Mary M Austin , RD, MA, CDEImmediate Past President, American Association of Diabetes Educators

Originally printed in:
» US Endocrine Review 2005 - September 2005

Diabetes Management a report by Mary M Austin, RD, MA, CDE Immediate Past President, American Association of Diabetes Educators Diabetes educators are healthcare professionals such as nurses, dietitians, pharmacists, exercise specialists, physicians, and social workers, who specialize in diabetes education and who make a significant contribution to the care and management of persons with diabetes.The specialty of diabetes education has advanced to be based increasingly on evidence and focussed on achieving desired outcomes.The emphasis on outcomes-based interventions comes from both the National Standards for Diabetes Self-Management Education,1 which emphasizes program outcomes, and the Standards for Outcomes Measurement of Diabetes Self-Management Education2 of the American Association of Diabetes Educators, which focusses on individual patient outcomes as well as the reporting of aggregate patient data. Diabetes is a complex disease requiring the adoption of numerous skills and behaviors in order for the disease to be managed successfully.

Diabetes education seeks to reach these goals: • provide knowledge and skill training; • facilitate problem-solving; • help individuals identify barriers; • motivate for lifestyle adaptation; and • develop coping skills to achieve goals.

The unique and valued outcome of diabetes education is behavior change. Diabetes educators recognize the value of facilitating behavior change that can positively affect clinical indicators and lead to improved health status. Figure 1 outlines the process in which improved health outcomes are realized.

Diabetes educators help patients with diabetes acquire the knowledge and skills necessary to manage their disease on a daily basis. However, knowledge alone will not lead to improved clinical outcomes and the resulting long-term outcome of improved health—behavior change—is also necessary for clinical indicators to improve. Measurable behavior change is the unique outcome of working with a diabetes educator.

Diabetes self-management education begins with an assessment and development of an instructional plan, one that is heavily based on the patient’s goals, interests, abilities, and needs. The diabetes educator helps the person with diabetes to identify, prioritize, and work toward individualized goals—behavioral changes that lead to better self-management skills and self-care behaviors, better health and disease management, improved quality of life, and independence in lifestyle choices.As the multi-layered plan is implemented, the diabetes educator is able not only to provide digestible amounts of information and instruction but to assess the patient’s progress in learning, skill development, and behavior change.

Measuring, monitoring, and managing outcomes information helps the educator plan appropriate follow-up interventions, informs decision-making, and drives healthcare delivery.Tools include demonstration, observation, role playing, patient self-report, and analysis of data, records, and validated instruments.This article will examine the self-care behaviors a patient must foster.

Behavior 1: Healthy Eating • Improved metabolic control, a reduced risk of complications, and improved health are possible when attention is given to healthy eating and use of individualized meal plans.

Those affected by diabetes need to learn how food affects diabetes control and overall health.Healthy eating and an individualized meal plan should be part of the care plan for all persons with diabetes, regardless of medication regimen. Patients often struggle with family eating patterns and food preferences, poor eating habits and emotions, and limited choices. In recognition of the importance of an individualized meal plan and its impact on diabetes outcomes, medical nutrition therapy (MNT) provided by a registered dietitian (RD) is recommended in the standards of care for people with diabetes.1 Importance of Self-care Behaviors in Diabetes Management Mary Austin, RD, MA, CDE, is Immediate Past-President of the American Association of Diabetes Educators (AADE), a multi- disciplinary organization of more than 11,000 healthcare professionals dedicated to providing and advocating for quality diabetes self- management training (DSMT). She is President of The Austin Group and is also active with the American Dietetics Association, which honored her with its Distinguished Service Award in 1999. She is employed by Henry Ford Health System in Detroit, Michigan, as the research dietitian for the National Institutes of Health (NIH)-funded Action to Control Cardiovascular Risks of Diabetes (ACCORD) research trial. Ms Austin can be contacted on MAustinRD@aol.com 16 B USINESS BRIEFING: US ENDOCRINE REVIEW 2005 1. Mensing C, Boucher J, Cypress M et al., “National standards for diabetes self-management education”, Diabetes Care (2000);23: pp. 682–689.

2. Mulcahy K, Maryniuk M, Peeples M et al. (for the American Association of Diabetes Educators), “Standards for outcomes measurement of diabetes self-management education (position statement)”, Diabetes Educ. (Sep/Oct 2003);29: pp. 804–816.

18 B USINESS BRIEFING: US ENDOCRINE REVIEW 2005 Diabetes Management Working collaboratively, MNT recommendations are supported by the other members of the diabetes healthcare team. It is primarily the RD diabetes educator who assists the patient in gaining knowledge about the effect of food on blood glucose, sources of carbohydrates and fat, appropriate meal planning, and resources to assist in making food choices. Skills taught include reading labels, planning and preparing meals, and measuring foods for portion control, fat control, and carbohydrate counting.

Collaboratively, the diabetes educator and patient address barriers to healthier eating such as environmental triggers and emotional, financial, and cultural factors. At appropriate intervals, the diabetes educator evaluates relevant factors, such as the type of food choices made, amount eaten, alcohol intake, effect of food on glucose readings, special situations, and problem solving.

Behavior 2: Being Active • With appropriate levels of physical activity, both those at risk for and those with diabetes can improve glycemic control or reduce the risk of developing type 2 diabetes, improve body mass index, enhance weight loss, help control lipids and blood pressure, and reduce stress. Physical activity helps to increase overall mobility and improve cardiovascular function, glucose utilization, strength, and body composition.

Increased physical activity is often a primary goal of self-management education. Even small changes are considered beneficial. With the help of a diabetes educator, the person with diabetes can be guided to incorporate appropriate physical activity into daily life.

Twenty to 30 minutes of moderate aerobic activity three to five times a week is considered optimal for achieving greatest metabolic benefit. However, the patient and the diabetes educator define an appropriate and achievable goal together.

The educator assists the patient in gaining knowledge about appropriate types of physical activity and the proper duration, intensity, safety precautions, and any special considerations for the activities of choice.

Skills taught include developing an appropriate activity plan and balancing food and medication with the activity level. The diabetes educator and the patient collaborate to address barriers, such as physical, environmental, psychological, and time limitations. At appropriate intervals, the diabetes educator evaluates the patient’s progress toward goals, and revises goals as related to frequency, duration, and intensity.

Behavior 3: Taking Medication • Effective drug therapy in combination with lifestyle interventions can lower blood glucose levels, reduce the risk for diabetes complications, and produce other clinical benefits.

For all patients with type 1 and most patients with type 2 diabetes, pharmacotherapy is either initially required or eventually needed to achieve desired glucose treatment goals. All too often, poor medication regimen adherence and other inappropriate medication-taking behaviors interfere with achieving expected and desired therapeutic outcomes.A diabetes educator helps patients to acquire and improve their knowledge and skills that allow competent, confident, and safe use of medications. Diabetes educators recommend appropriate medication delivery systems, drug regimen aids, and innovative, situation-specific techniques to improve or simplify medication regimens. Some diabetes educators, depending on established work-site protocols and credentials, prescribe or adjust diabetes medications as well.

The educator assists the patient in gaining knowledge about each medication, including its action, side effects, efficacy, toxicity, prescribed dosage, appropriate timing and frequency of administration, effect of missed and delayed doses, and instructions for storage, travel, and safety. Skills taught include: • proper preparation, technique, and administration; • safe handling and disposal of equipment; • the ability to recognize, treat, and prevent side effects and low blood glucose levels; • adjusting for delayed or missed doses; and • other aspects of medical education as described by Figure 1: Diabetes Self-management Education Outcomes Continuum Knowledge skills AADE 7™ Core outcome measures Healthy eating Being active Taking medication Monitoring BG Problem-solving Healthy coping Reducing risk Clinical indicators A1c BP Lipids Weight Process measures Eye exam Foot exam Other measures Smoking cessation ASA use Pre-pregnancy counselling Improvement in Overall health status Quality of life Days lost from work/school Diabetes complications Healthcare costs Learning Behavior change Clinical improvement Improved health status Immediate Intermediate Post-intermediate Long-term Adapted from Peeples M, Mulcahy K,Tommy D,Weaver T,“The conceptual framework of the national diabetes education outcomes system (NDEOS). Diabetes Educator (2001);27: pp. 547–562.

Importance of Self-care Behaviors in Diabetes Management B USINESS BRIEFING: US ENDOCRINE REVIEW 2005 19 the US Pharmacopoeia Medication Counseling Behaviors Guidelines3 and other resources.

Collaboratively, the diabetes educator and the patient address barriers that may include issues of dexterity, vision, cognitive and math skills, fear of needles, and embarrassment in following medication regimens in public, and financial constraints. At appropriate intervals, the diabetes educator evaluates the patient’s progress in learning about prescribed medications and skill in taking them most effectively, including accuracy of dosing and adherence to the regimen.

Behavior 4: Monitoring • Self-monitoring of blood glucose (SMBG) provides patients with the information needed to assess how food, physical activity, and medications affect their blood glucose levels. SMBG is not the only monitoring behavior that may be required of the person with diabetes: monitoring of blood pressure, urine ketones, and weight are examples of other monitoring behaviors that may be required.

Self-monitoring connects the individual to the outcome—their own blood glucose level, blood pressure, urine ketones, and weight.

Daily SMBG is important for all people with diabetes, but especially important for those taking medications that may produce hypoglycemia. Monitoring of urine ketones is also appropriate at times. The diabetes educator is skilled in interpreting SMBG results so the patient and care team can evaluate the response to therapy and determine whether glycemic targets are being met.The educator can greatly assist the patient in establishing individualized glycemic goals with appropriate timing and frequencies. Diabetes educators provide much-needed help in incorporating SMBG into daily life and using the results to improve glycemic control and make adjustments in eating, activity, and medications.

The educator assists the patient in gaining knowledge about equipment choice and selection, timing and frequency of testing, target values, interpretation and use of results, and proper sharps disposal. Skills taught include learning accurate and reliable methods and techniques, use and care of equipment, and recording of blood glucose values. Collaboratively, educator and patient address barriers such as the physical, financial, emotional, and cognitive issues.At appropriate intervals, the diabetes educator evaluates the frequency and schedule of monitoring, schedule adherence, and planned and unplanned testing.

Behavior 5: Problem-solving • Quick and appropriate responses are crucial in emergency situations. Improved overall glycemic control and wellbeing also result from effective problem-solving.

On any given day, a hyperglycemic or hypoglycemic episode or a sick day will require rapid, informed decisions about food, activity, and medications. Even after decades of living with the disease, stability is never fully attained because the disease is progressive, chronic complications emerge, life situations change, and the patient is aging. Managing a treatment regimen for a chronic illness requires on-going problem-solving and coping skills, continued acquisition of information and skill, and behavior modification, even for well informed self-managers. The diabetes educator helps individuals learn to recognize and respond appropriately to situations with serious health consequences—most notably, hypoglycemia,hyperglycemia,and sick days.The educator helps the person set individualized blood glucose goals to optimize glycemic control and emphasize wellbeing.With guidance from a diabetes educator, a person with diabetes transitions from being totally reliant on a prescribed regimen to being a reasonably independent functioning self-manager.

The educator assists the patient in gaining knowledge about sick day management and hypoglycemia and 3. United States Pharmacopoeia (USP) medication counseling behaviors guidelines, in: Klasco R K (ed), USP Drug Information for the Healthcare Professional Vol 1. Greenwood Village, Colo:Micromedex (2002).

Diabetes is a complex disease requiring the adoption of numerous skills and behaviors in order for the disease to be managed successfully.

hyperglycemia, including signs, symptoms, causes, treatment, guidelines, safety precautions, and prevention strategies. Skills taught include treatment for hypoglycemia, glucagon administration, and use of blood glucose data to determine appropriate actions regarding food, activity, and medication. Collaboratively, the diabetes educator and patient address barriers such as physical, emotional, cognitive, and financial obstacles, and develop coping strategies. At appropriate intervals, the diabetes educator evaluates blood glucose testing results, the number of blood glucose tests per month requiring assistance,and the number of times ketones are tested (adjustments made to food, activity, and medication; days absent from work, school, and activities; and contacts with healthcare providers for problem resolution).

Behavior 6: Healthy Coping • Health status and quality of life are affected by psychosocial factors. Psychological distress directly affects health and indirectly influences self-care behaviors. When motivation is dampened, the commitments required for effective self-care are difficult to maintain. When barriers seem insurmountable,good intentions alone cannot sustain the behavior. Coping becomes difficult and self- management deteriorates.

An important part of the diabetes educator’s work is identifying the individual’s confidence and conviction to change behavior, then helping to set achievable behavioral goals and guiding the patient through multiple obstacles. The work entails more than providing information and teaching self-care skills; the diabetes educator helps elicit and reinforce the patient’s motivation to change behavior and supports the change.The educator listens for issues of concern to the individual and helps set goals that are consistent with the participant’s circumstances, comfort level, and ability to cope with the requirements of managing a chronic disease. Goals effectively met are collaboratively set, which builds self-efficacy.

The educator assists the patient in gaining knowledge about the benefits of treatment and the large role of self-care, realizing that motivation is an internal function and everyone has problems to be worked through, and, therefore, creating awareness and recognition of psychosocial distress. Skills taught include goal-setting, problem-solving, coping strategies, and self-efficacy. Collaboratively, educator and patient address barriers such as physical, financial, and emotional impediments (e.g. a lack of support).

At appropriate intervals, the diabetes educator evaluates depression scores, stress, quality of life, functional measurement, treatment self-efficacy, and patient empowerment.

Behavior 7: Reducing Risks • Effective risk-reduction behaviors reduce diabetes complications and maximize health and quality of life.

The patient must be vigilant in monitoring disease indicators and be actively engaged in preventing complications.An important part of self-care is learning to understand, seek, and regularly obtain an array of preventive services. The diabetes educator works to develop and increase self-initiated risk-reduction behaviors. The educator seeks first to help patients understand the importance of the preventive services that reduce complications.To optimize the frequency of visits, the educator personalizes a schedule of visits to each provider; thus, the patient gains not only information, but a self-directed goal and expectations about the care team.

Figure 2: Behavior Change as an Intermediate Outcome in Improved Health Status Learning Knowledge Skill acquisition Immediate outcomes Intermediate outcomes Post-intermediate outcomesBehaviorchange Improved clinical indicators Long-term outcomes Improved health status Diabetes Management B USINESS BRIEFING: US ENDOCRINE REVIEW 2005 20 Measuring, monitoring, and managing outcomes information helps the educator plan appropriate follow-up interventions, informs decision-making, and drives healthcare delivery.