaurants are too large. Suggest that patients set aside part of the food for a to-go container before starting the meal.  Then the pressure to clean their plate will not cause them to eat too much. It has been said that only 30% of the food we eat is to ease hunger; the remaining 70% is eaten to quell stress, boredom, or anger or to perpetuate a habit. Help patients recognize when they are eating for reasons other than hunger, and teach them different ways of coping with stress, boredom, and anger.

Patients with DM need to have a clear understanding of carbohydrate sources. It is not enough to just reduce or eliminate sweets. Encourage patients to reduce the amounts of white foods in their diet (eg, bread, pasta, rice, potatoes), which can raise BG levels asmuch as sweets do. SMBG can help patients determine the effects of different foods on their BG. Ask patients for their ideas on improving their diet, and work with them to set goals they think they can achieve. Revisit these goals at follow-up appointments, exploring what did and did not work and modifying plans until success is achieved.

Exercise and Physical Activity—Being physically active is of prime importance, especially in patients with T2DM. Benefits of exercise cannot be overstated, and include weight loss; improvements in insulin sensitivity, lipids, and BP; and simply feeling better.⁹ Although exercise is inexpensive and cost-effective, many patients have difficulty inaugurating an exercise regimen. Again, the key is motivating patients, not just telling them what to do.

In motivating your patients to be more active, remember that any amount of physical activity is better than no activity. Patients need not exercise 30 minutes a day to reap important benefits. In a classic study, data on fitness and all cause mortality were collected over an average of slightly more than 8 years from 10,224 men and 3120 women.¹⁰ As might be expected, age-adjusted all-cause mortality rates were highest in the least fit individuals and declined across quintiles of increasing physical fitness. Perhaps the most intriguing finding was that the relative risk of all-cause mortality fell sharply from the least fit group to the next higher fitness quintile. Using a relative risk for all-cause mortality of 1.0 for the highest fitness quintile, the relative risk was 3.44 in the lowest fitness quintile and 1.37 in the next-least-fit group in men and 4.65 in the lowest quintile and 2.42 in the next-least-fit group in women. These data illustrate the sizeable impact on mortality of becoming even slightly more physically fit than a couch potato.

Recommend that your patients integrate exercise into their daily schedule. Some people are more likely to exercise regularly if they do it with a friend; encourage them to find an exercise partner. People who prefer to walk alone may find that listening to an audiobook or music makes the time fly. A pedometer can be a useful tool to motivate patients to exercise. Suggest that they wear the pedometer for a week to find their baseline number of steps and encourage them to increase that number by small amounts each week. You may even ask them to call in their weekly number of steps to your office staff to help them track their progress.

Many parents will do anything to help improve their children’s health, even if they neglect their own health; this fact can be used as a motivator for certain individuals. Based on genetics, the offspring of people with DM are also at risk for DM. Suggest to parents that they exercise and eat in a healthful manner so as to serve as role models for their children. Small changes such as parking the car at the far end of the lot at the shopping mall, or taking the stairs instead of the elevator, can lead to major  benefits over time. Help your patients identify ways to incorporate physical activity into daily life. The basic message about physical activity cannot berepeated too often—anything is better than nothing.

Many guidelines recommend 30-60 minutes of exercise at least 3-4 days a week—a challenge for many people. One of the most effective approaches to exercise I have found is what I call the 5-minute rule. Ask patients if there is something they can do for just 5 minutes a day; maybe they have a treadmill or an exercise bike. Five minutes is easy and doable for most people. Encourage them to do 5 minutes of exercise every day. Suggest that they use a chart or calendar and check off each day they do the activity. The beauty of this plan is that, once patients start to exercise, even if it is only for 5minutes, they find that they can do more. From a psychological standpoint, reaching this easily achievable goal is self-affirming. Exercising for 15 minutes a day will feel like a triumph. By contrast, if they strive for 30 minutes a day of exercise and then exercise for only 5 minutes, they will feel that they have failed.

Medications—C. Everett Koop, MD, a former Surgeon General of the United States, put it best when he said, “Drugs don’t work in patients who don’t take them.” Rozenfeld and colleagues11 evaluated the relationship between medication adherence and glycemic control in 249 adults with newly initiated oral anti-diabetes drugs (OADs) for T2DM. The investigators found an inverse relationship between OAD adherence and HbA1c values. Each 10% increase in adherence to the OAD regimen was associated with a 0.1% decrease in HbA1c (P = .0004). Data from the late 1990s showed that total treatment costs and risk for hospitalization for patients with DM were increased in those with lower adherence to medication.¹²

Insulin therapy, especially basal or long-acting insulin, can be a useful tool in a primary-care setting to help patients with poorly controlled DM achieve glycemic control. Many patients and even practitioners resist initiating insulin therapy. The term psychological insulin resistance, coined to describe this opposition, develops as a result of patients’ basic beliefs and knowledge (or lack of knowledge) about DM and insulin; their negative self-perceptions and attitudes, which create barriers; fear of side effects and complications associated with insulin use; and the lifestyle adaptations and restrictions required by an insulin regimen. Recognizing the presence of psychological insulin resistance is an important part of DM management in patients who need insulin therapy.¹³

Patients initiating injection therapy, whether insulin or incretins, require additional education. I discuss the benefits of insulin with patients, as well as the fact that this therapy can be discontinued in those with T2DM if glycemic control improves with lifestyle changes (ie, weight loss or exercise). I then instruct them in how to give their first insulin injection, much as I do when using the incretin analogs. With practice, you can carry out this teaching in 5-10 minutes. Once patients have given themselves the first injection, a major barrier to insulin use has been overcome. Teach patients to rotate injection sites on the body, as well as to rotate sites within a specific body area.

What can NPs do to make medication regimens easier for patients to follow? In addition to instructing patients verbally on how to take a medication, I include an explanation of why it is being taken. For example, in the “sig” formetformin, I write “take 1 PO bid for diabetes.” The pharmacist then includes this information on the prescription label, which assists patients in understanding the purpose of each medication, as well as how to take it. If you have any concerns about medications being taken properly, ask patients to bring all their medications to the appointment and review how each one is being taken. You may find that patients are not taking a medication you thought they were taking or they may not be taking the prescribed doses in the correct way. The same is true with insulin. Have patients show you how they draw up the insulin and administer it. Whenever possible, simplify the treatment regimen. Can medications be taken once daily? Can the number of medications be reduced?

Motivation and behavior change are essential to effective DM treatment. Prescribing the right medications alone will not lead to success. Patients need to be active players in the care of their disease. If the time required to accomplish all these goals seems overwhelming, consider scheduling more frequent office visits and imparting smaller amounts of information at each visit. Seeing patients every 2 weeks at first is an acceptable and effective strategy that can be used instead of extending a regular visit or trying to put too much information into a 15-minute visit. Be sure to affirm even small changes made toward reaching goals. I give patients a written summary of their treatment plan, which they can refer to at home and share with family members. Write down the dietary and exercise goals they have set, and encourage them to post their plan in a place where they can easily see it.

Nurse practitioners who treat patients with DM faces a challenging task in helping them make changes in their lives. Effective care and behavior change can be achieved with simple and clear techniques. Be sure to actively involve your patients, and work as a consultant for, not the director of, their care. After all, patients are the ones who need to do the work…and receive credit for successful results.