These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly.

Opportunity Is Knocking—The Time Is Now

Anne Daly, MS, RD, LD, CDE

Editor’s note: This article is adapted from the address Ms. Daly delivered as the American Diabetes Association Outstanding Educator in Diabetes for 1998.

I was drawn to diabetes because I wanted a field in which a dietitian could make a difference, one in which our role would be obvious. I began my career in the mid 1970s. Back then, laser surgery for retinopathy was a new treatment. Diabetic diets consisted of a fixed macronutrient composition delivered in three meals and snacks. Patients were told to never skip meals, always eat on time, and avoid sugar and concentrated sweets. The American Association of Diabetes Educators (AADE) was in its infancy. Most educators practiced solo, doing the best they could to provide quality diabetes care and education.

In the 1990s, the Diabetes Control and Complications Trial (DCCT) demonstrated that complications can be reduced by 40–70% and thus mandated that meticulous glycemic control should be the therapeutic goal of diabetes care. Now, diabetes management focuses on individualized goals and treatment regimens that include medical nutrition therapy (MNT), physical activity, medication, and monitoring. We practice with National Standards for Diabetes Education, and we urge health professionals to implement the peer-reviewed Standards of Medical Care for Patients With Diabetes Mellitus. Diabetes education is considered integral to diabetes care.

The DCCT showcased the critical role of a multidisciplinary, integrated diabetes team. Both ADA and AADE have endorsed team management as the ideal model for delivery of diabetes care. We all realize, however, that the person with diabetes is always the key team member.

But we live in an age of change. The ’90s will be remembered as an era of turbulence and a decade of reform for health care. Shifts in referral patterns and reimbursement policies have affected our jobs, and a plethora of new medications and technological advances have dramatically expanded our care options.

The diabetes population has changed, too. The number of Americans with diabetes has tripled in the past 30 years. The Centers for Disease Control and Prevention (CDC) and the World Health Organization predict that the number of people with diabetes worldwide will double by 2025. CDC is calling diabetes a "coming epidemic."

The stage is set for diabetes educators to play a leading role in diabetes care for the next century. But while opportunity is knocking, we face significant challenges.

Our first challenge is to promote the message of prevention. Diabetes is vastly underdiagnosed. Intervention comes too late, with the greatest expenditures for end-stage complications.

Three elements are necessary to label a disease a public health concern: high disease burden, rapid increase in disease burden, and fear. Diabetes clearly meets the first two criteria. But public fear of diabetes remains low. It is hoped that the National Diabetes Education Program (NDEP) will provide the missing element of public and physician awareness necessary and thus shift the paradigm of care.

NDEP will spread the word that diabetes is serious, common, costly, and controllable. We must work to promote NDEP’s message, participate in widespread screenings, and achieve earlier diagnosis.

Our second challenge is to increase access to comprehensive diabetes care. We must promote legislation to expand coverage to those who are uninsured and work to eliminate discrimination against people with diabetes. Lack of reimbursement for supplies and education has been a major barrier. Only 35% of patients with diabetes have had any diabetes education.¹

Practice patterns for MNT are even more ludicrous. Only 20% of adults with diabetes have seen a dietitian in the past year. In a community study in Michigan, the most frequently reported reason for patients not seeing a dietitian was that their physician did not refer them.² When patients were referred, more than 90% saw a dietitian. Patients treated with insulin are more likely to be referred to a dietitian than those treated by either diet only or oral therapy.

There is, however, a positive trend toward moving diabetes care and education out of hospitals and into ambulatory care, home health care, and community settings. Recent published membership data from the American Dietetic Association show that more than half of registered dietitians practice outside of inpatient/acute care settings, in areas such as community nutrition, consultation and business, education, and research.³

Our third challenge is to improve adherence to the Standards of Care. Why don’t physicians follow these standards? One reason is that they are not aware of them. Although the ADA has published these recommendations annually since 1989, the standards reach a small percentage of primary care physicians, the group that cares for 80% of people with diabetes.

Another reason is that diabetes is underemphasized in medical schools. The average second-year medical student receives only 3–8 hours of instruction on diabetes. Most medical residents’ experience with diabetes is limited to patients with complications severe enough to require hospitalization.⁴ Their experience working on a diabetes team or observing diabetes education in action is very limited.

Primary care providers practicing in managed care settings are usually strongly discouraged and even penalized for sending their patients anywhere for anything.

Meeting the standards of care will require major changes in the health care system and in patient self-care practices. Primary care physicians will have to become intimately involved with intensive therapy.

We also must educate managed care decision makers about what we have learned about behavior change. The diabetes model of care is a four-step process of assessment, goal setting, intervention, and evaluation.⁵ Behavior change involves skill development, which requires time and experience. One-time instructions are woefully inadequate. Follow-up is essential.

Our fourth challenge is to use innovative ways to better deliver our services. There is no one right way to provide diabetes education. Use whatever works. But take the time to set goals that can be systematically evaluated, and if things are not working, select different interventions.

We must maximize the role of the health care team, moving toward interdisciplinary care. An interdisciplinary team model demands a shift toward shared leadership, with mutual problem solving, open communication, and team cohesiveness. There is no room for turf battles.

Our job is also to develop more efficient office systems to identify patients with diabetes, monitor progress toward care goals, increase team involvement, and allow for systematic follow-up.

We must prevent spending effort and dollars on ineffective programs and products. We must offer guidance about how to spend our resources.

Our fifth challenge is to conduct outcome studies to document that we can improve diabetes control and that the result is cost savings. Policy makers demand proof that treatment is effective and efficient and that it favorably affects health outcomes. This is not unreasonable, and we must be up to the task. Each of us must make time to extract data from our databases and to conduct original, rigorous, scientific studies. That may mean we need more training or we need to raise funds to support these studies.

Medical care for patients with diabetes costs an estimated $100 billion per year, accounting for 10–15% of all health care costs and 25% of all Medicare costs in the United States. This means more than $11,000/ patient/year, which is three times the cost for nondiabetic patients.⁶

We have documented the cost-effectiveness of intensive management for type 1 and type 2 diabetes,^7,8 medical nutrition therapy,⁹ preconception glycemic control,¹⁰ and routine screening for diabetic retinopathy¹¹ and nephropathy,¹² as well as the costs of poor glycemic control.¹³ But Medicare, private insurers, and managed care organizations are still reluctant to provide coverage for preventive strategies. They have chosen to be penny wise and pound foolish by focusing on the additional costs of covering preventive services in the here and now, while ignoring the real bottom line: the long-term cost savings of prevention. We must effectively organize the cost-savings data already collected and use it consistently to get those who fund medical services to look at the big picture.

So now let me present my strategies.

Our first strategy must be to create partnerships with others who share our goals. We are now organized and strategically positioned to work together. Most of us are masters at networking.

We must nurture a partnership between endocrinologists and general practitioners. The current antagonistic attitude is tragic, since our primary concern should be for the welfare of our patients. Our office offers a diabetes practicum for nurse practitioners and physician assistants to observe our diabetes care team in action. As a result, we know more about who is interested in diabetes, what their skill and knowledge level is, and how we can better serve as a resource for them.

We need even more collaboration among the ADA, AADE, and the American Dietetic Association. The members of the Diabetes Care and Education Practice Group of the American Dietetic Association, which won the 1997 American Diabetes Association Charles H. Best Award for Distinguished Service in the Cause of Diabetes, are proud of the role we have played in getting both staff and volunteers of these associations together.

We must reach out to our communities and encourage new and diverse players. We must increase our efforts directed at special populations.We must have a shared sense of ownership that says diabetes care is our commitment to the community.

We must create opportunities for career development, and we must create relationships of trust, respect, and commitment. Knowing and caring about people is what diabetes educators do best.

A second strategy is to expand our roles. We must be willing to move out of our comfort zones. We must be experts not only in basic science and clinical care, but also in epidemiology, accounting, management, health policy, and politics. We must lobby in Washington, D.C., and on a grassroots level and work with the media to promote Medicare legislation, state insurance legislation, and federal research spending. And we must work to find more resources and to advise on how financial resources should be spent.

The ADA exemplifies how health care professionals can be involved. Last year, Davida Kruger, a certified nurse practitioner from Detroit, Mich., raised more than $1 million for the ADA Research Foundation. Maria Romero, RN, received an Advocacy Award for her efforts to get diabetes legislation passed in New Mexico. Health care professionals have been front and center in all 23 of the states that have passed such legislation so far.

Despite our successes, we need to do more. A third strategy is to become involved in our professional organizations. Join the ADA professional section, the AADE, and, if you are a registered dietitian, the Diabetes Care and Education Practice Group. These organizations offer innumerable opportunities at the local, state, and national levels.

As we move into the next millenium, opportunity is knocking for diabetes educators. The increasing number of people with diabetes, the increasing awareness of the seriousness of the disease, and the increasing level of third-party payment for diabetes care and education signal an emerging marketplace in which diabetes educators can be leaders. I urge you to be entrepreneurial in studying your practice setting and finding opportunities. Become involved. The time is now to improve diabetes care and education and to find your own niche in this exciting field.

References

¹Coonrod BA, Betschart J, Harris MI: Frequency and determinants of diabetes patient education among adults in the U.S. population. Diabetes Care 17:852-58, 1994.

²Arnold MS, Stepien CJ, Hess GE, Hiss RG: Guidelines vs. practice in the delivery of diabetes nutrition care. J Am Diet Assoc 93:34-39, 1993.

³Bryk JA, Kornblum TK: Report of the 1995 membership database of the American Dietetic Association. J Am Diet Assoc 97:197-203, 1997.

⁴Hiss RG, Davis WK: Intensified glycemic control and changes in training and continuing education of physicians. Diabetes Rev 2:310-21, 1994.

⁵Diabetes Care and Education, A Practice Group of The American Dietetic Association, Tinker LF, Heins JM, Holler H: Commentary & translation: 1994 nutrition recommendations for diabetes. J Am Diet Assoc 94:507-11, 1994.

⁶Roman SH, Harris MI: Management of diabetes mellitus from a public health perspective. Endocrinol Metab Clin North Am 26:443-74, 1997.

⁷Herman WH, Dasbach EJ, Songer TJ, Thompson DE, Crofford OB: Assessing the impact of intensive insulin therapy on the health-care system. Diabetes Rev 2:384-88, 1994.

⁹Ohkubbo Y, Kishikawa H, Araki E, Miyata T, Isami S, Motoyoshi S, Kojima Y, Furuyoshi N, Shichira M: Intensive therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract 28:103-17, 1995.

⁹Franz MJ, Splett PL, Monk A, Barry B, McClain K, Weaver T, Upham P, Bergenstal R, Mazze RS: Cost effectiveness of medical nutrition therapy provided by dietitians for persons with non-insulin-dependent mellitus. J Am Diet Assoc 95:1018-24, 1995.

¹⁰Kitzmiller J, Gavin LA, Gin GD, Jovanovich-Peterson, L, Main EK, Sigrang WD: Preconception care of diabetes: glycemic control prevents congenital anomalies. JAMA 265:731-36, 1991.

¹¹Rand LI: Financial implications of implementing standards of care for diabetic eye disease. Diabetes Care 15 (Suppl 1):32-35, 1992.

¹²Siegel, JE, Kroleski AS, Warram JH, Weinstein MC: Cost effectiveness of screening and early treatment of nephropathy in patients with insulin dependent diabetes mellitus. J Am Soc Nephrol 3 (Suppl 4): S111-19, 1992.

¹³Gilmer TP, O’Connor PJ, Manning WG, Rush WA: The cost to health plans of poor glycemic control. Diabetes Care 20:1847-53, 1997.

Anne Daly, MS, RD, LD, CDE, is director of nutrition and diabetes education at the Springfield Diabetes & Endocrine Center in Springfield, Ill.

Return to Issue Contents

Copyright © 1999 American Diabetes Association

Last updated: 2/99
For Technical Issues contact webmaster@diabetes.org