Fresh Views

Transforming Primary Care Encounters: The Prediabetes Conversation

“The secret of living well and longer is: eat half, walk double, laugh triple, and love without measure.” ~ Tibetan Proverb

As we revisit our series on transforming primary care encounters, we’d like to take a step back, if you will, to the diagnosis of prediabetes. In our clinical experience there is a vast difference in these early conversations in the health care setting – sometimes a stern warning to change habits “or else”, to almost no recognition of the elevated blood glucose at all, with no discussion about the potential risk of developing type 2 diabetes. Deb discovered that both of her parents had been living with prediabetes for years, but neither of them had even been told of their lab levels except, “things look good.” As with a new diagnosis of type 2 diabetes, we believe that incorporating a solution-focused approach with a prediabetes diagnosis is equally as important. 

If you’ve read our previous blogs you know that  a solution-focused approach is the opposite of a more traditional “problem-focused” approach. The goal is to help the individual recognize exceptions (times when their problems did not happen) and help them to focus on health behavior changes by doing “more of what works.” How can we use this approach in the prediabetes conversation?

Using a solution-focused approach at the prediabetes diagnosis conversation

The ADA 2022 Standards of Medical Care indicate that screening for prediabetes should start at age 35, but earlier for those with risk factors. We are advocates that everyone who meets the criteria for a prediabetes diagnosis deserves the information as early as possible so they may decide what types of health behavior changes they are willing and able to make. Thus, using a solution-focused approach from the beginning is critical to set the stage for a lifetime of ongoing conversations. A clinician’s approach to this conversation can make the difference in early action to help prevent or delay type 2 diabetes – and thus potential prevention of long-term complications, reduction in medication, and living a healthier life.

Current guidelines suggest enrolling individuals with prediabetes into a National Diabetes Prevention Program (DPP) given DPP study outcomes that showed a 58% reduction in risk of progression to type 2 diabetes with lifestyle intervention. Research shows that participants who lose 5-7% of their body weight and add 150 minutes of exercise per week cut their risk of developing type 2 diabetes by up to 58% (71% for people over 60 years old). 

The guidelines also recommend metformin for those with a higher BMI, higher A1C, and history of gestational diabetes. Since many don’t want to take medication, there is a great need for open discussion from the beginning to use shared decision-making to lay out the facts, what is known, what the research indicates, and their overall level of risk.  

We know that patients (clients) greatly value what their primary care provider (PCP) recommends to them, so having these open discussions can help the PCP identify what the individual is willing and able to do. If they might benefit from medication, and are likely to be challenged to engage in physical activity or choose more healthful foods, then medication might be a beneficial option. It’s important to balance goals from the PCP perspective against the capacity of the person with the new diagnosis. Asking questions and engaging in problem-free talk can be more impactful than giving a list of instructions. Maybe you simply state, “I know this is hard to hear, how can I help?” and “What information would you like to hear from me today as you start to learn about prediabetes?” 

As we shared in our type 2 diabetes diagnosis blog, the American Diabetes Association encourages four critical conversations that promote “early positive conversations about the nature of diabetes.” We believe that applying this during the prediabetes diagnosis can be equally as valuable. These conversations address many tenets we value in a solution-focused approach, including person-centered, strength-based language, problem-free talk, listening, and building a partnership with clients.

4 critical conversations

There are four critical conversations that need to happen early in the diagnosis. We’ve modified these questions to fit prediabetes and encourage you to build upon these questions at each visit. Start small with a few comments and then build upon them as the person is learning to accept the diagnosis and is ready to learn more. At diagnosis, conversation #1 is the most significant. (adapted from ADA Overcoming Therapeutic Inertia)

  1. Prediabetes may progress to type 2 diabetes over time, as your body’s insulin production changes.

I want you to know that prediabetes is an opportunity to make health behavior changes that may prevent or delay type 2 diabetes. However, it’s important to know that even if you follow every guideline you may still develop type 2 diabetes.

  1. Your treatment plan will change over time as your prediabetes changes.

You may need to add a medication as your prediabetes changes. This is not a personal failure, just a part of how the progression to diabetes may happen.

  1. You can’t do this alone.

I am here to help you.

  1. Share your difficulties with following diabetes prevention guidelines.

Managing prediabetes day in and day out can be hard. Share anything that may be getting in the way of managing your diabetes and also share your successes.

Close the conversation with a scaling question.

On a scale of 0-10 where zero is no stress and 10 is the worst stress you’ve ever experienced, where are you right now?

Use their answer to finish the visit and provide one action for them to focus on.

If 0-4:  Encourage doing some research online at trusted sources like the ADA, CDC or ADCES.

If 5-7:  Identify one strength they already have and build upon it

What is one thing you do for yourself every day that makes you feel healthy? How can  you do more of that?

If 8-10: just encourage them to breathe and take some time to let it sink in and to come back with questions in one week

I know how hard this can be, take some time, write down questions you have, and let’s meet and talk more next week.

Create a supporting environment

Reinforce that small changes can help move them in the right direction, and that you don’t expect perfection. If they do the best that they can do, that’s the best they can do.  Remind them that you are partners on this journey. We believe that creating a supportive environment from day one, can empower people to learn to live with their diabetes.

Stop back by in 2 weeks as we wrap up our series on incorporating a solution-focused approach when managing type 2 diabetes in the primary care setting. We’ll focus on interpreting diabetes data in primary care in a solution-focused way.

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Deb is employed by Dexcom, but her words and opinions in this blog are her own.

Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.