Diabetes Management with 4 M

Diabetes is a complex disease that requires a comprehensive management plan. Bartol pointed out that a comprehensive diabetes plan must be composed of what he calls the “4 Ms” of diabetes management: Motivation, Meals/exercise, Monitoring blood sugar, and Medications.[2] The most successful clinicians and patients integrate all 4 of these modalities.
Motivation

Of the 4 modalities, motivation is most likely the most important. A patient who is unmotivated to take an active role in the management of his diabetes is less likely to successfully manage the disease.[2] Bartol stated, “Motivation is crucial for those with diabetes, more so than any other disease, as 95% of all diabetes care must be carried out by the patient.”[2]

Healthcare providers often struggle with the patient who appears to be unmotivated to take control of his diabetes. One role of a healthcare provider is to develop and use techniques or strategies to improve a client’s motivation. Motivation to manage diabetes or alter behaviors will come if the patient feels in control of the disease.[2] Bartol emphasized that feeling in control is facilitated by involving the patient in the decision-making process. This is done by empowering him/her to make decisions that are appropriate for his given situation.[2]

Bartol provided a number of examples of patient empowerment. For instance, a clinician can discuss the various medications that are available and appropriate with the patient. Rather than telling the patient what he needs to do, the clinician should ask the patient “Which of the medications discussed do you think would be best?”[2] This type of process allows the patient to take a more active role in the management of the disease.

Bartol cautioned the NPs in attendance that patients are often erroneously labeled as being “noncompliant.” This seasoned speaker believes that, in fact, there is no such thing as noncompliance.[2] If a clinician perceives a patient as being “noncompliant,” the clinician needs to stop and critically re-examine the situation. What is often labeled noncompliance is a communication problem rather than a behavioral issue and, in fact, may be 2 people working toward 2 different, nonarticulated goals.[2]

The job of the clinician is that of an advocate, educator, cheerleader, and consultant. No longer should the clinician dictate what is appropriate for any given patient but should enable the patient to take charge to lead the entire diabetes team in the management of disease.[2]
Meals/Exercise

Patients with diabetes should be referred to a dietitian, preferably one who is a certified diabetic educator.[2] Nutrition therapy is essential to adequately manage this disease. However, there is no such thing as one diet fits all. Each individual with diabetes should have a customized diet, tailored to fit his lifestyle. Dietitians who are able to design and customize a diet to fit into the particular patient’s lifestyle will be the most successful.

If a registered dietitian is not available, NPs can encourage the patient to make small yet significant dietary changes. The patient can be encouraged to eat smaller portion sizes, snack on vegetables, or reduce the amount of fat in his diet. Even small changes can result in a significant improvement in glycemic control.[2]

Exercise is also essential. According to Bartol, “Exercise is the best insulin sensitizer on the market; better than any medication we currently have available”[2] Initiation of exercise is often difficult for the patient with diabetes. The clinician can increase the chances of the patient “buying into” the exercise regimen by asking the patient to set his own exercise goals.[2] Although it would be ideal to have the individual with diabetes exercise daily, it is important to remember that even some exercise is better than none.

Routine weight checks should also be done at every visit, regardless of the nature of the appointment. By routinely checking the weight, the patient is often reminded of the need for weight loss. If the patient loses or even maintains his current weight, encouragement and affirmation should be provided by the clinician. In his practice, Bartol has learned that “a small amount of positive affirmation goes a long way.”[2]
Monitoring of Blood Glucose

The individual with diabetes must be instructed to test his own blood glucose. This enables the patient to monitor his blood glucose in relation to various foods. Rather than telling a patient that a food is “bad,” “good,” or will raise his blood sugar, Bartol recommended that we tell a patient to eat the particular food and then check his 2 hour postprandial blood sugar.[2] If the blood glucose is elevated beyond 140-160 mg/dL 2 hours after starting the particular food, it provides the patient with useful, objective feedback. This type of feedback is invaluable and serves as a positive behavioral modification tool.

In addition, Bartol recommended that the patient check his blood sugar 4 times/day, 2 days weekly.[2] Rather than checking the blood sugar once daily, checking the blood sugar 4 times daily on selected days provides very useful information for both the patient and the clinician.[2] It gives the clinician a view of the blood sugars in the context of other results over a given day.
Medications

There are a number of medications available for the patient with diabetes. One of the latest medications to come on to the market for individuals with diabetes is insulin glargine (Lantus). This insulin is a 24-hour basal insulin. One advantage of this insulin over a product such as NPH insulin is that there is no peak. By eliminating a peak in its action, there are fewer hypoglycemic events. When given at night, it is a useful tool for individuals with type 2 diabetes who are unable to be controlled by other modalities.

Bartol recommended starting the patient with type 2 diabetes on 10 units of insulin glargine at bedtime.[2] The units are then adjusted based on fasting blood sugars. Bartol recommended increasing the dosage by 4 units if the fasting blood glucose is > 140 mg/dL or by 2 units if the fasting blood glucose is between 120 and 140 mg/dL.[2] According to the American Diabetes Association, the target goal for a fasting plasma glucose should be </= 110 mg/dL