Changing your approach to type 2 diabetes as a GP

By Campbell Murdoch
5th April 2019
In Depth
 
1340

A large proportion of the health issues that GPs see do not have a quick drug fix.  Conditions such as type 2 diabetes, heart disease, mental health, respiratory diseases, and many neurological diseases affect the whole person. To treat, manage or improve these conditions a whole-person focus is important and necessary. This means a GP needs to have some understanding of what matters most to a person and their goals. With this focus the best personalised management plan can be created. Patch Adams summed this up with the phrase, “You treat the disease – you win, you lose. You treat a person I guarantee you win – no matter the outcome.”

This approach is now widely accepted across healthcare and is known as “person-centred care” or “personalised care”.

In treating type 2 diabetes there are a number of important roles for a GP to undertake; a person-centred approach is centre to this.

My approach as a GP

Type 2 diabetes is no longer defined as being a ‘chronic progressive disease’, despite what medical school textbooks and lectures taught me 20 years ago!

How we frame a disease, and our core beliefs are important. They will influence our goals and decisions. I now hold the core belief that improvement in type 2 diabetes is possible for everyone, to a greater or lesser degree. Also, many people with type 2 diabetes are achieving significant health improvement, including placing the condition into remission.

The range of options for type 2 diabetes management means it is important to take a person-centred approach and enable a person to choose the management option(s) that are best for them. As a GP the approach I will take with different people will of course vary. Every person and every consultation is different. However, there is a common pathway I follow which is described below. In this article I’ll offer some thoughts on how a low carbohydrate approach, if that is the patient’s chosen management option, can be shoe-horned into a 10 minute appointment. In addition we’ll consider the wider resources and opportunities that are available to GPs and patients outside of the standard short GP appointment.

Throughout a consultation with a patient I’ll be aligning my thinking and approach with four key areas to help ensure the person-centred goals are achieved:

  • Needs and goals
  • Physiology
  • Preferences, options and choices (options includes drawing on the best clinical evidence)
  • The journey

The consultation

Prior to the patient coming into the consultation room I will review their medical record (in under 15 seconds!). This comprises:

  1. Review of most recent consultations
  2. Current and past medical history, and any significant recent events. Including other diagnoses suggestive of poor metabolic health such as; obesity, hypertension, NAFLD, dyspepsia, cardiovascular disease, gout.
  3. Blood tests (recent and historical, and trends). Particularly looking at HbA1c and for other blood tests that signify poor metabolic health (e.g. high triglycerides, low HDL-C, raised liver function tests, raised uric acid)
  4. Current medications

I will then welcome the patient to the room and discover the reason for their visit. If the consultation is specifically to address their type 2 diabetes I’ll ask if they were aware that type 2 diabetes is no longer just a disease that can only get worse, and that most people are able to significantly improve the condition, and some are able to achieve a normal blood sugar whilst come off drugs.

We’ll review the evidence based management options for type 2 diabetes [albeit briefly due to the 10 minute appointment limit], and we will utilise this decision aid:

We will briefly [due to time constraints] discuss the various options, their pros and cons and their appropriateness for the person. The majority of patients chose “aim to improve / place into remission”.

We will then review current lifestyle including food preferences, physical activity and wider life interests/needs/demands such as work or family life)

Next, we explore “what matters” or “what’s important” to the person. Uncovering this can be very helpful to assist with behaviour change. An example might be “wishing to improve health to be around for the grand kids in years to come”. These life aspirations are often more motivating for many people than the more clinical focus of seeing an improvement in my HbA1c”.

Many people choose a low carbohydrate approach to improve their type 2 diabetes because it:

  1. Sounds enjoyable to most people (once explained and understood)
  2. Is easiest to implement as it does not need any additional medical referral or medical resources

With the low carbohydrate approach chosen, the clinical tasks for GPs are then:

  1. Perform a more detailed review of relevant blood tests, blood pressure, pulse and weight (are they up to date? Within the last 8 weeks is reasonable). More recent tests would be required if there had been a recent significant recent health issue. If necessary arrange for tests to be performed.
  2. Review medication; particularly diabetes drugs that may need to be adapted when their carbohydrate intake is reduced [link to table] and anti-hypertensives (On top of lowering blood glucose, a low carbohydrate diet can cause an improvement in blood pressure. Anti-hypertensive doses may need to be reduced if someone’s blood pressure is already at the lower end of the range).
  3. Provide the patient with resources (or signpost them to appropriate resources) that offer the necessary information and support required to move towards a low carbohydrate diet.
  4. Provide detail of the common side effects of a low carbohydrate diet. These side effects, if they occur, are typically seen in the first 1-2 weeks. [Side effects handout]. Also highlight the commonly reported positive effects (including loss of constant hunger, weight loss – especially centrally, and often better mood and clearer mind). Behaviour change can be hard, so it is important to assist people in becoming motivated to change.

The follow-up

To conclude the appointment we will agree on a follow-up visit. This will typically be at 12 weeks (if no further medication adjustments are needed). Blood tests will be arranged for within a few days prior to the follow up appointment (typically HbA1c and lipids, plus any patient specific tests).

The review could be sooner if diabetes drug doses, or anti-hypertensives, will likely require further adjustment within the initial 12 weeks (review could be face-to-face or via telephone consultation)

At follow-up appointment we will review what has worked well, any challenges and solutions (I like to hear about a “top tip” that the person would like to share with others). Blood test results will be reviewed, as well as weight and blood pressure. Then we will decide if the approach is appropriate for them (physiology and life preferences), and if any adjustments are required. Celebrate successes, and agree next steps, possibilities may include:

  1. Return to annual review
  2. Further 12 week review
  3. Change in management plan.
  4. Referral on to wider primary care team for support (e.g. health coach or social prescriber)

Making the most of the consultation

A typical 10-minute GP appointment is not really designed for addressing conditions such as type 2 diabetes. Although it is possible within this very short consultation to undertake a person-centred consultation, complete the clinical duties, and to build a management plan (that could include behaviour change plans). It is certainly a challenge, so to best meet patient’s needs it can help to consider how care could be better delivered. This can include:

  • Making use of the primary care team
    • Practice nurse – who may already be the lead clinician for diabetes care in the practice
    • Pharmacist – who could assist in adjusting medications
    • Health coach / Social prescriber – to support the patient with behaviour change
  • Group education/consultations – these are becoming an increasingly popular and effective way of supporting people to manage and improve their type 2 diabetes. They allow more time for discussion, and patients can learn from and support each other.
  • Digital solutions – many of the tasks relating to a low carbohydrate diet for improving type 2 diabetes are non-clinical. A digital solution to educate, empower and support a person with type 2 diabetes can remove many of the tasks from a clinical appointment. The Low Carb Program has been designed for this purpose. It can be “prescribed” during a short consultation, just like a clinician would prescribe a medication. The Low Carb Program could also be used alongside group consultations.

In the general practice setting patients with type 2 diabetes who choose a low carbohydrate approach will be able to improve their health. At least 25% of people will likely be able to place their type 2 diabetes into remission. Supporting patients to better manage their type 2 diabetes can transform health, reduce medication, reduce clinical workload and likely reduce the rate of future complications. It is also a very rewarding part of GP daily work.

Learn more about how low carb can help reduce medication and visit DDM’s award-winning Low Carb Program. One in four users of the program put their type 2 diabetes into remission within one-year, and other benefits members experience include better mood, increased energy and better quality of life.

Register your interest for healthcare professional training.

What do you think?