Some of the key messages that need to be considered for patients are:

Diabetes educators on the diabetes health care team play an important, albeit underutilized, role in the care of patients with diabetes. The most optimistic estimate is that <30% of patients with diabetes receive any diabetes education at all. As diabetes continues to increase in the population and to consume greater and greater proportions of health care resources, the health care system will need to address this mismatch of patient need and service.

The UKPDS further underscored the opportunity to improve diabetes control and therefore outcomes for patients with diabetes. The role of diabetes educators can be an important part of achieving these improved outcomes efficiently. If diabetes education is to be delivered in a cost-effective manner, consistent messages should be developed and included in the curriculum and supported by the entire diabetes care team. The messages and educational strategies to deliver them are outlined below and summarized in Table 1.

Table 1. Messages From the UKPDS for Diabetes Educators Message What they need to know Educational strategies Diabetes is not a character flaw. (It is not your fault, but it is your responsibility.) 1. Pathophysiology of type 2 diabetes 2. Natural history of diabetes Establish a plan based on patient priorities. Use teaching tools, such as the Body Apron. Empower patients to take charge of diabetes control and outcomes.          Complications are not the consequence of diabetes. They are caused by high blood glucose and high blood pressure. (This sets the goals for control.) 1. Goals for control, HbA1c, and blood glucose monitoring levels 2. An individualized take-action level Set individual goals for control and take-action goals. Instruct patients on therapies employed to achieve goals, and let them know that progressive therapies may be needed to address this progressive disease.          Diabetes is a progressive disease and therefore needs ongoing, progressive education. 1. Diabetes is a progressive disease, and -cell function is lost over time regardless of therapy. 2. Insulin should be seen as another therapy option and not a failure on the part of patients. Diabetes education is a process, not an event. Education must be paced to address self-management skill training needs as they occur.

Maybe the observation that most people with type 2 diabetes are overweight has triggered the character-flaw label, or maybe the success of a minority of UKPDS patients (16% initially) in controlling their diabetes with diet and exercise has spawned the belief that all patients could do it if they tried hard enough.¹ Because diabetes responds to weight loss and exercise initially in a few people, many health care professionals have made the conceptual leap to the notion that type 2 diabetes is, therefore, a failure on the part of patients to follow the diet and exercise regimens that would prevent them from developing diabetes.

Shulman et al.² eloquently showed that nondiabetic people with a family history of diabetes had muscle glycogen synthesis rates about one-third of those for people with no family history of diabetes, regardless of whether they exercised. It is clear from their data that exercise improves muscle glycogen synthesis but that the initial defect of type 2 diabetes is not "lack of exercise."

As we continue to discover the complex metabolic processes that lead to type 2 diabetes, it is important to translate the research into ordinary language so that patients can fully understand the disease and the therapies that affect the condition. It is important to explain the development of type 2 diabetes and its progressive nature in a way that empowers rather than blames patients so that they can begin to accept treatment.

By continuing to characterize the condition as "a disease of sloth and gluttony," the health care system and society send the message to patients that everyone with type 2 diabetes could attain blood glucose control if they would only lose enough weight and exercise hard enough. At this time, evidence from the UKPDS does not support this. We will have to wait for the results from the Diabetes Prevention Program to see whether this approach will be more successful in an American trial.

Meanwhile, newly diagnosed or not-so-newly diagnosed people with type 2 diabetes need to start their journey with diabetes feeling empowered rather than downtrodden as they cope with the disease. Robert Anderson eloquently describes an approach of patient empowerment that attempts to "enhance the patients' ability to influence their own lives by helping them learn how to make informed choices about the care of their diabetes."³ Helping people understand that "type 2 diabetes is not your fault . . . but it is your responsibility" will set them on a course of empowerment so that they can manage their own condition.

This news will not make people who are new to diabetes happy, but it will arm them with an understanding of the essential nature of the disease so that they can be prepared to manage it. It also gives people permission to ask for appropriate treatment to achieve goal-range control of blood pressure and blood glucose.

Patients' psychological status will also affect their learning. Denial, depression, and anxiety can affect their willingness or ability to learn and participate in their care. The assessment should also include their social/cultural/religious environment, as well as an understanding of patients' literacy and willingness to participate in an educational program.

Using a learning needs assessment, diabetes educators can develop individualized educational plans to address patients' identified priorities while respecting their learning style. Using principles of adult learning, the educational process should be patient-directed, problem-oriented, and relevant to their lives.⁴ Additional techniques that engage learners in the disease management process include:

Topics that support patient understanding that diabetes is not a character flaw include an understanding of the pathophysiology of type 2 diabetes. A discussion of insulin resistance as the initial defect, the relative insulin deficiency that eventually occurs as the pancreas "poops out," and the excessive hepatic glucose production that is responsible for high fasting blood glucose levels helps patients understand the treatment strategies that will be employed to manage their condition.

Too many patients do not understand what their current blood pressure is, let alone what their blood pressure goal should be. The UKPDS illustrated the importance of a goal level of <130/85 mmHg in significantly improving stroke (44% reduction), diabetes-related endpoints (24% reduction), and death related to diabetes (32% reduction).⁶ As many as one-third of the patients required a combination of three medications to achieve the goal-range blood pressure.

The results from the blood glucose control levels established by the UKPDS must be shared with patients. The American Diabetes Association has long promoted a goal-level glycosylated hemoglobin (HbA_1c) of 7% or less and a take-action point of 8%. With the UKPDS conventional therapy group at a median HbA_1c of 7.9%,⁷ perhaps we should rethink the number at which we suggest that patients take action.

Goals for blood glucose control to achieve these levels are not so clear now that most of the glucose monitoring equipment has changed to plasma-referenced calibration. In our experience, most educators find that the recommendation of a pre-meal blood glucose of 80–120 mg/dl avoids confusion and continues to be appropriate for most people. Most diabetes educators would agree that what is needed is a consensus on the postprandial glucose goal. Many patients learn to manage the meal-planning aspect of their diabetes management plan with postprandial monitoring.

Once patients have established goals for control, they must be given the tools to achieve them. Diabetes educators must give them permission to ask for the appropriate therapies needed to achieve their goals. The UKPDS taught us that multiple therapies are required to achieve the blood pressure and blood glucose goals that deliver optimal outcomes. As patients begin to understand the goals for control, health care teams must be prepared to work collaboratively with empowered patients who will insist that they receive the multiple therapies and complex regimens needed to achieve these levels.

Too often, patients do not understand the progressive nature of type 2 diabetes or that -cells continue to "poop out" over time. This was shown in UKPDS 16,¹ with a comparison of conventional, sulfonylurea therapy, and metformin therapy in both nonobese and obese patients. The decline in -cell function was similar in all three approaches. This is important for patients to understand and underscores the need for progressive therapy to address this phenomenon.