Original Article: Diabetes Self-Management: Facilitating Lifestyle Change

Issue Date: September 15, 2017

See additional reader comments at: https://www.aafp.org/afp/2017/0915/p362.html

To The Editor: We were elated to read your article on lifestyle changes to promote weight loss and improve glycemic control in persons with diabetes mellitus. The program outlined includes measurable tools not only to assess the patient's readiness for behavioral changes but also to create short, realistic goals, which is a model we would want to implement with our patients and residents.

The article acknowledges that the Look AHEAD (Action for Health in Diabetes) study¹ was conducted with a carefully selected population with an abundance of resources, and it briefly mentions that psychosocial factors can be barriers to the interventions. As such, adapting these tools in practice can have some challenges in a resource-poor community. Therefore, when teaching and practicing in a low-income area, which makes up the largest portion of patients with diabetes and chronic diseases, we recommend some small changes to the protocol to address the social determinants of health.

Many of our patients reside in communities with high obesity rates, comparable with studies showing that counties with poverty rates exceeding 35% have obesity rates 145% greater than in wealthy counties.² This patient population is afflicted with safety concerns prohibiting them from walking in their neighborhoods and is often unable to afford gym memberships or sometimes even proper clothing for exercise. Thus, meal replacement or phone tracking models are luxuries that patients in the greatest need cannot afford. Although case management can help with basic needs, we also suggest alternative methods for implementing the programs discussed in the article, such as physician- or police-guided safe walking groups, paper logs for tracking food consumption and physical activity, instructions on how to count and chart heart rate, and a review of fresh items available through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) that can be cooked in bulk.

It is often patients with the greatest need who realistically cannot benefit from new treatment models simply because of the lack of resources. As physicians, we must challenge ourselves to make the needs of these patients a priority if we are to adequately address the epidemics of obesity, prediabetes, and diabetes.