Chronic disease management is a pact I enter into with patients. In this pact, I commit to helping them find new and safe ways to achieve their best quality of life. Every patient’s experience is unique and manifests itself in various ways. These manifestations run the continuum from crankiness to active resistance to evidence-based interventions or behavior modifications. By identifying hardships and fears, dispelling myths and misunderstandings, and finding individualized options, health care providers can help patients relieve some of the burdens of chronic disease and improve patients’ longevity and quality of life.
Diabetes and Heart Disease
Diabetes prevalence among adults continues to increase. The Centers for Disease Control and Prevention estimates that 34.2 million people, or 10.5% of the US population, have diabetes.1 Cardiovascular disease (CVD) is the primary cause of death in people with diabetes.2 People with diabetes have been shown to have a 2- to 4-fold increased risk of developing CVD compared with the general population.3,4
In 2019, more than 6.5 million people in the United States had heart failure (HF).5 The incidence of HF in patients with diabetes is 4 times that of the general population. The pathophysiologic mechanism underlying the association between CVD, HF, and diabetes is hypothesized to be vascular damage caused by uncontrolled hyperglycemia. This damage is thought to be diverse, widespread, and complex.6,7
These comorbid diseases share common risk factors that include hypertension, dyslipidemia, atherosclerosis, tobacco use, and obesity.8 With aggressive intervention and counseling on reducing this common set of risk factors — including a focus on diabetes management, exercise, and diet — patients with diabetes and comorbid heart disease can greatly reduce their risk of acute injury or progressive disease.8
The Patient Connection
Mr G is a 61-year-old man who presents for a new patient visit with his spouse. He has had few check-ups during the past 25 years and has a history of cancelling his appointments. He is overdue for many health-maintenance screenings, vaccines, and preventive tests. However, the patient’s elevated blood pressure (177/102 mm Hg) is of most concern.
Mr G notes that he is nervous and does not like going “to the doctor”. He added, “All I’m ever told is what I’m doing wrong.” I quickly realized that I had a chance to connect with this patient — to listen, acknowledge his story, explore what mattered most to him, and convey my concerns and desire for a therapeutic alliance.
The challenges to acquire and integrate skills in order for clinicians to connect with patients persist.9 Researchers have reported that health care providers’ connections with their patients improve diagnosis,10 adherence to prescribed regimens,11 and even some outcomes.12 Before I can effectively counsel my patients on chronic disease prevention or management, I first strive to connect by “flipping the script.” For new patients, I take stock of the experiences they have had before coming to me. For returning patients, I check in on current concerns, hardships, or fears.
Zulman et al suggest 5 similarly aligned practices to promote more meaningful connections with patients, especially at the start of the visit (Table 1).13
With Mr G, I put my papers aside, moved away from the computer, and edged closer to him. I listened without interruption. When he was finished, he invited my response. After thanking him for what he shared, I worked to connect with the part of his story that seemed to upset him most — that he heard only what he was doing wrong. So, I tried to focus on what he was doing right: coming to my office and sharing his feelings about past health experiences. At the end of the visit, we agreed on what mattered most and to enter a pact that included starting an antihypertensive medication. Mr G has returned regularly and has met key health targets.
Self-Management and Lifestyle Medicine Pillars
Self-management in diabetes and heart disease requires patients to be actively involved in choices related to medication use, blood glucose monitoring, diet, exercise, and resource planning. The 2021 American Diabetes Association (ADA) consensus guidelines provide an excellent framework for discussions on adopting new lifestyle behaviors, which is included in the decision cycle for patient-centered glycemic management algorithm.14 The decision cycle shifts the traditional narrow focus on glycemic control to the broader goals of preventing complications, decreasing risk, and optimizing quality of life. The cycled approach begins with a skilled, comprehensive assessment followed by a shared decision-making process on treatment options,15 agreement on a plan of interventions, and follow-up for continual reassessment.
Recent studies suggest strong correlations between glycated hemoglobin A1c (HbA1c) and blood glucose time in range (TIR). The ADA standards and international consensus report recommends the new HbA1c and TIR goals for patients based on age and coexisting chronic disease (Table 2).16,17
For patients with diabetes and multiple comorbid conditions including HF, HbA1c and TIR goals should be individualized based on clinical and functional status, history of hypoglycemia, self-management capacity, support system, and overall treatment burden.18,19
Lifestyle medicine is the evidence-based practice of helping patients adopt and sustain behaviors to improve their health and quality of life.20 Several studies have demonstrated significant associations between lifestyle variables and incidence-rate reductions in diabetes and HF.21,22 These studies have shaped the landscape for consensus guidelines on weight, physical activity, diet, and other self-care goals and behaviors.23 Yet, only 3% of US adults live a healthy lifestyle as defined by the pillars of activity, diet, sleep, substance use, relationships, and stress management.24,25 In addition, clinicians often cite major barriers to counseling patients effectively on lifestyle medicine including lack of confidence, knowledge, and skill.20 These poor appraisals among providers have led to mounting calls to establish minimum lifestyle medicine competencies for clinicians.26
When we engage patients in setting lifestyle medicine goals, we empower them to take ownership of their health and create a space for meaningful exchange. The overall goal is to establish a collaborative alliance, address the most pressing barriers, and aim for progress over perfection while avoiding blame at all costs.
Research on emotional intelligence suggests that emotions prepare us to respond to events that caused the emotion in the first place and indicates that we function more effectively in life by better integrating emotional information into our thinking.27 Out of this research has emerged the RULERapproach as a practical method to develop skills to recognize, understand, label, express, and regulate emotion toward greater well-being.28 The problem is not that we have the emotions (fear, anger, shame) but rather that we don’t recognize them or we unquestioningly believe their messages (eg, “I am bad, weak, a failure”). Emotions are not inherently bad, but we need to help patients recognize and learn from them.
When addressing and counseling patients on lifestyle medicine, we certainly must target best practices and prioritize our visits, given resource and time limitations. However, if we don’t explore emotional barriers and set incremental goals, the proportion of adults living a healthy lifestyle will remain low. The evidence is clear for the benefits of 150 minutes of exercise per week; a whole-foods, plant-based diet; and an initial 5% to 10% weight loss for patients with a BMI >24.9.18,21,29 However, many patients view these immediate targets as unattainable, especially if clinicians don’t actively engage them on strategies or don’t stress progress over perfection. Thus, along with a conversation about blood pressure and blood glucose readings, I also check in at every visit on individual lifestyle vitals of diet, activity, and weight.
Ms O is a 62-year-old woman with type 2 diabetes, HF with preserved ejection fraction (HFpEF), and BMI of 38. She has had multiple unsuccessful attempts at lifestyle changes including blood glucose management, activity, diet, and weight-loss goals. In the course of exploring emotional cues, Ms O realized she was blaming herself for failing to meet unrealistic goals and not giving herself credit for her small successes. In assessing her lifestyle vitals, I asked questions about her baseline activity and diet to engage in realistic goal setting by asking the following questions:
- What kinds of physical activity do you do each week?
- What do you think stops you from being more active?
- How many meals and/or snacks do you eat in a day?
- How many meals a week do you eat out?
- What is the hardest thing about managing your health right now?
- What do you fear most about your health right now?
The SMART goals mnemonic — specific, measurable, achievable, realistic, time-limited — was a helpful guide for providing customized care, identifying barriers, and engaging in constructive next steps in lifestyle planning with Ms O.18 After identifying emotions that created hurdles, helping her download a free pedometer to her smartphone, and writing a personalized activity prescription, her baseline of 2000 steps per day eventually increased to 10,000 steps per day. She subsequently adjusted her diet pattern and reduced meal portion sizes. Ms O’s glycemic control improved and continues at target, she lost 20 lb in 12 months, and she has recently purchased a stationary bike.
Individualizing lifestyle goals might feel imprecise and random at times. However, the SMART approach allows for collaboration on the most important decisions and building on every success, no matter how small. One colleague has referred to this as “finding the sweet spot” with patients during the shared decision-making process.30
Team Approaches to Chronic Disease Management
Building trusting therapeutic relationships with providers and applying a team approach is central to effective chronic disease management.31 Diabetes self-management education and support (DSMES) is comprehensive clinical, educational, psychosocial, and behavioral care that is recommended for all people with diabetes.32 Effective DSMES includes building collaborative and multidisciplinary teams to evaluate for wide-ranging care and counseling for patients with diabetes and comorbid conditions at 4 critical times33,34:
- At diagnosis;
- Annually and/or when not meeting treatment targets;
- When complicating factors develop that influence self-management; and
- When transitions in life and care occur.
The process of learning the complex skills needed to manage diabetes and other comorbid diseases requires time, repetition, and ongoing support. The field of lifestyle medicine presents new and challenging approaches to address the prevention and treatment of chronic diseases including diabetes, CVD, and HF, which are the most prevalent causes of increased morbidity and mortality worldwide. The need for concerted action in this field of medicine is clear. To raise the status quo on the numbers of US adults living a healthy lifestyle, clinicians will need to acquire new skill sets and competencies in behavior-change counseling, and healthcare systems will need to support the provision of these preventive care services.
Jonathan Weber, MA, PA-C, is assistant professor of internal medicine, associate director of academic education, and course director of behavioral health and preventive medicine at the Yale School of Medicine Physician Associate Program. He has practiced internal medicine for more than 20 years in the Yale University and Yale New Haven Health Systems. He currently practices at the Yale Medicine Diabetes Center, a joint clinical practice of the Yale School of Medicine and Yale New Haven Health.
- Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Dept of Health and Human Services. Accessed April 22, 2021. https://www.cdc.gov/diabetes/data/statistics-report/index.html
- Baena-Díez JM, Peñafiel J, Subirana I, et al. Risk of cause-specific death in individuals with diabetes: a competing risks analysis. Diabetes Care. 2016;39(11):1987-1995. doi:10.2337/dc16-0614
- Emerging Risk Factors Collaboration, Sarwar N, Gao P, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375(9733):2215-2222. doi:10.1016/S0140-6736(10)60484-9
- Tancredi M, Rosengren A, Svensson AM, et al. Excess mortality among persons with type 2 diabetes. N Engl J Med. 2015;373(18):1720-1732. doi:10.1056/NEJMoa1504347
- Benjamin EJ, Virani SS, Callaway CW, et al. Heart Disease and Stroke Statistics-2018 update: a report from the American Heart Association [published correction appears in Circulation. 2018 Mar 20;137(12 ):e493]. Circulation. 2018;137(12):e67-e492. doi:10.1161/CIR.0000000000000558
- International Diabetes Federation. IDF Diabetes Atlas, 9th ed. Brussels, Belgium: 2019. Available at: https://www.diabetesatlas.org
- Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care. 2007;30(1):162-172. doi:10.2337/dc07-9917
- Zannad F, Rossignol P. Cardiorenal syndrome revisited. Circulation. 2018;138(9):929-944. doi:10.1161/CIRCULATIONAHA.117.028814
- Sanders L, Fortin AH 6th, Schiff GD. Connecting with patients—the missing links. JAMA. 2020;323(1):33-34. doi:10.1001/jama.2019.20153
- Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423-1433.
- Harmon G, Lefante J, Krousel-Wood M. Overcoming barriers: the role of providers in improving patient adherence to antihypertensive medications. Curr Opin Cardiol. 2006;21(4):310-315. doi:10.1097/01.hco.0000231400.10104.e2
- Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796-804.
- Zulman DM, Haverfield MC, Shaw JG, et al. Practices to foster physician presence and connection with patients in the clinical encounter. JAMA. 2020;323(1):70-81. doi:10.1001/jama.2019.19003
- Davies MJ, D’Alessio DA, Fradkin J, et al. Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2018;41(12):2669-2701. doi:10.2337/dci18-0033
- Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367. doi:10.1007/s11606-012-2077-6
- American Diabetes Association. 6. Glycemic targets: standards in medical care in diabetes-2021. Diabetes Care. 2021;44(Suppl.1):S73-S84. doi:10.2337/dc21-S006
- Battelino T, Danne T, Bergenstal RM, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the International Consensus on Time in Range. Diabetes Care. 2019;42(8):1593-1603. doi:10.2337/dci19-0028
- American Diabetes Association. Standards of medical care in diabetes -2021. Accessed May 21, 2021. https://care.diabetesjournals.org/content/44/Supplement_1
- Dunlay SM, Givertz MM, Aguilar D, et al. Type 2 diabetes mellitus and heart failure: a scientific statement from the American Heart Association and the Heart Failure Society of America. Circulation. 2019;140:e294-e324. doi: 10.1161/CIR.0000000000000691
- Lianov L, Johnson M. Physician competencies for prescribing lifestyle medicine. JAMA. 2010;304(2):202-203. doi:10.1001/jama.2010.903
- Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care. 2002;25(12):2165-2171. doi:10.2337/diacare.25.12.2165
- Fleg JL. Healthy lifestyle and risk of heart failure: an ounce of prevention well worth the effort. Circ Heart Fail. 2016;9(4):e003155. doi:10.1161/CIRCHEARTFAILURE.116.003155
- Association of Diabetes Care & Education Specialists. Heart disease and diabetes prevention. 2020. Accessed May 21, 2021. https://www.diabeteseducator.org/docs/default-source/living-with-diabetes/tip-sheets/cardiovascular-disease/cvdprevention.pdf?sfvrsn=12
- Loprinzi PD, Branscum A, Hanks J, Smit E. Healthy lifestyle characteristics and their joint association with cardiovascular disease biomarkers in US adults. Mayo Clin Proc. 2016;91(4):432-442. doi:10.1016/j.mayocp.2016.01.009
- American College of Lifestyle Medicine. Accessed May 21, 2021. https://lifestylemedicine.org/What-is-Lifestyle-Medicine.
- Kelly J, Karlsen MC, Lianov L. Establishing competencies for physicians who specialize in the practice of lifestyle medicine. Am J Lifestyle Med. 2019;14(2):150-154. doi:10.1177/1559827619856542
- Brackett MA, Rivers SE, Salovey P. Emotional intelligence: implications for personal, social, academic, and workplace success. Soc Personal Psychol Compass. 2011;5(1):88-103. doi:10.1111/j.1751-9004.2010.00334.x
- Brackett MA, Bailey CS, Hoffmann JD, Simmons DN. RULER: a theory-driven, systemic approach to social, emotional, and academic learning. Educat Psychologist. 2019;54(3):144-161. doi:10.1080/00461520.2019.1614447
- Murray CJ, Atkinson C, Bhalla K, et al. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591-608. doi:10.1001/jama.2013.13805
- Fried TR. Shared decision making—finding the sweet spot. N Engl J Med. 2016;374(2):104-106. doi:10.1056/NEJMp1510020
- Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: a systematic review. Prev Chronic Dis. 2013;10:E26. doi:10.5888/pcd10.120180
- Beck J, Greenwood DA, Blanton L, et al. 2017 national standards for diabetes self-management education and support [published correction appears in Diabetes Educ. 2017;43(6):650]. Diabetes Educ. 2017;43(5):449-464. doi:10.1177/0145721717722968
- Powers MA, Bardsley JK, Cypress M, et al. Diabetes self-management education and support in adults with type 2 diabetes: a consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Diabetes Educ. 2020;46(4):350-369. doi:10.1177/0145721720930959
- Del Valle KL, McDonnell ME. Chronic care management services for complex diabetes management: a practical overview. Curr Diab Rep. 2018;18(12):135. doi:10.1007/s11892-018-1118-x