From ATLANTA Medicine, Vol. 85, No. 4
Diabetes is a chronic, progressive disease that requires ongoing complex medical management, and the physician’s role extends well beyond glycemic management. A large body of evidence exists to support a range of interventions to improve diabetes outcomes, including Diabetes Education. Diabetes Education includes Diabetes Self-Management Education (DSME), Diabetes Self-Management Support (DSMS) and Medical Nutrition Therapy (MNT).
According to the American Diabetes Association’s (ADA) Clinical Practice Recommendations, “DSME is an essential element of diabetes care.” This fact has been recognized for more than 15 years by the Centers for Medicare and Medicaid Services as evidenced by their DSME reimbursement structure. Medicare reimburses for 10 hours of DSME and three hours of MNT during the first year of diagnosis or the first year under Medicare, if the education is delivered by an education center recognized by the ADA as meeting the National Standards for Diabetes Patient Education Programs.
Diabetes Self-Management Education (DSME)
The mission of diabetes self-management education and support (DSME/DSMS) and Medical Nutrition Therapy (MNT) is to help individuals with diabetes acquire the knowledge, skills, attitudes and behaviors needed to optimize both their self-management skills and their quality of life. As the field of diabetes education has developed over the last several decades, the profession has evolved from skill based to helping people with diabetes (PWD) gain the knowledge of behavior change that will help them live with an overall sense of improved well-being. Diabetes Education now includes knowledge and skill acquisition as well as problem-solving, goal setting and coping skills.
Preferably, education will be provided by Certified Diabetes Educators (CDEs). CDEs are experientially and educationally prepared to provide education, support and guidance through the healthcare system.
Comprehensive self-management education is best delivered as a combination of group classes and individual counseling. Groups provide support, socialization, the opportunity to learn from others and to garner support from their peers. Because diabetes management in integral to daily life, it is in some ways a family disease. Family members and significant others are encouraged to participate in all aspect of diabetes education.
In 2014, a “one-size fits all” approach to diabetes education is recognized as ineffective and will likely lead to a discouraged, unengaged patient. There are core elements of education, but each topic will be modified to the individual. Each patient must recognize the importance and relevance to their own life to improve the likelihood of adherence.
Below are the seven components of diabetes self-management as defined by the American Association of Diabetes Educators.
- Heathy Eating
- Being Active
- Taking Medications
- Problem Solving
- Healthy Coping
- Reducing Risk
Each of these topics is addressed with the individual at some point in the education process. How and when they are addressed is based on a thorough assessment by the CDE.
Oftentimes, in the outpatient setting, it is more appropriate to begin with problem solving or healthy coping to first prepare the patient for the unavoidable lifestyle changes that lie ahead. Knowledge of healthy eating and being active is of little use to the patient who is unable or unwilling to adapt his/her current lifestyle to incorporate this new knowledge. If a patient is newly diagnosed and insulin therapy is being initiated, monitoring and medication rise to the top of the list for immediate education, even before the patient has had time to developany coping skills for dealing with diabetes.
Diabetes Self-Management Support
DSME is effective and necessary for initial and ongoing diabetes care, but it is taking place in a healthcare setting. Actual self-management takes place in the patient’s home and community. Initial improvements in metabolic control have been found to diminish after about six months.
According to the National Standards for Diabetes Self-Management Education and Support, it is incumbent upon the diabetes educator to help the patient develop a plan for ongoing support. There are many types of support (behavioral, educational, psychological, etc.) and a variety of resources available.
The patient is likely to find support through membership in the American Diabetes Association, ongoing participation in follow-up programs, online communities and local community events as well as from their PCP.
Medical Nutrition Therapy
Nutrition therapy recommendations for people with diabetes have changed dramatically over the last 20 years. Gone are the days of confusing exchange lists, the “one size fits all” approach and the elimination of entire food groups. Today’s nutrition focuses on moving patients from a place of unhealthy eating to healthy eating. Meal planning takes into account the individuals’ metabolic goals, current treatment plan, likes and dislikes, their usual eating patterns, comorbidities, ethnicity, literacy and numeracy, income, support system, availability of healthy food and willingness to change. Based on the individual’s need, a number of approaches may by be used.
According to the latest Nutrition Therapy Guidelines published in 2013, the goal of MNT is “to promote and support healthful eating patterns, emphasizing a variety of nutrient dense foods in appropriate portion size, in order to improve overall health. …”
Highlights of the guidelines:
- There is no one meal plan or eating pattern that works universally for all people living with diabetes, nor is there an optimal mix of macronutrients.
- A variety of eating patterns are acceptable for the management of diabetes.
- Evidence is inconclusive for an ideal amount of carbohydrate intake.
- For people with DM and diabetic kidney disease (either micro or macroalbuminuria), reducing the amount of protein below usual intake is not recommended because it doesn’t alter glycemic measure, cardiovascular risk or the course of GFR decline.
The person living with diabetes must make multiple decisions each day that affect their diabetes management and consequently, their lives. These decisions are difficult even with DSME; without it, these uninformed decisions are likely to be far less than optimal.
Multiple studies have found that DSME is associated with improved diabetes knowledge, self-care behaviors, clinical outcomes and quality of life. In spite of its proven success, less than 50 percent of people living with diabetes have ever received any formal diabetes education. Findings from a study published in 2009 assessing the value of diabetes education indicate that diabetes education is associated with increased use of primary and preventive services and lower use of acute, inpatient hospital services.
Diabetes Education is associated with higher compliance rates for nearly all Healthcare Effectiveness Data and Information Set (HEDIS) measures. Conclusions reached by the studies are that the collaboration between diabetes educators and physicians yield positive clinical quality and cost savings. The cost savings are entirely related to reduced inpatient costs. Conversely, outpatient costs are higher due to increased utilization of primary care and pharmacy services. Over time, however, patients who use diabetes education services are more likely to receive recommended care and have lower average costs and better clinical outcomes.
To locate a Recognized Diabetes Education program near you, consult the American Diabetes Association’s website at www.diabetes.org.
- Nutrition Therapy Recommendations for the Management of Adults With Diabetes, Position Statement , Clinical Practice Recommendations, Diabetes Care, 37, Suppl1, January 2014.
- National Standards for Diabetes Self- Management Education and Support, Position Statement, Clinical Practice Recommendations, Diabetes Care, 37, Suppl1, January 2014.
- The Art and Science of Diabetes Self-Management Education, AADE, 2006.