Setting the Foundation and Tools to Help

This is the first post in the series “Dialed in on Diabetes.” Here, we’ll take a big-picture look at type 2 diabetes - as it runs throughout our practices, and yours. Who are the patients in your practice with type 2 diabetes? Are they mostly in a certain age group? What barriers or challenges do they face in taking care of their health? 

Diabetes can affect all ages and stages of people. Read on to learn about the factors that contribute to the onset of type 2 diabetes and the many factors we need to take into account to effectively help our patients and reverse the course.

Diet Dilemmas
Familiar events bring people together to celebrate over food and drink. Common stresses may also move patients to seek out specific foods and drinks when stressed, feeling emotional or just need comfort.

Celebrating with food
Food is certainly a central event to our celebrations and even our schedules. Think “taco Tuesday” or the Family Friday Pizza Night traditions. We like to celebrate birthdays, anniversaries, promotions, bar mitzvahs, quinceaneras, sporting events. You name it, there is a food for it!
This is what brings people together to celebrate over food and drink! For some, those food and drink habits may include highly processed carbohydrates and sugars such as donuts, sweet breads, ice cream, cookies, cakes, candies, soda pop, juice -- all of which aggravate and worsen type 2 diabetes and cause weight gain.

As we identify these challenging situations, we can help our patients consider healthier options for celebrating with others. Many patients will be grateful to identify ways to still celebrate with others or manage their emotions, without sabotaging their desire to get better control of their T2DM. They often find these new approaches are fun and much more effective.

We can help our patients consider healthier options for celebrating with others. You’ve likely heard: “Every time there is a celebration at work there are always treats!” People are constantly bringing and sharing foods that are special to them. We need to validate this very real, very common phenomenon in our patients’ lives. In addition, our patients may worry about offending co-workers by avoiding their treats.

Switch up the Snacks
Ask your patients to ask their coworkers for support: “Can you help me? I am going to bring some veggies and a low-sugar dip, so I won't be tempted by all the delicious food.” Remind patients that asking for help or to “partner with” coworkers invites them to be a positive resource for the patient.

Explore workplace health initiatives, such as a walking group, or fitness incentives. Perhaps create a “healthy office/work site treats lists and ideas for party planning.” In fact, many school systems no longer allow students to bring in “Birthday Treats,” especially to protect students with food allergies and to take more of a wellness approach to food at school. Instead they are finding more creative ways to celebrate every classroom birthday during the school year. Many patients will be grateful for ideas to celebrate with others or manage their emotions, without sabotaging their efforts to better control their type two diabetes. They often find these new approaches are more fun and soon see the positive results.

Hunger on the go
For our every day “on the go” lifestyle, keeping healthy low carb snacks like nuts and cheese sticks in the car or at work can temper hunger that could otherwise lead to a fast food stop or overeating at home. Keeping hydrated can also help decrease hunger. Recommend always keeping a reusable water bottle handy and sipping often. Some patients find that adding ice, citrus slices, or mint sprigs makes water more appealing without spiking their blood sugar.

Emotional Eating
On the flip side, food is often a go-to for times when patients are stressed, feeling emotional and need comfort. For example, patients can often be “emotional eaters,“ in good times and tough times. We have to acknowledge is that in these moments, food works for patients! You can simply validate this by saying “That makes sense, we all figure out ways to soothe ourselves and food has worked for you. How about if we think of other things that soothe you and are still healthy and helpful for your diabetes?” A quick 2-to 3-minute brainstorming session can help. Write down the ideas you agree on directly on a prescription pad to hand to your patient, or in the section of your EMR that the patient will receive. This sends a powerful message about the health benefits of food.

Food is fuel
Rather than thinking that some foods are “bad”, it helps to remember that all foods affect our body in some way. Food is necessary to nourish and provide our body with fuel. The goal is to empower patients to identify challenging scenarios and choose the foods that promote their health AND that they can enjoy - the foods that allow their bodies to thrive.

Cultural awareness
Some patients’ cultural backgrounds, religious traditions, or personal preferences may also factor into your recommendations. For example, the effect of fasting during Ramadan on both type 1 and type 2 diabetes has been extensively studied. Likewise, nutrition counseling must be culturally conscious in order for it to be a plan the patient can act on-- if the patient doesn’t recognize any of the foods on the plan, he or she won’t know what to eat and what to limit. Many hospitals have team members who can specifically address cultural factors in designing a nutrition plan.

The Prescription for Exercise
There is nothing more powerful than exercise and being physically active. No pill or intervention has a greater effect on our health. Physical activity stimulates and boosts every cell in the body, improves physical health and promotes mental well-being. It’s a way to turn on your body’s natural cellular regeneration capacity.
What kind of exercise is best? How much? When?
Move every day, and often, throughout the day.
Walking is a simple way to start. If you can’t walk for long, just walk for as long as you can. Any movement is better than none, and the effects last long into life. One study found that 80 year old people who walked for just 15 minutes at least 4 times a week lived significantly longer than those who walked less than 4 times a week.1

Every 30 minutes, patients should be thinking about standing up and moving around. Sitting or lying down for long periods of time causes the body to start to break down. Get up and move. Give your patients some easy tips that they can do every single day. Stand up during that phone call, use a stand-up desk if that’s an option. Take an occasional lap around the office or a flight of stairs at work, so you send a signal to your body to regenerate and thrive!

Set a goal with the patient. If the American Diabetes Association goal of 150 minutes a week of exercise2 is too big a goal at first-- and it is for many people-- what do they think they could start doing today that would get them moving? The ADA also recommends daily exercise; at a minimum, encourage patients to not let more than two days go between exercise.3

Our patients’ schedules often affect their lifestyle habits. Are they unemployed, on a fixed income, working two jobs, or a professional with a busy travel schedule? Are they caring for children or an elderly relative?
Talk about their sleep and wake schedules, their commutes, their travel times. Do they work unusual or inconsistent schedules?
Make sure you include all these factors in designing a plan that meets your patients where they are and gets them to where they want to be!
Involving patients in the development of the plan increases the likelihood of success! Instead of just telling patients again and again to eat right and exercise, ask them what 1 or 2 changes they think they can start making to put them in the right direction. Listen to their fears and work with their first steps, then incorporate your own as the patient is ready.

Systemic Barriers that We Share
What about you, the family physician? What are the barriers you face in taking care of your patients? As providers, we face RVU targets to meet, insurance coverage issues, check boxes to complete, administrative paperwork, etc. A lot of little things take us away from focusing on our patients.
We’ve heard a lot about burnout. Another term for what we face is moral injury, which reflects how we are hurt by the systemic factors that keep us from providing the best possible care. If you haven’t heard this term, please check out our links on the Dialed in on Diabetes website. This is something that is done to us, not a failure by us, and we need to recognize this difference. We also need to talk about it and advocate within our systems to eliminate the root causes of this moral injury as we push to deliver the best care we know we can give.
While we can’t solve all these issues here today, we can provide some places to start. Learn more at our resource center at We hope we set a foundation to help care for your patients with type 2 diabetes. The next post in this series will look at the behavioral health issues patients experience.

Resources Available:
IAFP CME of New ADA Standards of Medical Care 2019
Illinois State Diabetes Plan
AAFP Education 
American Family Physician has compiled a collection of articles on type 2 diabetes and related issues. 
AAFP News - New research on FPs prediabetes knowledge and practices
AAFP Patient Education -
Patient prescription assistance programs
Many programs offer patients reduced cost or free medications and access to insulin at lower costs. Visit from the American Diabetes Association with links for help

Moral Injury
Reframing Clinician Distress: Moral Injury Not Burnout
Medical Economics on Moral Injury
Medscape article on Moral Injury (free subscription required)


1 Fortes C, Mastroeni S, Sperati A, Pacifici R, Zuccaro P, Francesco F, Agabiti N, Piras G, Ebrahim S. Walking four times weekly for at least 15 min is associated with longevity in a cohort of very elderly people. Maturitas. 2013 Mar 1;74(3):246-51.
2 Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, Horton ES, Castorino K, Tate DF. Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes care. 2016 Nov 1;39(11):2065-79.
3 Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, Horton ES, Castorino K, Tate DF. Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes care. 2016 Nov 1;39(11):2065-79.

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