additional adults in Florida have diabetes, but will not know it until confronted with one of as well as diabetes outpatient self-management training …
Patient Education
Diabetes Self-Management Education: The Key to Living Well with Diabetes
By Evelyn P Schumacher, MS, RD, CDE, Shands Jacksonville
Diabetes self-management education DSME is the foundation of care for all individuals with diabetes, including Type 1, Type 2, and Gestational Diabetes, who desire positive health-related outcomes1 Research has shown that the first steps of treatment for diabetes involve lifestyle changes–improving diet, decreasing weight, and exercising As a chronic illness, diabetes requires continuing medical care and patient selfmanagement education to prevent acute complications and reduce the risk of long-term complications2 Healthcare experts and business experts agree that documentation of providing educational services is a critical factor in clear communication as well as providing a solid basis on which to deliver quality diabetes education Diabetes self-management education is an integral part of diabetes care and is an evolving process To meet the challenge of developing standards in diabetes self-management education, a Task Force was developed The Task Force to Review and Revise the National Standards for Diabetes Self-Management
Education Programs was convened in October, 1998 and their final document was submitted for publication in the spring of 2000 The Task Force developed ten standards See Table 1 by which diabetes self-management education should be delivered1 These same standards also serve as the basis for obtaining American Diabetes Association ADA Recognition of Diabetes Education Programs ADA Program Recognition is essential in order for outpatient facilities to obtain reimbursement for DSME and for physicians to ensure that the program meets the national standards and is teaching all necessary content areas By referring patients to an ADA recognized program see Table 2, physicians and other healthcare providers can be sure that the standards set forth are being provided In addition to National Standards of Diabetes Self-Management Education, the State of Florida Agency for Health Care Administration has also published Diabetes Medical Practice Guidelines which were endorsed in October 2001 Nationwide there are 182 million Americans who have diabetes and approximately 1/3 of that number have not been diagnosed In Florida, over 1,000,000 persons have been diagnosed as having diabetes It is
estimated that approximately 300,000 additional adults in Florida have diabetes, but will not know it until confronted with one of its serious complications In 1996, the Florida legislature passed legislation requiring all insurance policies and HMO plans to provide coverage for all medically appropriate equipment and supplies as well as diabetes outpatient self-management training and educational services used to treat diabetes This was passed as a result of recognition of the devastating effects of diabetes when a comprehensive approach to treatment is not utilized3 It is important for healthcare providers in all disciplines to keep in mind that a critical element for the successful treatment of all patients with diabetes is participation in a comprehensive selfmanagement care and education program Continued patient and caregiver participation is required to meet the goals of ongoing support, maintenance, and modifications in treatment regimens and lifestyle changes
Among chronic health conditions, diabetes is unique: the majority of the treatment depends on selfmanagement
Among chronic health conditions, diabetes is unique because the majority of the treatment depends on
selfmanagement The management of diabetes has the patient as the primary team member and includes other members of the healthcare team, such as the physician, certified diabetes educator, registered dietitian, and others playing a vital role in the treatment of the disease The patients participation in a comprehensive outpatient self-management education program is critical to the treatment outcomes of diabetes4 Diabetes self-management education is crucial to the treatment and management of the disease during the initial onset and should be introduced within the first few weeks of diagnosis A minimum of ten to twelve hours of education should be provided to all patients within twelve months of the initial diagnosis The preferred method is that instruction be provided within twelve weeks of the initial diagnosis4 Since diabetes self-management is ever evolving, two hours of follow-up education may be needed annually and will vary depending on medical need The treating physician must document medical necessity of follow-up training
32 Spring 2005 Northeast Florida Medicine www DCMS online org
DSME starts with an assessment of individual education needs, which provides guidance in
planning teaching and learning strategies This will be the basis of the individual education and lifestyle plan Patient outcomes are monitored and the education and lifestyle plan is revised as necessary In order to be considered a quality diabetes self-management education program, it must provide comprehensive instruction in content areas that impact the target population and participants enrolled The teaching curriculum, strategies and education materials used should be appropriate for the audience and should consider the type and duration of diabetes, the age of the participants, cultural sensitivity and the individual learning abilities and special education needs Guidelines state that if a certified diabetes educator and licensed registered dietitian are not used, a written explanation must be present in the patients chart4 Florida Diabetes Medical Practice Guidelines state that based on demographics and needs of the target population, the selfmanagement education program should provide in-depth instruction in eight content areas see Table 3
Motivation
Diabetes is a chronic disease that is very demanding on a daily basis Due to the fact that approximately 99 of caring for
the disease is self-care; personal, family and other resources are critical for success in daily management5 Family members or significant others should be encouraged to attend DSME classes In order to motivate the person with diabetes to make necessary lifestyle changes, several areas need to be examined to determine whether the patient is ready and capable to make the required changes Some areas that need to be examined include: self-esteem; depression; clinical anxiety disorder; eating disorders; substance abuse and stress acute or chronic Each of these areas can have an impact on the ability of the person with diabetes to be motivated Motivation can be closely linked to self-esteem, depression and anxiety Self-esteem can be positively related to motivation; whereas, depression and anxiety can relate negatively Major depression affects approximately 20 of patients with diabetes and it severely hinders quality of life and other functional aspects, which include sleep patterns, sexual functioning, self-care behavior and metabolic control Depression has been associated with significant physical decline in patients with diabetes Based on a large-scale survey5 there was indication
that a significant proportion of depressed patients were not being diagnosed for the disorder Diabetes educators may be able to assist in the screening of depression in patients with diabetes using a series of simple questions Healthcare providers then have access to several standardized tests These tests can be used to screen for common psychiatric disorders, which may significantly impact the management of diabetes Available tests include the SF-36 scale; the Center for Epidemiological Studies Depression Scale, the Zung Depression Scale and the Hospital Anxiety and Depression Scale5 Available teaching and learning strategies should also be explored and considered for motivating learners Options include:
Brief lecture Discussion–more participatory and active Demonstration for teaching psychomotor or social skills Printed materials for reinforcement Audio visual aides to enhance presentation Role playing Games Computers to increase patient knowledge and increase problem-solving skills Patient examples
Most diabetes educators want patients to be motivated, involved, responsible and committed learners Education is much more rewarding for participants and educators if
participants are active and committed learners6 Providers can have a powerful impact on how a person with diabetes views the importance of self-management education By emphasizing the benefit of education, during the first visit of diagnosis and at all follow-up visits, they may motivate the individual to become actively involved in their own education process Learning needs to be continuous and cannot be a one-time event to motivate change It should also be thought of as an ongoing process similar to medical care that is lifelong for people with diabetes6 The time between diagnosis and the first educational visit is a crucial time psychologically During this time, efforts should be made to help guide the person with diabetes to the acceptance stage of their disease rather than focusing on overwhelming lifestyle changes A person who is still in the denial stage will not retain education points as well as one who has been provided information on coping skills One comprehensive website with extensive information relating to diabetes is available at wwwndepnihgov Diabetes educators, clinicians, patients and the public can find the information located there to be very helpful It also
provides a set of links to other diabetes websites as well Another extremely valuable site is wwwdiabetesorg , sponsored by the American Diabetes Association These two locations can be depended upon to provide accurate and reliable information
www DCMS online org
Northeast Florida Medicine
Spring 2005
33
Table 1
National standards for diabetes self-management education
Standard 1 Standard 2 Standard 3 Standard 4 Standard 5
Standard 6 Standard 7
Standard 8 Standard 9 Standard 10
The DSME entity will have documentation of its organizational structure, mission statement, and goals, and will recognize and support quality DSME as an integral component of diabetes care The DSME entity will determine its target population, assess educational needs, and identify the resources necessary to meet the self-management educational needs of the target populations An established system committee, governing board, advisory body involving professional staff and other stakeholders will participate annually in a planning and review process that includes data analysis and outcome measurements, and addresses community concerns The DSME entity will designate a coordinator with academic and/or
experiential preparation in program management and the care of individuals with chronic disease The coordinator will oversee the planning, implementation, and evalua tion of the DSME entity DSME will involve the interaction of the individual with diabetes with a multifaceted education instructional team, which may include a behaviorist, exercise physiologist, ophthalmologist, optometrist, pharmacist, physician, podiatrist, registered dietitian, registered nurse, other healthcare professionals, and paraprofessionals DSME instructors are collectively qualified to teach the content areas The instructional team must consist of at least a registered dietitian and a registered nurse Instructional staff must be Certified Diabetes Educators CDEs or have recent didactic and experiential preparation in education and diabetes management The DSME instructors will obtain regular continuing education in the areas of diabetes management; behavioral interventions; as well as teaching, learning and counseling skills A written curriculum, with criteria for successful learning outcomes, shall be available Assessed needs of the individual will determine which content areas are delivered Content areas
include: diabetes disease process; nutritional management; physical activity; medications; monitoring; acute complications; chronic complications; goal setting; psychosocial adjustment; preconception care; pregnancy and gestational diabetes management An individualized assessment, development of an education plan, and periodic reassessment between participant and instructors will direct the selection of appropriate educational materials and intervention There shall be documentation of the individuals assessment, education plan, intervention, evaluation, and follow-up in the permanent confidential education record Documentation also will provide evidence of collaboration among instructional staff, providers, and referral sources The DSME entity will utilize a continuous quality improvement process to evaluate the effectiveness of the education experience provided, and determine opportunities for improvement
Medical nutrition therapy
One of the most important aspects of diabetes education is medical nutrition therapy MNT MNT is the preferred term and replaces terms such as diet, diet therapy, and di 
etary management It involves the use of specific nutrition services to treat
illnesses or conditions and promotes individualized nutrition care7 Gone are the days of the ADA diet The American Diabetes Association no longer endorses one particular diet No single meal plan is appropriate for all individuals with diabetes It is not possible, nor is it appropriate, to provide a single teaching sheet that is able to address the complexities of the nutrition management of diabetes Upon the diagnosis of diabetes, nutrition is often the first concern that provokes interest in education and can be used as a motivational tool to encourage attendance in a diabetes self-management education program The goal of MNT, according to the American Association of Diabetes Educators, is to assist the person with diabetes in making self-directed behavior changes that will improve their overall health and the management of their diabetes7 There are different goals of diabetes MNT for specific populations and conditions8 which include: 1 Youth with Type 1 diabetes 2 Youth with Type 2 diabetes 3 Pregnant and lactating women 4 Prevention and treatment of acute complications of diabetes for those treated with oral agents and/or insulin 5 Prevention and treatment of chronic
complications associated with diabetes 6 Individuals at risk for diabetes
34
Spring 2005
Northeast Florida Medicine
www DCMS online org
Unfortunately, many misconceptions exist concerning nutrition and diabetes The best available evidence for nutrition principles and recommendations to treat and prevent diabetes must take into account individual circumstances, preferences, cultural and ethnic preferences They must include the person with diabetes in the decision-making process Because of the complexity of nutritional issues, it is recommended that a registered dietitian, knowledgeable and skilled in implementing nutrition therapy in diabetes management and education, be the team member providing medical nutrition therapy8 With regard to carbohydrate intake, clear evidence from well-conducted, generalized, randomized controlled trials is available and adequately powered to make the following recommendations8 for MNT: 1 Carbohydrate-containing foods from whole grains, fruits, vegetables, and low-fat milk should be included in a healthy diet 2 Total amount of carbohydrate in meals or snacks is more important than the source or type of carbohydrate 3 Sucrose-containing foods do
not need to be restrictedby people with diabetes, as sucrose does not increase glycemia to a greater extent than isocaloric amounts of starch They should, however, be used in conjunction with a meal plan and counted as sources of carbohydrates For those who use insulin and count carbohydrates, they need to be included in insulin calculations 4 Non-nutritive sweeteners are considered safe when used within the acceptable daily levels established by the FDA Expert consensus exists for the following nutrition guidelines:8 First, that carbohydrate and monounsaturated fat together should provide 60 to 70 of energy intake But keep in mind that the metabolic profile and need for weight loss should be considered when determining the monounsaturated fat content of the diet Second, sucrose and sucrose-containing foods should be eaten in the context of a healthy diet
Table 2
Diabetes self-management education content areas
Diabetes overview Medication
Definition and basic pathophysiology of diabetes, reasons for treatment and complications
Definition, types, proper storage and inspection of insulin; dose and times of taking insulin; injection site, correct techniques, syringe reuse,
insulin pump therapy; no diabetes medication to diabetes medication or oral medication to insulin; types of oral agents; relationship of glucose levels to exercise, food intake, stress and reasons for changes in insulin and oral agents; hypoglycemia and treatment; importance of family members and/or significant other knowing about insulin and use of glucagon; management of sick days Monitoring Definition, purpose and results of monitoring; equipment used in monitoring; correct method; and use of usual frequency and timing of monitoring; examples of suggested schedules for monitoring; results examples of sug gested adjustments for twice daily and other insulin regimens; common causes of monitoring errors; appropriate use and limitations of urine testing; appropriate ketone testing; studies or evolutions that may be necessary; laboratory-performed monitoring Nutrition Functions of energy nutrients and other nutrients including alcohol, timing and spacing of meals and snacks, label reading, shopping and preparation tips, sick day management, growth years, adjustment for exercise, pregnancy, lactation, weight management, and eating disorders Exercise and Need for pre-exercise medical
evaluation; use of proper footwear and other appropriate protective activity equipment; avoidance of extreme heat or cold; inspect feet and shoes daily after exercise; discontinuing exercise during periods of poor metabolic control Stress and Factors that cause emotional distress; importance of support system knowing about diabetes, how psycho-social they can support adherence to goals, and how to respond in emergencies; strategies to improve and adjustment maintain adherence to treatment plan; examples of coping skills and stress reduction techniques; benefits of individual, group and family counseling; depression and anxiety disorders; eating disorders among teenage girls and young women; effects of substance abuse Foot, skin, Incidence; causes; symptoms; role of monitoring; short and long term effects and complications; dental care treatment; preventive strategies and use of preventive foot wear; review of recommended schedule for evaluation Healthcare Importance of providing the support team with accurate telephone numbers of healthcare team systems and members and emergency services; identification and explanation of available community resources community for supplies,
services, information, and support groups; identifying and utilizing agencies within resources the community to assist with specific needs
www DCMS online org
Northeast Florida Medicine
Spring 2005
35
The typical average energy intake from protein in the meal plan is 15-20 This amount is fairly consistent across all ages throughout the life span and appears to be similar in the person with diabetes Less than 10 of caloric intake should come from saturated fat and those with LDL cholesterol 100 may benefit from reducing this amount to 7 Dietary cholesterol should remain below 300 mg per day and again those with LDL cholesterol 100 may benefit from an intake below 200 mg/day8 An excellent resource for more comprehensive nutrition guidelines can be found in Diabetes Care Volume 27 Supplement 1 of the American Diabetes Association Clinical Practice Recommendations 2004
DSME programs available in Northeast Florida
Baker County Health Department Diabetes Education Program Macclenny, FL 904- 259-6291 Memorial Medical Center Living Well With Diabetes Program Linda Strecker, RN , CDE 904-391-1541 Naval Hospital Jacksonville Health Education Dept/Diabetes Clinic Sharon Gladden RN,
BS, CDE 904-232-2751 srgladden@sarmednavymil NE Florida Endocrine Diabetes Associates, PA Diabetes Education Program 904-384-2240 Orange Park Medical Center Diabetes Treatment Center of OPMC Debbie Slocum, RD, CDE 904- 213-2545 Shands Wellness Education Center Diabetes Education Program Bobby Marcus, RN, BSN, CDE 904- 350-1118 Baptist Medical Center Diabetes Outpatient Education Program wwwe-baptisthealthcom 904- 202-2140 Nassau County Health Department Deborah S Jones, MSH, CDE 904- 225-9510 NE Florida Pediatric Diabetes Center at Wolfson Childrens Hospital 904- 202-8531 St Lukes Hospital Sara S Aton, RN, BSN, Diabetes Educator 904-296-3733 St Vincents Medical Center Diabetes and Nutrition Group Classes 904- 308-7534 Shands Jacksonville Diabetes Education Program Evelyn Schumacher, MS, RD, CDE or Christy Davis 904-244-2540
ADA-recognized programs Editors note: List complete at press time to the best of authors knowledge; please direct additions or corrections to us at editor@dcmsonlineorg
Self-monitoring of blood glucose
Another foundational topic of diabetes self-management is self-monitoring of blood glucose SMBG Blood glucose monitoring may help with the motivation of some
patients to proactively manage their diabetes and make the necessary lifestyle changes For those with Type 1 diabetes the current recommendations for SMBG are based on the research protocols of the Diabetes Control and Complication Trial as well as the Stockholm Diabetes Intervention Study The times of monitoring blood glucose in these trials included fasting, pre-meal and nighttime checks Patients with Type 1 diabetes should perform three or more checks per day, with the frequency and timing of the checks guided by individual needs and goals9 There have only been a few randomized controlled trials regarding SMBG in Type 2 diabetes and the evidence produced inconsistent results Those with Type 2 diabetes should be encouraged to use SMBG as a means of understanding and gaining control of their disease Understanding the impact of medication, food choices and physical activity is improved when SMBG is conducted on a regular basis as part of a daily routine Patients with Type 2 diabetes who use intensive insulin therapy or multiple daily injections may benefit from SMBG as frequently as those with Type 1 diabetes For women with gestational diabetes or those with diabetes complicated by
pregnancy, the evidence is extensive to support frequent SMBG for tight control and improved obstetrical outcomes9
Conclusion
Patients diagnosed with diabetes need to be provided the opportunity to attend diabetes self-management education classes in order to better understand their disease, the progression of the disease, and the importance of good control During the critical time following diagnosis, diabetes self-management education and the team offering the education can offer help, which may help motivate further education Providers should make the referral to diabetes education during the first visit in which diagnosis occurs Also, patients who were diagnosed with diabetes in the past–or who present as new patients to the provider and have never attended a diabetes education program–need to be offered the same opportunity Presently, very few barriers block the way of a motivated patient receiving DSME Most insurance companies now pay for DSME as a covered benefit For those patients who are either uninsured or underinsured, there are resources in Northeast Florida that will offer effective diabetes education at very low or no cost Diabetes self-management education, a
vital and integral part of diabetes care, is an evolving process The standards previously stated serve as a benchmark for patient education These standards are based on a combination of best available scientific evidence and best practice, if evidence is lacking As new research is completed, standards for an ongoing effective program can be improved and incorporated into diabetes education Diabetes education will always play a vital role in positive patient outcomes
36 Spring 2005 Northeast Florida Medicine
www DCMS online org
[References for Diabetes Self-Management Education: The Key to Living Well with Diabetes, continued from previous page]
1 American Diabetes Association: National standards for diabetes self-management education Position Statement Diabetes Care 27 Suppl 1; S143-150, 2004 2 American Diabetes Association: Standards of medical care in diabetes Position Statement Diabetes Care 27 Suppl 1;S15-35, 2004 3 State of Florida, Agency for Health Care Administration: Diabetes: Medical Practice Guidelines p 1, 2001 4 State of Florida, Agency for Health Care Administration: Diabetes: Medical Practice Guidelines p 27, 2001 5 Rubin RR, Napora JP Psychosocial assessment
In: A Core Curriculum for Diabetes Education: Diabetes education and program management 4t h ed Chicago: American Association of Diabetes Educators; 2001:23-59 6 Anderson RM Applied principles of teaching and learning In: A Core Curriculum for Diabetes Education: Diabetes education and program management 4t h ed Chicago: American Association of Diabetes Educators; 2001:1-18 7 Franz MJ Medical nutrition therapy for diabetes In: A Core Curriculum for Diabetes Education: Diabetes management therapies 4t h ed Chicago: American Association of Diabetes Educators; 2001:1-51 8 American Diabetes Association: Nutrition Principles and Recommendations in Diabetes Position Statement Diabetes Care 27 Suppl 1;S36-46, 2004 9 American Academy of Family Physicians Self-control: A physicians guide to blood glucose monitoring in the management of diabetes, 2004 Available from wwwaafporg/x25813xml
www DCMS online org
Northeast Florida Medicine
Spring 2005
37
Source:kerrdrug.com
