The needs of a person living with diabetes changes through the various transitions of life so the specific needs for self management and support. There is no cookie cutter. Federal legislation, HR 1840 and S 8143, expands the current diabetes self management training that is covered by Medicare. How does it do this?
Allows the initial 10 hours of DSMT during first year after diagnosis of diabetes to remain available until fully utilized. Life happens and it may not always be possible to utilize the 10 hours of training the first year.
Increases the hours of DSMT from 2 to 6 hours in subsequent years.
Allows DSMT and Medical Nutrition Therapy (MNT) to be provided on same day as currently they can not be provided on same day.
Excludes DSMT from Medicare Part B cost sharing and deductible requirements.
Permits physicians and non-physician practitioners who are not directly involved in managing an individual’s diabetes to refer them to DSMT services. For example, with this expansion, an emergency room provider could refer a person for diabetes education.
Allows DSMT to be provided in a community based location (i.e. community center, churches, etc). Meeting people where they are.
Establishes a 2 year demonstration of virtual DSMT. It is not always feasible for various reasons for a person to travel to a diabetes education center.
Whether you are a person living with diabetes, a caregiver, diabetes educator or healthcare professional, please contact your Congressman and Senators, and ask them to co-sponsor HR 1840 and S 814. Diabetes is a bipartisan issue.
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Imagine being informed that you have prediabetes,
gestational, Type 2 or Type 1 diabetes.
A range of thoughts flood the mind. What? How? Are you serious? Not me!
Now life takes a new twist. As a diabetes
educator who has walked the journey alongside persons with prediabetes,
gestational diabetes, Type 2 and Type 1, I have had the gut-wrenching
experience of seeing first-hand the anguish, grief and disappointment the
diagnosis can bring. Walking the journey
after being given one of these diagnoses is certainly not easy yet it does not
have to be travelled alone. The health
care team, peer support community, loved ones and friends are valuable resources
on the journey. Within the health care
team, a diabetes educator is a unique resource for those living with
prediabetes, gestational diabetes, Type 2 or Type 1 diabetes. You may be wondering, who is a diabetes
educator? What support and services can they provide? When is it appropriate to
see an educator?
Who? Diabetes education is considered a specialty with the diabetes educator having a primary health discipline (i.e. medicine, nursing, pharmacy). A Diabetes educator, from a discipline standpoint, can be a nurse, dietician, physician assistant, nurse practitioner, pharmacist, physician, physical therapist, social worker, clinical psychologist, exercise physiologist, health educator, occupational therapist, optometrist, podiatrist, and additional disciplines – what a variety! Diabetes educators can become Certified Diabetes Educators (CDE) through National Certification Board for Diabetes Educators (NCBDE).
What? Unfortunately, some folks imagine someone reading off
a list of dos and don’ts with a handout thrown in when they consider the “what”
of diabetes educator services. Wow, it is SO much more. Rather, a diabetes educator can provide a
broad spectrum of services for the person living with diabetes and prediabetes
and their caregivers. In terms of education, consider someone sitting down with
you to discuss your concerns and needs, developing a plan for self-managing
your diabetes in collaboration with you, and providing ongoing support in the
day to day of living with diabetes and prediabetes addressing the unique needs
and concerns at various times. Depending on the educator’s primary discipline,
clinical management of diabetes in collaboration with person living with diabetes
is also a service. Providing technology
support in terms of tools (continuous glucose monitors, insulin pumps, apps,
etc.), interpreting data to adjust treatment based on the data and driving
innovation with use of technology. Supporting the emotional well-being of the
whole person living with diabetes or prediabetes with a focus on behavioral
health. Ultimately, the diabetes
educator’s day to day activities may look different based on their primary
discipline yet all educators are advocates for person centered care and all
persons living with diabetes and prediabetes.
When? According to a joint statement from American Diabetes Association, American Association of Diabetes Educators and Academy of Nutrition and Dietetics, the four critical times for diabetes self-management education and support for person with Type 2 diabetes are at diagnosis; annually to assess education, nutrition and emotional needs; when complicating factors influence self-management, and when transitions in care occur. Complicating factors that influence self-management are health conditions (i.e. kidney disease, stroke, heart attack), complicated medication regimen, steroid therapy, limitations such as visual or physical impairments, anxiety, depression, limited access to food and financial limitations. Transitions in care goes beyond discharge from hospital back into community. Also change in medical care team, treatment change due to insurance coverage or age-related changes that impact cognition or ability to care for one’s self.
For persons living with Type 1 diabetes, diabetes educators are often housed within endocrinologist, some primary care offices or hospitals. Within this population, diabetes educators are often collaborating with person with Type 1 diabetes in technology such as insulin pumps in starting and adjusting pump therapy and continuous glucose monitor. Additionally, educators teach survival skills and provide vital ongoing support.
In terms of prediabetes, diabetes educator will work collaboratively with individuals to help facilitate behavior change in nutrition and physical activity to prevent the development of Type 2 diabetes. This collaboration often occurs in a group setting through Diabetes Prevention Programs which is a covered benefit for Medicare and many private insurance plans. The prevention programs are typically a year in length with focused sessions on aspects of behavioral change and vigorous ongoing support. As we all know, behavioral change can be a challenge for ALL of us.
I have provided several links below with more information on
critical times for diabetes self-management and support, diabetes certification
and diabetes prevention programs.
The Center for Disease Control (CDC) has lead the way in diabetes diabetes prevention particularly in developing the standards for diabetes prevention programs. The American Diabetes Association additionally has made got strides in their online diabetes screening tools. Lifestyle changes (nutritional and physical activity) are vital for diabetes prevention. I know this personally as I had prediabetes previously, made significant lifestyle changes and my glucose is within normal. I also know the struggle in making changes in nutrition and increasing physical activity. The recent findings from National Health Interview Survey for 2016 and 2017 found significant gaps in advice provision and referrals to diabetes prevention programs. Diabetes prevention programs are covered benefit of Medicare and many commercial insurance plans. Many state health departments also have diabetes prevention programs. To learn more about the survey results and diabetes prevention programs, please click below.
A rare potentially fatal infection of the perineum, fournier gangrene, is associated with sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Dr. Bersoff-Matcha published a review of 55 cases reported to FDA Adverse Event Reporting System through January 2019. A SGLT-2 inhibitor class label warning for fournier gangrene has been in place since mid 2018. To learn about this review, please click below.
Technology has transformed the face of diabetes care and the day to day of living with diabetes. Sharing data with family and caregivers is particularly important for pediatric patients. Freestyle Libre now has app, LibreLinkUp (for iPhone, iPad, iPod touch), that provides remote monitoring. Caregiver can specifically see the current value and trend. Unfortunately, this app is not available for Android devices. To learn more, please click below.
Who would have thought? An anti-malarial medication having potential as adjunctive treatment of type 2 diabetes. Yes, hydroxychloroquine (Plaquenil) provided similar hemoglobin A1c reduction as canagliflozin when added to vildagliptin and metformin in persons with diabetes unable to achieve glycemic goals. To learn more, please click on link below.
Historically we have been limited to metformin and/or insulin in adolescents and children with Type 2 diabetes. Unfortunately, metformin alone is often not enough to maintain control of glucose long term in children and adolescents with Type 2 diabetes. In recently published 52 week study, metformin with liraglutide reduced both hemoglobin A1c (primary outcome) and fasting glucose (secondary outcome) as compared to increase in hemoglobin A1c and fasting glucose with metformin alone. We can conclude that daily liraglutide with metformin does improve control of glucose over one year. To learn more, please click below.
Recently, Dr. Akshay Jain wrote an excellent article on how to guide persons with diabetes through fasting and feasting associated with Ramadan. He did an excellent job providing tips to avoid hypo- and hyperglycemia during this holiday. I highly encourage you to read this most useful article.
Much emphasis has been placed on cardiovascular benefits associated with particular diabetes medications. Until now, data supporting renal benefits of specific diabetes medications has been absent. CREDENCE trial which enrolled persons with diabetes and chronic kidney disease produced results revealing positive renal benefits of canagliflozin. Persons enrolled in the study were on a stable dose of medication blocking renin-angiotensin system. Positive results were also found in terms of cardiovascular outcomes. Interestingly no increased risk of amputation with canagliflozin was found in this study. Potential for novel renal indication can be anticipated for canagliflozin in the future. To learn more about this game changing study, please click below.
When it comes to diabetes, one size does not fit all. So it only makes sense that nutrition and eating for persons with diabetes is not one size fits all. The ADA has released updated nutrition recommendations. Most importantly, it is clear all persons with type 1 and 2 diabetes should be referred for medical nutrition therapy – a refresher on medical nutrition is so helpful. It only makes sense that these recommendations encourage non-starchy veggies, eating whole foods, limiting sugar intake and gives green light for low carb eating — some essentials for healthy eating. Assessing current dietary habits then customizing guidance on carbohydrate to achieve glycemic targets is key.
