The Science of Diabetes Self-Management and Care

Therapeutic lifestyle intervention, with a focus on weight loss, is the cornerstone of cardiometabolic risk factor reduction, but many patients find it difficult to make the changes that are needed to achieve meaningful improvements in risk markers. There are a variety of pharmacologic options for the management of individual risk factors, such as hypertension, dyslipidemia, and insulin resistance. However, agents that are currently available to assist patients in their weight loss efforts are limited by their potential for adverse effects. The American Association of Diabetes Educators (AADE) has identified 7 behavioral targets of self-management, the AADE7™ Self-Care Behaviors, which include healthy eating, being active, monitoring, taking medications, problem solving, healthy coping, and reducing risk factors. The case scenarios in the article illustrate some of the challenges clinicians face in managing cardiometabolic risk factor reduction in the context of these recommended behaviors. A common theme among these cases is the importance of assessing patients' understanding, beliefs, and readiness to change their behaviors.

Overweight and obesity are associated with multiple cardiometabolic risk factors. In a national survey of nearly 200000 adults, the prevalence of hypertension was 28% among adults who were overweight compared with only 16% among normal-weight adults. Other epidemiologic studies have also clearly established the association of increases in body mass index with an increase in the age-adjusted relative risk for the development of type 2 diabetes in both men and women. In men, the relative risk of diabetes has more than doubled in overweight individuals whose body mass index is 25 compared with lean individuals with a body mass index of <23. The risk rises exponentially as body mass index increases: risk is increased 12-fold in obese men with a body mass index of 31 and 42-fold in severely obese men with a body mass index greater than or equal to 35. Even more precipitous increases in the risk of diabetes with increases in body mass index are seen in women. In the Nurses' Health Study, relative risk rose about 8-fold in women with a body mass index of 25 compared with women whose body mass index was less than 22. The risk quintupled to about 40-fold in women with a body mass index of 31. In severely obese women, the relative risk of type 2 diabetes was 93-fold greater than in lean women.

The prevalence of obesity has reached epidemic proportions in recent years. Therapeutic lifestyle change is widely accepted as the best first step for managing cardiometabolic risk factors. Patients, however, find it difficult to adhere to these recommendations, and many ultimately require pharmacotherapy to achieve treatment goals for blood pressure, glucose, and lipids. Although there are many safe and effective agents for managing these 3 cardiometabolic risk factors, pharmacologic options for weight loss are limited. Researchers have shown that dietary counseling helps some patients achieve weight loss, but these improvements diminish over time. The combination of diet with exercise results in greater initial weight loss than diet alone, but this loss is only partially sustained after 1 year. The American College of Sports Medicine/American Heart Association recently published updated recommendations for physical activity for healthy adults that reiterate the value of relatively moderate exercise: as little as 30 minutes a day, 5 days a week, can yield substantial health benefits. Unfortunately, most individuals find it just as difficult to adhere to an exercise regimen over the long term as they do to maintain a weight-loss diet. Only 11% to 19% of patients with diabetes who begin an exercise regimen will continue to exercise for an entire year.