- Email: [email protected]
A Clinical Practice Lifestyle Intervention for Type 2 Diabetes
BRIEF REPORT
A Clinical Practice Lifestyle Intervention for Type 2 Diabetes Nancy Tarr Anderson, DNP, AGPCNP-BC, RD, and Ellen P. Moore, DNP, AGPCNP-BC ABSTRACT
Lifestyle interventions that incorporate healthy eating, routine physical activity, and frequent follow-up are required to achieve clinically meaningful weight loss in patients with type 2 diabetes. Only 42% of primary care providers address weight management during the office visit, citing the lack of time and a disbelief that such discussions are effective, yet most patients at least attempt lifestyle change when advised. By briefly discussing the impact of modest weight loss, including the importance of physical activity during the clinic visit and providing a simplified strategy to the patient with type 2 diabetes, self-efficacy can be enhanced and outcomes improved. Keywords: diabetes, exercise, lifestyle, remote support, weight management Ó 2016 Elsevier Inc. All rights reserved.
T
welve percent of the adult population in the United States has diabetes, resulting in $245 billion in direct and indirect costs to the nation’s shrinking health care budget.1 In addition, 37% of adults have prediabetes, a significant risk factor for the development of overt type 2 diabetes mellitus (T2DM).1 Overweight and obesity are preventable risk factors associated with both conditions, yet > 75% of those affected remain overweight.2 Evidenced-based lifestyle interventions aimed at weight reduction in these patients must be integrated into the clinical practice setting where they can have the most impact. The purpose of this report is to provide the advanced practice nurse with a review of the benefits of physical activity for patients with T2DM and best practice recommendations for improving adherence in this patient population. GAP IN EFFECTIVELY ADDRESSING WEIGHT AT CLINIC VISIT
Sustained weight reduction of 5% in overweight patients with T2DM has been associated with improved glycemic control and reduction in cardiac risk factors.3 To improve outcomes through clinically meaningful weight reduction in patients with T2DM, intensive lifestyle programs are required that incorporate routine physical activity and frequent www.npjournal.org
follow-up.3 Only 42% of primary care providers discuss weight management lifestyle interventions with their patients during the office visit. These providers cite lack of time and a disbelief that such discussions are effective, yet most patients at least attempt weight loss when advised.4 Effective strategies are needed to target lifestyle interventions that can be efficiently integrated during the clinic visit. PHYSIOLOGIC RESPONSE TO EXERCISE
Physical activity has acute positive effects on blood glucose levels by causing an increased uptake of glucose into the active muscles.5 Furthermore, both low- and high-intensity physical activity improve systemic insulin action for 2-72 hours.5 Patients should be informed that physical activity improves insulin sensitivity both during exercise and times at rest, independent of weight loss. The risk of exercise-induced hypoglycemia is minimal, except for patients with T2DM who take insulin secretagogues or exogenous insulin.5 When selecting diabetes medications, consideration must be given to reducing the risk of hypoglycemia and mitigating weight gain.3 Patients who take exogenous insulin or secretagogues should be counseled on hypoglycemia risk and treatment, and The Journal for Nurse Practitioners - JNP
e35
every effort should be made to adjust these medications to compensate for the improved insulin sensitivity gained through exercise. Patients should be engaged in the process and encouraged to check their blood glucose levels before and after the exercise session. OVERVIEW OF EXERCISE AND DIABETES TRIAL OUTCOMES
A large, multicenter trial in the United States, the Action for Health in Diabetes (Look AHEAD) Trial, investigated the impact of an intensive lifestyle intervention (ILI) in overweight and obese patients with T2DM on reducing cardiovascular events.6 The ILI incorporated frequent individual and group counseling, reduced calorie meal plans, and 175 minutes per week of moderate-intensity physical activity, but it did not reduce the rate of cardiovascular events over a median follow-up period of 9.6 years. Compared with a control group, however, the ILI participants attained significantly better improvements in glycated hemoglobin and fitness and, during the first 4 years of the trial, were more likely to have a partial remission of diabetes compared with the control group.6 Additional benefits of the ILI, in a comparison with a control group, included reductions in urinary incontinence, sleep apnea, and depression, and improvements in quality of life, physical functioning, and mobility.7 Weight loss and maintenance are best achieved in patients with T2DM through the combined approach of calorie reduction, exercise, and behavioral modification.7 The American Diabetes Association Standards of Medical Care for individuals with diabetes include the recommendation of 150 minutes per week of moderate-intensity aerobic physical activity, such as brisk walking, spread over 3 days within 1 week, with no more than 2 consecutive days without exercise.3 Increased physical activity, independent of weight loss, can reduce depressive symptoms and improve health-related quality of life in patients with T2DM.5 The Diabetes Prevention Program, a major multicenter research study, was designed to determine whether modest weight loss through physical activity and dietary changes or treatment with an oral diabetes drug, metformin, could prevent or delay the onset of e36
The Journal for Nurse Practitioners - JNP
T2DM in high-risk adults of various ages and ethnicities.8 Participants in the lifestyle intervention group received intensive counseling and support on effective diet and exercise strategies, aiming for a 7% weight loss and 150 minutes of exercise per week. The remaining 2 intervention groups included standard lifestyle recommendations plus either metformin or placebo. The cumulative incidence of diabetes throughout the average follow-up period of 2.8 years was lowest in the intensive lifestyle group compared with both the metformin and placebo groups.9 Although both the Look AHEAD Trial and the Diabetes Prevention Program of the National Institutes of Health provide evidence of the benefits of lifestyle interventions in patients with and at risk for T2DM, they have been criticized for being too costly and time-consuming to be scalable to the realworld clinical practice setting where patients may not be as highly motivated.10 Furthermore, patients with diabetes complain that there are too many “rules” to follow regarding diet and exercise and that they often feel confused and overwhelmed.11 It is essential that health care professionals provide simple, clear, and concise nutrition and physical activity advice to patients with T2DM.12 Patients must understand why physical activity is so important, how much is necessary to impact change, and the importance of consistent adherence (Table 1).13 SELF-EFFICACY: IMPROVING PATIENT OUTCOMES
Self-efficacy is a phenomenon of concern that is integrated into self-management behaviors directed at achieving weight loss and controlling diabetes.12 By briefly discussing the importance of weight loss, including the importance of physical activity during the clinic visit, and providing a simplified approach for the patient in writing, along with follow-up supportive care, self-efficacy is enhanced and optimal outcomes obtained.14 For example, the American Diabetes Association’s “Create Your Plate” and physical activity recommendations should be provided in written format and discussed during the office visit.3 A 5% weight loss goal should be calculated and discussed. Each patient should be given a written exercise prescription much like those used to prescribe medications. In addition, referrals to a certified Volume 13, Issue 1, January 2017
Table 1. Practice Pearls for Supporting T2DM Patients Through Lifestyle Change B
B
B
B
B
B
B
B
B
B
B
B
B
A 5% weight loss improves blood glucose control and reduces cardiovascular risk factors. Use terms “nutrition plan and physical activity” rather than “diet and exercise”-both components are important. Benefits are achieved by routine physical activity, independent of weight loss. Focus on behavior, not the scale. Physical activity helps the body use insulin more effectively and can decrease the need for additional diabetes medications. Check blood glucose levels frequently when implementing an exercise program. Check before and after physical activity to reinforce benefits. If taking insulin injections or insulin secretagogues, carry a quick source of carbohydrate when exercising. Physical activity not only lowers blood glucose levels during the activity session, but also throughout the day, even when the body is at rest. Break up 30-minute daily exercise session into several smaller segments if needed. Use a pedometer or fitness tracker to measure steps; establish a baseline, then increase steps gradually each week. Join a fitness class or recruit an exercise buddy to keep motivated. Set realistic goals and progress slowly to decrease injury risk. Refer to certified diabetes educators and exercise specialists when possible. PROVIDE remote support: check in on patients between visits; remember that patients “don’t care how much you know until they know how much you care.”
T2DM ¼ type 2 diabetes mellitus.
diabetes educator or a group fitness class should be considered. The internet provides an abundance of helpful information for patients with diabetes and these resources should be discussed (Table 2). Follow-up appointments should be scheduled to check weight and progress and to provide reinforcement when possible. Routine supportive phone calls to patients who are implementing lifestyle changes have been associated with improved outcomes, and the frequency of contact is directly related to the degree of adherence and weight loss. Eakin et al. also demonstrated that weight loss outcomes do not differ based on who provides the remote support. Trained medical assistants have been effectively utilized.15 www.npjournal.org
Table 2. Free Helpful Websites, Fitness, and Calorie Trackers B
B
B
B
B
B
B
American Diabetes Association www.diabetes.org/are-you-at-risk/ (under food and fitness tab) National Diabetes Education Program www.ndep.nih.gov US Centers for Disease Control and Prevention www.cdc.gov/diabetes/ Mayo Clinic www.mayoclinic.org/diseases-conditions/type-2-diabetes/ in-depth/diabetes-prevention/art-20047639 My Fitness Pal http://www.myfitnesspal.com/ WebMD http://www.webmd.com/diet/food-fitness-planner/ Fit Day http://www.everydayhealth.com/calorie-counter.aspx
CONCLUSION
The advanced practice nurse has the opportunity during each T2DM patient visit to emphasize the importance of physical activity and proper nutrition. By coordinating a simple office process combined with remote follow-up support and engaging the health care team, patients with T2DM are more likely to adhere to the recommended lifestyle interventions that can improve outcomes. References 1. US Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States. 2014. http:// www.cdc.gov/diabetes/pubs/statreports14/national-diabetes-report-web.pdf/. Accessed April 25, 2016. 2. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes [position statement]. Diabetes Care. 2013;36:3821-3842. 3. Cefalu WT, ed. American Diabetes Association Standards of Medical Care in Diabetes [special issue]. Diabetes Care. 2016;39(Suppl 1). 4. Banerjee ES, Gambler A, Fogleman C. Adding obesity to the problem list increases the rate of providers addressing obesity [faculty paper]. 2013. http:// www.jdc.jefferson.edu/. Accessed April 25, 2016. 5. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association joint position statement. Diabetes Care. 2010;33:e147-e167. 6. The Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369:145-154. 7. Franz MJ, Boucher JL, Rutten-Ramos S, van Wormer JL. Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. J Acad Nutr Dietetics. 2015;115:1447-1463. 8. National Institute of Health. Diabetes prevention program (DPP). 2013. http:// www.niddk.nih.gov/. Accessed April 25, 2016. 9. Knowler WC, Barrett-Conner E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403. 10. West DS, Krukowski RA. Translating the Look AHEAD Trial into action. Obesity. 2015;23:1738. 11. Fayyaz J. Nutrition and lifestyle modifications for diabetes patients. 2016. http://www.diabetesincontrol.com/. Accessed April 25, 2016.
The Journal for Nurse Practitioners - JNP
e37
12. Pender N, Murdaugh C, Parsons MA. Health Promotion in Nursing Practice. 6th ed. Upper Saddle River, NJ: Prentice Hall; 2010. 13. Delahanti LM. Improving diabetes outcomes through nutrition and lifestyle change—translating research to practice. October 24, 2015. http://touchend ocrinology.com/. Accessed April 25, 2016. 14. Celano CM, Beale EE, Moore SV, Wexler DJ, Huffman JC. Positive psychological characteristics in diabetes: a review. Curr Diabetes Rep. 2013;13:917-929. 15. Eakin EG, Reeves MM, Winkler E, et al. Six-month outcomes for Living Well with Diabetes: a randomized trial of a telephone-delivered weight loss and physical activity intervention to improve glycemic control. Ann Behav Med. 2013;46:193-203.
MSN, APRN, RD, CDE, can be reached at [email protected]. Ellen P. Moore, DNP, AGPCNP-BC, is an assistant professor of adult health nursing. Nancy is employed as a Senior Medical Liaison by Novo Nordisk, Inc. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Both authors are affiliated with the College of Nursing at the University of South Alabama in Mobile. Nancy Tarr Anderson,
1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.07.021
e38
The Journal for Nurse Practitioners - JNP
Volume 13, Issue 1, January 2017
A Clinical Practice Lifestyle Intervention for Type 2 Diabetes Nancy Tarr Anderson, DNP, AGPCNP-BC, RD, and Ellen P. Moore, DNP, AGPCNP-BC ABSTRACT
Lifestyle interventions that incorporate healthy eating, routine physical activity, and frequent follow-up are required to achieve clinically meaningful weight loss in patients with type 2 diabetes. Only 42% of primary care providers address weight management during the office visit, citing the lack of time and a disbelief that such discussions are effective, yet most patients at least attempt lifestyle change when advised. By briefly discussing the impact of modest weight loss, including the importance of physical activity during the clinic visit and providing a simplified strategy to the patient with type 2 diabetes, self-efficacy can be enhanced and outcomes improved. Keywords: diabetes, exercise, lifestyle, remote support, weight management Ó 2016 Elsevier Inc. All rights reserved.
T
welve percent of the adult population in the United States has diabetes, resulting in $245 billion in direct and indirect costs to the nation’s shrinking health care budget.1 In addition, 37% of adults have prediabetes, a significant risk factor for the development of overt type 2 diabetes mellitus (T2DM).1 Overweight and obesity are preventable risk factors associated with both conditions, yet > 75% of those affected remain overweight.2 Evidenced-based lifestyle interventions aimed at weight reduction in these patients must be integrated into the clinical practice setting where they can have the most impact. The purpose of this report is to provide the advanced practice nurse with a review of the benefits of physical activity for patients with T2DM and best practice recommendations for improving adherence in this patient population. GAP IN EFFECTIVELY ADDRESSING WEIGHT AT CLINIC VISIT
Sustained weight reduction of 5% in overweight patients with T2DM has been associated with improved glycemic control and reduction in cardiac risk factors.3 To improve outcomes through clinically meaningful weight reduction in patients with T2DM, intensive lifestyle programs are required that incorporate routine physical activity and frequent www.npjournal.org
follow-up.3 Only 42% of primary care providers discuss weight management lifestyle interventions with their patients during the office visit. These providers cite lack of time and a disbelief that such discussions are effective, yet most patients at least attempt weight loss when advised.4 Effective strategies are needed to target lifestyle interventions that can be efficiently integrated during the clinic visit. PHYSIOLOGIC RESPONSE TO EXERCISE
Physical activity has acute positive effects on blood glucose levels by causing an increased uptake of glucose into the active muscles.5 Furthermore, both low- and high-intensity physical activity improve systemic insulin action for 2-72 hours.5 Patients should be informed that physical activity improves insulin sensitivity both during exercise and times at rest, independent of weight loss. The risk of exercise-induced hypoglycemia is minimal, except for patients with T2DM who take insulin secretagogues or exogenous insulin.5 When selecting diabetes medications, consideration must be given to reducing the risk of hypoglycemia and mitigating weight gain.3 Patients who take exogenous insulin or secretagogues should be counseled on hypoglycemia risk and treatment, and The Journal for Nurse Practitioners - JNP
e35
every effort should be made to adjust these medications to compensate for the improved insulin sensitivity gained through exercise. Patients should be engaged in the process and encouraged to check their blood glucose levels before and after the exercise session. OVERVIEW OF EXERCISE AND DIABETES TRIAL OUTCOMES
A large, multicenter trial in the United States, the Action for Health in Diabetes (Look AHEAD) Trial, investigated the impact of an intensive lifestyle intervention (ILI) in overweight and obese patients with T2DM on reducing cardiovascular events.6 The ILI incorporated frequent individual and group counseling, reduced calorie meal plans, and 175 minutes per week of moderate-intensity physical activity, but it did not reduce the rate of cardiovascular events over a median follow-up period of 9.6 years. Compared with a control group, however, the ILI participants attained significantly better improvements in glycated hemoglobin and fitness and, during the first 4 years of the trial, were more likely to have a partial remission of diabetes compared with the control group.6 Additional benefits of the ILI, in a comparison with a control group, included reductions in urinary incontinence, sleep apnea, and depression, and improvements in quality of life, physical functioning, and mobility.7 Weight loss and maintenance are best achieved in patients with T2DM through the combined approach of calorie reduction, exercise, and behavioral modification.7 The American Diabetes Association Standards of Medical Care for individuals with diabetes include the recommendation of 150 minutes per week of moderate-intensity aerobic physical activity, such as brisk walking, spread over 3 days within 1 week, with no more than 2 consecutive days without exercise.3 Increased physical activity, independent of weight loss, can reduce depressive symptoms and improve health-related quality of life in patients with T2DM.5 The Diabetes Prevention Program, a major multicenter research study, was designed to determine whether modest weight loss through physical activity and dietary changes or treatment with an oral diabetes drug, metformin, could prevent or delay the onset of e36
The Journal for Nurse Practitioners - JNP
T2DM in high-risk adults of various ages and ethnicities.8 Participants in the lifestyle intervention group received intensive counseling and support on effective diet and exercise strategies, aiming for a 7% weight loss and 150 minutes of exercise per week. The remaining 2 intervention groups included standard lifestyle recommendations plus either metformin or placebo. The cumulative incidence of diabetes throughout the average follow-up period of 2.8 years was lowest in the intensive lifestyle group compared with both the metformin and placebo groups.9 Although both the Look AHEAD Trial and the Diabetes Prevention Program of the National Institutes of Health provide evidence of the benefits of lifestyle interventions in patients with and at risk for T2DM, they have been criticized for being too costly and time-consuming to be scalable to the realworld clinical practice setting where patients may not be as highly motivated.10 Furthermore, patients with diabetes complain that there are too many “rules” to follow regarding diet and exercise and that they often feel confused and overwhelmed.11 It is essential that health care professionals provide simple, clear, and concise nutrition and physical activity advice to patients with T2DM.12 Patients must understand why physical activity is so important, how much is necessary to impact change, and the importance of consistent adherence (Table 1).13 SELF-EFFICACY: IMPROVING PATIENT OUTCOMES
Self-efficacy is a phenomenon of concern that is integrated into self-management behaviors directed at achieving weight loss and controlling diabetes.12 By briefly discussing the importance of weight loss, including the importance of physical activity during the clinic visit, and providing a simplified approach for the patient in writing, along with follow-up supportive care, self-efficacy is enhanced and optimal outcomes obtained.14 For example, the American Diabetes Association’s “Create Your Plate” and physical activity recommendations should be provided in written format and discussed during the office visit.3 A 5% weight loss goal should be calculated and discussed. Each patient should be given a written exercise prescription much like those used to prescribe medications. In addition, referrals to a certified Volume 13, Issue 1, January 2017
Table 1. Practice Pearls for Supporting T2DM Patients Through Lifestyle Change B
B
B
B
B
B
B
B
B
B
B
B
B
A 5% weight loss improves blood glucose control and reduces cardiovascular risk factors. Use terms “nutrition plan and physical activity” rather than “diet and exercise”-both components are important. Benefits are achieved by routine physical activity, independent of weight loss. Focus on behavior, not the scale. Physical activity helps the body use insulin more effectively and can decrease the need for additional diabetes medications. Check blood glucose levels frequently when implementing an exercise program. Check before and after physical activity to reinforce benefits. If taking insulin injections or insulin secretagogues, carry a quick source of carbohydrate when exercising. Physical activity not only lowers blood glucose levels during the activity session, but also throughout the day, even when the body is at rest. Break up 30-minute daily exercise session into several smaller segments if needed. Use a pedometer or fitness tracker to measure steps; establish a baseline, then increase steps gradually each week. Join a fitness class or recruit an exercise buddy to keep motivated. Set realistic goals and progress slowly to decrease injury risk. Refer to certified diabetes educators and exercise specialists when possible. PROVIDE remote support: check in on patients between visits; remember that patients “don’t care how much you know until they know how much you care.”
T2DM ¼ type 2 diabetes mellitus.
diabetes educator or a group fitness class should be considered. The internet provides an abundance of helpful information for patients with diabetes and these resources should be discussed (Table 2). Follow-up appointments should be scheduled to check weight and progress and to provide reinforcement when possible. Routine supportive phone calls to patients who are implementing lifestyle changes have been associated with improved outcomes, and the frequency of contact is directly related to the degree of adherence and weight loss. Eakin et al. also demonstrated that weight loss outcomes do not differ based on who provides the remote support. Trained medical assistants have been effectively utilized.15 www.npjournal.org
Table 2. Free Helpful Websites, Fitness, and Calorie Trackers B
B
B
B
B
B
B
American Diabetes Association www.diabetes.org/are-you-at-risk/ (under food and fitness tab) National Diabetes Education Program www.ndep.nih.gov US Centers for Disease Control and Prevention www.cdc.gov/diabetes/ Mayo Clinic www.mayoclinic.org/diseases-conditions/type-2-diabetes/ in-depth/diabetes-prevention/art-20047639 My Fitness Pal http://www.myfitnesspal.com/ WebMD http://www.webmd.com/diet/food-fitness-planner/ Fit Day http://www.everydayhealth.com/calorie-counter.aspx
CONCLUSION
The advanced practice nurse has the opportunity during each T2DM patient visit to emphasize the importance of physical activity and proper nutrition. By coordinating a simple office process combined with remote follow-up support and engaging the health care team, patients with T2DM are more likely to adhere to the recommended lifestyle interventions that can improve outcomes. References 1. US Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States. 2014. http:// www.cdc.gov/diabetes/pubs/statreports14/national-diabetes-report-web.pdf/. Accessed April 25, 2016. 2. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes [position statement]. Diabetes Care. 2013;36:3821-3842. 3. Cefalu WT, ed. American Diabetes Association Standards of Medical Care in Diabetes [special issue]. Diabetes Care. 2016;39(Suppl 1). 4. Banerjee ES, Gambler A, Fogleman C. Adding obesity to the problem list increases the rate of providers addressing obesity [faculty paper]. 2013. http:// www.jdc.jefferson.edu/. Accessed April 25, 2016. 5. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association joint position statement. Diabetes Care. 2010;33:e147-e167. 6. The Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369:145-154. 7. Franz MJ, Boucher JL, Rutten-Ramos S, van Wormer JL. Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. J Acad Nutr Dietetics. 2015;115:1447-1463. 8. National Institute of Health. Diabetes prevention program (DPP). 2013. http:// www.niddk.nih.gov/. Accessed April 25, 2016. 9. Knowler WC, Barrett-Conner E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403. 10. West DS, Krukowski RA. Translating the Look AHEAD Trial into action. Obesity. 2015;23:1738. 11. Fayyaz J. Nutrition and lifestyle modifications for diabetes patients. 2016. http://www.diabetesincontrol.com/. Accessed April 25, 2016.
The Journal for Nurse Practitioners - JNP
e37
12. Pender N, Murdaugh C, Parsons MA. Health Promotion in Nursing Practice. 6th ed. Upper Saddle River, NJ: Prentice Hall; 2010. 13. Delahanti LM. Improving diabetes outcomes through nutrition and lifestyle change—translating research to practice. October 24, 2015. http://touchend ocrinology.com/. Accessed April 25, 2016. 14. Celano CM, Beale EE, Moore SV, Wexler DJ, Huffman JC. Positive psychological characteristics in diabetes: a review. Curr Diabetes Rep. 2013;13:917-929. 15. Eakin EG, Reeves MM, Winkler E, et al. Six-month outcomes for Living Well with Diabetes: a randomized trial of a telephone-delivered weight loss and physical activity intervention to improve glycemic control. Ann Behav Med. 2013;46:193-203.
MSN, APRN, RD, CDE, can be reached at [email protected]. Ellen P. Moore, DNP, AGPCNP-BC, is an assistant professor of adult health nursing. Nancy is employed as a Senior Medical Liaison by Novo Nordisk, Inc. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Both authors are affiliated with the College of Nursing at the University of South Alabama in Mobile. Nancy Tarr Anderson,
1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.07.021
e38
The Journal for Nurse Practitioners - JNP
Volume 13, Issue 1, January 2017