Navigating the First Diabetes Discussion With Patients

Approximately 1.4 million people will receive a diagnosis of diabetes this year, per the American Diabetes Association.

That means 1.4 million conversations with patients about what it means to have this chronic condition and how to manage it effectively. That means 1.4 million patients asking, “What do I do now?”

These conversations, which largely happen in primary care settings, give providers an opportunity to impress upon their patients the importance of keeping their blood glucose levels under control.

But these discussions must also be intentionally tailored to each individual patient’s understanding of the disease and their role in caring for themselves.

Assess Your Patient’s Current Knowledge Base

Before diving into a discussion about treatment, the first step should be assessing your patient’s existing knowledge about diabetes. Research suggests low levels of health literacy can be a barrier to good self-management and positive outcomes, which makes this assessment — followed by education — especially crucial.

“It’s good to gauge their understanding of what this [disease] actually is,” said Absalon Gutierrez, MD, an endocrinologist with The University of Texas Health Science Center at Houston.

Learning some motivational interviewing skills can help with navigating this type of conversation, said Mohan Moreshwar Nadkarni, MD, an internist and chief of General Internal Medicine at University of Virginia Health in Charlottesville, Virginia.

Nadkarni uses these skills when seeing patients at a large primary care clinic where about 3src% of the patients have diabetes. He often starts by asking patients what they know about the disease and if they have any relatives with diabetes and what that has meant for them.

Nadkarni asks questions to help gauge what might inspire patients to take charge of their health. The evidence-based approach improves patient engagement by encouraging patients to explore their own motivation to change their behaviors, rather than just listening to a set of instructions.

Bryan Cochran, MD, family medicine physician at MedStar Health Primary Care in Alexandria, Virginia, tailors each conversation to the individual patient because every patient has a different level of preparation for hearing such news.

“For some patients, they’ve been anticipating the diagnosis, and they may have been prediabetic or have a family history, so they are ready to hit the ground running with dietary changes or medications,” said Cochran. “For others, it can feel like a blind-sided diagnosis. They can feel shocked and overwhelmed to have to start a myriad of new lifestyle rules and restrictions, as well as potentially a whole host of new medications.”

Emphasize the Seriousness of the Disease

Type 2 diabetes is associated with a wide range of possible comorbidities, including a higher risk for certain kinds of cancer, cardiovascular disease, obstructive sleep apnea, liver and kidney disease, and cognitive decline.

Neil Soskel, DO, primary care physician at Mount Sinai South Nassau in Lynbrook, New York, noted that some newly diagnosed patients don’t quite grasp the seriousness of the diagnosis.

“I tell them that this is a lifetime disease,” Soskel said. “It’s always going to be with them. They’re just going to control it, and then I go into all the secondary complications.”

“You’ve kind of got to go with tough love,” he added.

Gutierrez said it can be useful to specifically tell patients that they likely won’t feel a difference just from having elevated blood glucose levels.

But over time, uncontrolled diabetes can lead to several potential complications such as diabetic retinopathy, diabetic neuropathy, and even possibly amputation, as well as the increased risk for other comorbidities.

“You’re trying to stop some things that are silent killers down the line,” Gutierrez said.

Handle With Care

Brent Smith, MD, family physician in Greenville, Michigan, and member of the board of directors of the American Academy of Family Physicians, recommends approaching conversations that you have with patients with care.

“We have to couch it in a way that will make it have weight without being overly harsh,” said Smith.

Some patients may have struggled with their weight their entire adult lives, and suddenly they are finding out that they have diabetes.

“There’s a lot of doubt and anger and all the bad emotions that go along with that,” said Smith. “If you approach that too casually or too negatively, it can immediately check them out of the process.”

Nadkarni agreed about the need for care, noting that his program holds seminars for residents to learn how to break bad news, including sharing with patients they have a chronic illness like diabetes.

“Because this is going to totally turn their lives topsy turvy, at least at first,” Nadkarni said.

A type 2 diabetes diagnosis may be particularly difficult for some younger adults (<45 years) to receive, according to a 2src21 study in Journal of General Internal Medicine.

Remind Patients That They Have an Active Role

Positive behavioral changes — including changes to physical activity levels, diet, and monitoring the effect of behaviors on blood glucose levels — lead to better management of diabetes and better outcomes, according to research.

In some cases, it also requires patient adherence to medication regimens that may change over time.

The primary care clinician can help newly diagnosed patients figure out what motivates them to change their behavior. “Do you want to be around for your grandchildren and to be a part of their life?” Smith might ask a patient. “If you do, we need to start making some changes.”

Primary care physicians can also encourage patients by emphasizing their ability to make positive changes and stick to their treatment plans.

“You can assure them that they can actually do well,” said Nadkarni. “They have it within their control to keep their diabetes at a safe level. That’s something that I can’t do for them. The locus of control has to be the patients themselves, being motivated to care for themselves.”