Why Is the Best Diabetes Treatment Unavailable to Us?

Yes, diabetes education is by far the best treatment for diabetes, but why is this treatment so seldom taught to people with diabetes. This is a blog to answer a speech by Dr. Margaret Powers at ADA last month. Dr. Powers asked why access is so low. She is the current President of Health Care and Education at the American Diabetes Association and promotes diabetes self-management education, or DSME for diabetes patients.

Her speech could have been more effective if she would have declared that DSME was for people with type 1 diabetes. Then she could have correctly stated that only 7% of individuals with private insurance and 5% of those on Medicare receive this type of diabetes education. Those numbers are much lower than many would expect.

In her address, titled “If DSME Was a Pill, Would You Prescribe It?”, Dr. Powers argued that diabetes education is one of the best treatments available. She received a standing ovation from the packed ballroom, arguing that access to education must improve.

“Here are three highlights from her presentation:

1. If diabetes education were a medication, it would score highly across the official ADA/EASD diabetes management criteria: efficacy, hypoglycemia risk, weight loss, other side effects, and costs. Studies have shown diabetes education provides significant reductions in A1c and the risk of hypoglycemia, improves weight loss and other side effects, and is reimbursable by Medicare and most private insurers.

2. Diabetes education can increase healthcare savings. Dr. Powers pointed to one notable study (Health Care Use and Costs for Participants in a Diabetes Disease Management Program, United States, 2007-2008) that found the average annual hospital charges for 33,000 patients who received any education was 39% less than the yearly average for those who received no education.
3. Diabetes education provides psychological benefits that medications do not. Dr. Powers shared that education reduces diabetes distress and the often hidden emotional burdens that come with managing diabetes (see past diaTribe coverage on distress with insight from Dr. Bill Polonsky). Studies show diabetes education also improves quality of life, coping skills, knowledge, self-care behaviors, healthy food choices, and physical activity.”

The above is true, but much of this excludes people with type 2 diabetes. What Dr. Powers fails to talk about is lighting a fire under the members of the American Association of Diabetes Educators (AADE) and especially the insurance cartel to properly pay CDEs for their time if they actually teach education.

Many do little education and most use mandates, mantras, and dogma instead of education. Then when they also have a second title of registered dietitian, most of these dual titled CDEs switch to teaching nutrition and do no diabetes education. Our support groups knows this from first hand experience and they refuse to do any diabetes education when the insurance companies notify them that the session is for diabetes education only.

Most CDEs refuse to work with people with type 2 diabetes. Considering the numbers of CDEs that work full-time as CDEs, it is not surprising that there are so few CDEs available to work with people with type 2 diabetes.

We Are Upset at Others with Diabetes

Ben, Barry, Allen, Jason, and I have been in a discussion after reading a blog by another type 2. We agree with some of what she says about the CGM and insulin pump, but most of the rest, we are in full disagreement. We may be of thicker skin than most people with type 2 diabetes and we don't get too upset with people that make comments about not eating something and we just tell them off, if they become too bullying in nature.

In general, we look at most encounters as teaching moments and we sometimes are a bit aggressive in what we teach, but we never put a hand on anyone or physically threaten them. Three of us needed to leave a gathering for a birthday party recently, because of two people that thought they were diabetes experts, were just following us around making snide comments about the food we were eating and not eating. Education was not working and even suggesting that they leave us alone only caused them to become more annoying.

We felt better after leaving and called the host and before Allen even started to apologize, he said he was the one that needed to apologize as he was not aware of how they felt about people with diabetes and if he had, he would not have invited them. Allen thanked him and said if the party had been smaller, we might have acted differently.

None of our support group uses an insulin pump, except our honorary type 1 who is away at college. We don't use CGMs and therefore we don't have to answer questions about these that often, but occasionally we are asked why we don't use them. This is an easy question for us as Medicare will not authorize the use of continuous glucose monitors and won't pay for them.

Most of the people are very receptive to diabetes education, with the exception of the two above. We are not afraid to talk about diabetes and even the possible complications. Yes, we receive some of the classic dumb questions like, you ate too much sugar, but we use education to turn these into positives and often people are surprised and receptive as well.

We do have people that try to tell us what we should and should not eat, but they get the surprise when we explain why we won't eat what they suggest and then explain why we consume the foods we do. Most, but not all, really listen to what we are telling them and many ask good questions. Jason says he enjoys giving education when this happens. We agreed with him.

We are upset by several bloggers that nit-pick issues and are upset because people ask certain questions. We don't know why they are not able to turn these into positives and education. Maybe we are fortunate that we use each other to bounce ideas off and talk through difficult areas. We have plenty of experience doing this and being retired really helps us in knowing when to push education.

Tim stopped by as we discussing our disagreement with what a few bloggers have written and asked why we were so angry. Allen said because we don't understand them and why they are so thin skinned. Jason said we have each other to talk to and get prepared for some questions. He added that most of us have no problems of turning situations that they are complaining about into positives and good education.

Tim said that is why we try to have a positive attitude and use education whenever possible. He admitted that some people are not able to do this and have trouble in many situations because they are too busy and can't or won't take the time for education like we are able to do when the questioner is not in a hurry.

Allen said this is why we need to not become so upset with others that do not have some of the skills we have acquired.

Glycemic Diabetes Management

The American Association of Diabetes Educators has completed their annual meeting. It is not a surprise that most of the topics were about and for those with type 1 diabetes. After the ADA and the joint statement about education for all people with diabetes, I expected more topics for type 2 diabetes, but this did not happen. Yes, they can say that this topic was for all people with diabetes as they did include insulin and about 20 percent of people with type 2 diabetes do use insulin.

While educating hospital staffs about hyperglycemia is important, unless there is education about the use of oral medications, many with type 2 diabetes will continue be left out in the cold and receive little help when hospitalized.

This statement by the speaker Jane Jeffrie Seley, BC-ADM, CDE, CDTC, of New York-Presbyterian/Weill Cornell Medical Center leaves me wondering. “Inpatient glycemic management is best accomplished through interdisciplinary collaboration with physicians, NPs, PAs, RNs, RDs, diabetes educators and pharmacists. Errors can be greatly reduced by implementing system changes that make it easier to do the right thing. One example is auto-calculating the basal insulin dose based on weight and expected sensitivity to insulin instead of requiring prescribers to do the math.”

Best practices for improving inpatient glycemic control have been identified. There are many barriers to implementing them, Seley said. The biggest obstacle to coordinating and implementing successful strategies is the need for ongoing staff education. Successful strategies also involve policy changes, infrastructure adaptations and culture change. None of these will be effective until the hospital administrators and the hospital board of directors adopt them and make this known to those at all levels.

Many institutions across the United States have successfully launched glycemic control programs to improve inpatient insulin safety. One approach that appears to be highly effective is computerized order sets. This approach auto-populates the most recent weight gain into a dosing algorithm that gives a safe yet effective recommendation. This weight-based dosing can significantly reduce insulin dosing errors. Basal and bolus insulins are also listed in separate sections to avoid mixing up insulin types.

“Electronic medical record systems (EMRs) such as Sunrise and Epic have the capability to develop comprehensive insulin order sets and decision support tools such as a medical logic memory to remind prescribers to order basal insulin when a patient with type 1 diabetes is switched from prandial insulin to NPO status,” Seley told Endocrinology Advisor.

Currently, many hospitals still do not have comprehensive diabetes management programs in place. By having the AADE emphasize everything for type 1 diabetes patients, those patients with type 2 diabetes will continue to take a back seat in hospital diabetes management.

This means that type 2 diabetes patients will continue to need to champion their own cause and they will need to work harder to get what they need in diabetes management when they are in the hospital.

The other problem facing those with type 2 diabetes will be using insulin when they are in the hospital as most hospitals convert every patient to insulin use when they are an inpatient in the hospital. When it comes to food plans, type 2 patients will need to avoid asking for diabetes menus because the dietitians will overload the meals with carbohydrates instead of serving a meal that could be lower in carbohydrates.

More on AADE Activities

This not an easy topic, but I feel very confident that the article written by ANH-USA is on target. Where the problem in the proposed bill starts and needs change is - (a) IN GENERAL. —Section 1861(qq) of the Social Security Act (42 U.S.C. 1395x(qq)) is amended — (1) in paragraph (1), by striking ‘‘by a certified provider (as described in paragraph (2)(A)) in an outpatient setting’’ and inserting ‘‘in an outpatient setting by a certified diabetes educator (as defined in paragraph (3)) or by a certified provider (as described in paragraph (2)(A)).’’

There is more in the bill than the AADE website shows, but at this point I am not allowed to use it. One of my Senators has told me this and he is stating that at this time, the bill is not scheduled for committee and several attempts to bypass committee approval have met with defeat. Both my Senator and the attorney have stated that it is doubtful there will be action this year on H.R. 1726 and S. 1345.

On September 25, I met with an attorney who specializes in Social Security law. He feels that the landscape has changed. I had a printout of the two bills and he read and reread both and asked if I had any other versions available. After his arrival in Washington DC, and a meeting with several Senators and Representatives he called me on Saturday and stated that I could blog about what I knew, but that he could not say more at this time other than what is in the paragraph above.

The attorney did state that the bills currently on file confirm the article published by ANH-USA. If the wording is not changed, what the AADE told Diabetes Mine indicates they are deflecting the truth.

On Monday Oct 5, the attorney called again and stated he does agree that some wording needs to be added to fairly reimburse CDEs for their time on education. He thanked me for sending a copy of my blogs for Oct 3 and 5 and he is upset by the law in Kentucky and the charge of a misdemeanor for violating the law.

I will continue to correspond with both my senators and my representative to urge them to not approve the version currently on file. It is also no surprise that the members of #DiabetesMiseducation Coalition oppose these bills.

Founding members of #DiabetesMiseducation Coalition include:

• International Association for Health Coaches
• National Association of Nutrition Professionals
• Nutrition Therapy Association
• National Health Freedom Coalition
• University of Natural Health
• Maryland University of Integrative Health
• Alliance for Natural Health USA
• American School of Natural Health
• Institute for Transformational Nutrition

These are all organizations that would be excluded under the changes, plus a few more.

This is speculation on my part, but I think that with all the AADE members and officers that have both the CDE and RD (registered dietitian)(dual) titles may be behind this and the Academy of Nutrition and Dietetics is making its presence felt in the actions of the AADE.

I will make my feelings known about the dual titles and that something needs action to specify that if they are acting as CDEs then they need to clearly state this at the beginning of any education and not stray into nutrition as many are doing. I have spoken about this with one of my Senators and she agrees that it should be one and not both and they should only bill Medicare for one topic and not two as some have been accused of doing.

The Diabetes Education Follies – Part 4

Dr. Robert Ratner, chief scientific and medical officer for the ADA says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," in talking about oral medications. Dr. Ratner must be muttering to himself now that the joint statement by the American Diabetes Association (ADA), The American Association of Diabetes Educators (AADE), and The Academy of Nutrition and Dietetics (AND) focuses primarily on type 2 diabetes.

Dr. Ratner is the person many doctors quote when they won't recommend testing supplies and has enjoyed a position of high esteem among these physicians. Unfortunately, he will maintain this position because very few CDEs will be doing education for people with type 2 diabetes. The few that may receive education will be among the 20 to 25 percent of type 2 people using insulin in the larger metropolitan areas.

In the conversation with my cousin Beverly, she asked why CDEs do not teach DSME to type 2 people on oral medication. I explained about Dr. Ratner and his statement and that CDEs will generally not teach even self-monitoring of blood glucose (SMBG) which is part of diabetes self-management education. Her husband Tom asked how the support group knew so much about it. I said because we have done our research and learned this by working with each other. I took time to show him Alan Shanley's blogs on the same topic and he bookmarked his blog for reading later.

Beverly said there is a lot of need for CDEs is this area, and I agreed. I said with three community colleges and four colleges in about an hour's drive, there is a great need even among type 1 people. I said that there are several type 2 diabetes support groups, but I am not aware of any type 1 diabetes support groups. Tom admitted that he felt most comfortable with our group even with most being older them him. He said it is probably because you accept people as they are and are not afraid to take on any topic. I thanked him and said we have had some growing pains and the last three weeks have been nail-biting, but we survived and now the summer is here and we will not have any meetings until September.

I told Tom that depending on his schedule, we could get together a few times and discuss different issues, or we could do most of it via email. Beverly then dropped a bomb on both of us. She said that the hospital had asked her to earn her CDE certificate because the two nurses that had certificates were retiring later this fall and they would be without a CDE. She said one of them really hadn't done much CDE work for the last two years. She concluded that the hospital would pay for her additional education and testing.

I told Beverly that as long as she could put up with my bias and not be upset with the comments I might make, that she should go for it if she had interest in doing it. Beverly said she had talked with the other CDE cousin that was not talking to me and felt that it could be interesting. We talked about the second CDE organization and I had her read a few of my blogs about it. She said that the seemingly exclusive attitude was a problem for her as she would be teaching a lot to Tom and she liked the peer mentor or peer-to-peer worker ideas I had promoted. At that point, Tom suggested that they needed to leave and they did.

The Diabetes Education Follies – Part 2

A phrase that Brian Cohen enlightened me with during the last week is "treat to failure" protocol of medications and many other aspects of diabetes. Thank you, Brian! Now I won't blame every doctor, as there are some that will prescribe insulin early and will actually work with patients to improve their health. It is unfortunate that most doctors do treat to failure and then belittle their patients and accuse them of failing when it is the doctors that have failed us.

Now granted, we could have been more informed and insisted that the doctors prescribe insulin, but even with this, most will not and will continue to blame us for their failure as doctors. Yes, I am on a rant and for good reason. This goes back to the recent ADA Scientific Session in Boston, which I did not attend. The joint statement issued by the American Diabetes Association (ADA), The American Association of Diabetes Educators (AADE), and The Academy of Nutrition and Dietetics (AND) is touted as the end-all, one-size-fits-all solution for our diabetes education woes. Not likely, is my response.

With approximately 30 million type 2 diabetes patients and at most about 18,000 CDEs, I will use the number of CDEs from the AADE 2015 Fact Sheet which states there is more than 14,000 CDEs. This means that for this many patients each CDE could spend one hour with all but 103 patients using 14,000. Let me explain why this will not happen. There are many retired CDEs, many are only working part-time, others are writing books and on book signing tours, and this does not even count those not working as CDEs. Many CDEs will only work with type 1 patients and this leaves those with prediabetes unserved.

From the AADE fact sheet (a PDF file) 61 percent are nurses, 11 percent are pharmacists, 25 percent are dietitians, and 3 percent are other health professionals. This means that most are required to work in their primary profession to earn a living. As such, CDEs seldom work with any diabetes patients other than those with type 1 diabetes. I have learned more on my own and from a nurse practitioner than from a CDE. Even my non-CDE pharmacist has given me good diabetes information. I have a second cousin that is a CDE, but we don't talk anymore because of my bias.

In the area of Iowa where I live, there are a few CDEs, but mostly they are working for hospitals and a couple of diabetes clinics. There are a few others, but not in the immediate area. My wife surprisingly received a good deal of her education from a nurse/registered dietitian. This did take me by surprise and the education was much better than I had expected her to receive. Carbohydrates were not pushed, but actually discouraged. Most fat was also discouraged, but not totally.

The Diabetes Education Follies – Part 1

When I wrote this blog, I did use the word 'may' instead of 'will' and the more I am seeing and hearing, I am very happy that I was cautious. My wife does not believe me, but I overheard two women talking while waiting for my wife to get a few groceries. They did not notice I was sitting in the car and how they missed me, I do not know. Or they could have just figured he is elderly and won't understand what we are talking about.

First they was talking about the joint statement (a PDF file) issued by the American Diabetes Association (ADA), The American Association of Diabetes Educators (AADE), and The Academy of Nutrition and Dietetics (AND). One mentioned that as long as she does not receive any direction from the headquarters, she will be happy. The other said she was happy not taking referrals and felt that she always received the worst patients when she was taking them. She continued that now she did not have to worry about what she said, as she probably would be in disagreement with the doctor in his promotion of low to medium carb, medium fat to high fat.

The other woman said that most do not understand how important whole grains are and said some are saying they can get the micronutrients from other foods. The other agreed and said that without referrals she does not need to teach anything about diabetes and does not like the fat people with type 2 diabetes. Other people were coming to the cars and the two ended their conversation and got into their cars and left. I guess I am fortunate not to know either person, but I would have liked to have given them a lecture.

This seems to be the attitude of many that have the title of CDEs or RDs. None of them especially like type 2 diabetes patients and for me the feeling is mutual. I have known too many CDEs that are too limited in their background and don't want to be in a room with anyone having depression. In discussing this with my nurse cousin, Beverly, she said that she has had too many CDEs not be able to counsel patients with diabetes and other conditions because they lacked the education or experience.

We had a great discussion on Saturday, 13 June after our last meeting was canceled. She said she could understand why very few of us felt like having a meeting. So she and Tom stopped by to talk with me. When I mentioned the ACDE she asked what organization that was and I told her that it is the new Academy of Certified Diabetes Educators that became official the beginning of the new year. Tom pulled it up on his laptop and he said this does create problems for fulfilling the joint statement.

I said this also makes transparency more difficult as the numbers just are hard to arrive at. No organization is willing to disclose the membership numbers, retired members, members working in corporations and not doing mainstream diabetes education, or even members working part time.

Diabetes, Why Isn't Medicine Doing What It Should?

This was published in the British Journal of Diabetes and Vascular Disease. Some of you might like to read the article. In reading this, I have to wonder why the doctors in the United States cannot do anything right. For this, I think some of the blame belongs to the American Diabetes Association and the American Association of Clinical Endocrinologists. More of the blame belongs to the certified diabetes educators that do not educate, but use mandates and mantras.

Most of the blame has to fall on our medical insurance industry that listens to the Centers for Medicare and Medicaid Services (CMS), especially now that the insurance industry has learned how to sidestep the no prior exclusion part of the Affordable Care Act, by almost monthly changing the formulary from which they will reimburse for diabetes and other medications. Some insurance companies are doing exactly this and as a result, many people with diabetes are having a difficult time staying on one medication that is doing well for them. Some of the better companies are consistent in their formulary which is a good thing.

Diabetes care cannot prevent complications in every patient, but surely, doctors could prevent much of the tissue damage that happens in their patients' lives. Unlike in England, here the electronic medical records (EMRs) are very proprietary so that data on diabetes is impossible to obtain. Presently there is not a government agency that can collect data on a national basis to track diabetes and what works and what does not work. These same government agencies rely on information provided on a voluntary basis, which leaves gaping holes in the successes and adverse events that happen with diabetes medications.

The information collection and sharing needs to improve or more doctors will be leaving the practice of medicine. Yet, with the government not staying ahead of the progress, it could be another decade or more before EMRs become usable for the benefit of all – government, health care providers, and patients. Maybe then, the insurance industry will be forced into compliance.

The United States medical system relies on voluntary reporting for much of the data that the different government agencies rely on and report to the public. They cannot give accurate numbers of people at different ages with any type of diabetes. They presently use algorithms for most reporting which gives a very good estimate, but not an accurate number.

When people with diabetes are in the hospital, care has been improving, but still too many errors happen. The first is some nurses that don't understand the ratio for insulin to grams of carbohydrates for each individual. Then many doctors over use basal insulin and cause hypoglycemia. The other big problem is that the food plan for people with diabetes that is promoted by dietitians. It is overloaded with carbohydrates at a time our body needs fat and protein to aid healing, but the dietitians will not allow this.

I can understand that young doctors are less likely to choose Diabetes and Endocrinology as a career. It is a well-known fact that medical, nursing, and other healthcare students have little training in diabetes. There are not enough certified diabetes educators to serve the current diabetes population and with the projected increase, there is little effort to train more. One CDE organization says they are working on this, but when everything is tied up in committee, who is to know what intentions have priority. The other CDE organization is trying to put a strangle hold on who can practice as a CDE. Both organizations work with so few people with type 2 diabetes that I must wonder when they will force their members to stay away from mandates and mantras and start teaching diabetes education.

Until the Federal and State governments start requiring insurance to cover telemedicine, little growth in treating rural diabetes patients will happen. When I think of the diabetes education that could be taught by a form of telemedicine, it stinks that most healthcare providers will not use this. Then we have other medical professions working to stop telemedicine through state medical boards. This is protectionism rather than education at its worst.

Diabetes Training Programs Are Underused

Study leader Rui Li, who is a researcher with the National Center for Chronic Disease Prevention and Health Promotion of the Centers for Disease Control and Prevention in Atlanta told Reuters Health in an email that diabetes training programs are underused.  For me it is easy to understand why they are underused. To begin, there are too few qualified people to teach diabetes self-management education and training (DSME/T) and some of those that could do this are more enamored with using mandates and mantras than actually teaching.

The other problem with the general delivery of the article, because no distinction is made between type 1 and type 2 diabetes. Some reference is made about those on insulin taking the classes, but here again, we are left guessing. A comment is made that those in the North Central region of the U.S. and in metropolitan areas generally have a higher participation rate in DSME/T. This is understandable as there are more certified diabetes educators in metropolitan areas and less in rural areas and often none in many rural areas.

The curriculum of DSMT often includes information about diabetes disease process and treatment options; healthy lifestyle; blood glucose monitoring; preventing, detecting and treating diabetes complications; and developing personalized strategies for decision making

When DSME/T is done correctly, it helps patients improve glycemic management which in turn reduces the risk for diabetes complications, hospitalizations, and health care costs. The study looked at claims data for almost 100,000 adults with private insurance that were diagnosed with diabetes in 2009 to 2012. They found that less than seven percent participated in diabetes self-management education training. Although many people with diabetes know about the classes, a major issue was that individuals with diabetes may not be attending DSME/T once they are referred.

Researchers said better marketing efforts, focusing on education of doctors, patients, and support persons, are needed to publicize the DSME/T programs. Promotion of the message that DSME/T is the foundation of diabetes care might be helpful in promoting the programs. In my own opinion, certified diabetes educators need to improve their method of delivery, actually do education, and stop with the mandates and mantras and then more people might attend the education classes.

The researchers stated that everyone in the study had private insurance, but Medicare and Medicaid programs cover the cost of DSME/T. They said that 40 states mandated private insurance cover DSME/T, but there are private plans that still do not cover it and others that require a co-payment. A person not involved in the study, Kate Lorig, director of the Stanford Patient Education Research Center at Stanford School of Medicine in California, stated that the system for becoming a recognized diabetes program eligible for Medicare reimbursement is difficult and restrictive, plus it is expensive for a program to apply for and receive recognition.

Lorig thinks the way to boost the use of diabetes training programs is to lower the barriers to reimbursement faced by the health care providers who do the training.

Right now reimbursement is usually based on first having a billing code and then have the right content in the education and the right person giving it, she said.

We Need Self-Monitoring of Blood Glucose Taught

Many government agencies don't want this to happen. Chief among them is the US Dept of Agriculture (USDA) and the National Institute of Health (NIH). Other federal agencies also follow suit. This means that the Academy of Nutrition and Dietetics (AND), Certified Diabetes Educators, the American Diabetes Association (ADA), and the American Association of Clinical Endocrinologists (AACE) follow in lock step.

Naturally, the medical insurance industry follow the recommendations of the ADA and AACE. This means that we as patients have to work harder to obtain the test strips to know what our blood glucose levels are for us to manage our diabetes more effectively. Not knowing and operating in the dark is not the way effectively to manage diabetes.

Most blogs by CDEs and RDs never mention using our blood glucose meters with test strips because they don't want us to know how the different foods affect our blood glucose levels. This is part of the reason many people get discouraged and seldom test their blood glucose levels. This almost guarantees that diabetes will become progressive and that the complications will affect the quality of life. Self-Monitoring of Blood Glucose (SMBG) is shunned by CDEs and not talked about by RDs.

If it wasn't the leadership of the USDA and the blind following by AND, we might have reason to listen to a few that do teach SMBG. A few CDEs that do not have to worry about other CDEs looking over their shoulders, do teach Diabetes Self-Management Education (DSME) of which SMBG is a part. Many will not even teach DSME because they only believe in mandates and dogma and expect people blindly to follow. With the internet of today, this will only get worse as people learn what following these people will do to damage their health.

At least some people from the Duke University of Nursing at Durham, NC are doing something about what the CDEs are unwilling to accomplish. Read about this in a recent blog here. They are at least reviewing various methods of delivering diabetes self-management education (DSME) via the internet.

Then people with type 2 diabetes and those with prediabetes will have resources to learn about managing their diabetes. Then if the certified diabetes educators want to be exclusive and continue to make it more difficult to become a CDE and for their numbers to grow, we can ignore them and learn on the internet.

The unfortunate part of this is that it is just a study and there is no sources of DSME as such on the internet for easy access. This in one time I sincerely wish that people would put information on the Internet and then do a study instead of studying other studies. Yes, I was honestly thinking that there was a source of DSME on the Internet and that it could be available to all people with type 2 diabetes. While the study details were interesting, that is as far as it was taken.

Is Internet DSME Beneficial?

People with type 2 diabetes can benefit from diabetes self-management education (DSME) and it does not need to be taught by certified diabetes educators. If done correctly and people with type 2 diabetes will learn, the internet can be a great place to learn and sharpen diabetes management skills.

Self-management of diabetes, includes medication, nutrition (food plan), and lifestyle strategies. This is essential for optimal glycemic control and minimizing complications of the diabetes. Education to teach and improve self-management skills is critical for success and, when delivered via the Internet, can lead to better glycemic control and enhanced diabetes knowledge compared to usual care.

“Katherine Pereira, DNP, Beth Phillips, MSN, Constance Johnson, PhD, and Allison Vorderstrasse DNSc, Duke University School of Nursing (Durham, NC), review various methods of delivering diabetes education via the Internet and compare their effectiveness in improving diabetes-related outcomes. In the article "Internet Delivered Diabetes Self-Management Education: A Review," the authors describe some of the benefits of this method of educating patients, including ease of access and the ability to self-pace through the materials.”

DSME delivered via the Internet is effective at improving measures of glycemic control and diabetes knowledge compared with usual care. In addition, results demonstrate that improved eating habits and increased attendance at clinic appointments occur after the online DSME. The researchers discovered that engagement and usage of Internet materials waned over time. Interventions that included an element of interaction with healthcare providers were seen as attractive to participants.

Internet-delivered diabetes education has the added benefit of easier access for many individuals, and patients can self-pace themselves through materials. More research on the cost-benefits of Internet diabetes education and best methods to maintain patient engagement are needed, along with more studies assessing the long-term impact of Internet-delivered DSME.

I commend the individuals involved for realizing that the Internet could help with diabetes self-management education. The increasing numbers of people with diabetes is resulting in limited availability and access to diabetes care services. This includes access to certified diabetes educators. It is estimated that there is about one certified diabetes educator per 1,400 patients with diabetes in the United States. Because of the many factors limiting access to diabetes education, innovative delivery methods for DSME will need to be developed. One potential avenue that has been studied over the last decade for addressing the reach and accessibility of DSME is the use of Internet-based interventions.

DSME as a vital component of the care of patients with diabetes and the ADA recommends that DSME be provided for every patient at the time of diagnosis of diabetes and as needed thereafter. Despite these recommendations and the proven effectiveness of DSME, many patients with diabetes never receive DSME or any form of diabetes education.

If the future plans of the American Association of Diabetes Educators come to fruition, then there may be some hope. With the Academy of Certified Diabetes Educators staying with the exclusive idea that they are the only ones capable of providing diabetes education, we cannot expect any help from them.

The full copy of the report is available to read here until November 6 and then it goes behind a pay wall.

Insulin Type 2 Patients Over 80 Have More Hypoglycemia

You will have to excuse me if I seem to be on a rant. Headlines lately have been so misleading and down right sensationalized that I have thought to bypass the articles. In reading the articles further, I felt that rather than pass them by, maybe there were some lessons to be learned.

The headline for this one is rather tame, but still somewhat misleading - Hypoglycemia in Insulin-Treated Patients. The summary to get your attention says the following - “The elderly with diabetes now experience episodes of hypoglycemia more frequently than hyperglycemia.” Oh really! Since this is Dr. Andrew Geller, a medical officer at the Centers for Disease Control and Prevention (CDC), I had hoped to get some facts and perspective. Instead, it is mainly misinformation and highly misleading.

I admit that when I am told that this is an expert commentary, I become skeptical about the accuracy of what I am being told. Most of the time information to inform readers and explain what they are talking about is missing. General terms of severe hypoglycemia bother me. Does this mean anything below 50 mg/dl or a number below that? I will also think when they are talking hyperglycemia they are talking blood glucose levels above 180 mg/dl. Yet we are not informed and cannot therefore draw any accurate comparisons.

The only statement of substance comes in the fourth paragraph when Dr. Geller states, “Insulin-treated patients who are 80 years of age or older are more than twice as likely to go to the emergency department as patients between 45 and 64 years old. They were also 5 times more likely to be hospitalized. These findings underscore the importance of taking the risks for hypoglycemia into account when making decisions to prescribe or intensify insulin, especially among older adults.”

The expert missed an opportunity, in my opinion, to alert other doctors about checking for memory problems. Instead he just regurgitated what was supposedly reported about meal planning saying, “Meal planning is a well-recognized component of diabetes education. However, among the emergency department visits involving medication errors, a meal-related issue was the most common problem that brought patients to the emergency department.”

In the example he used of the patient injecting the short or rapid acting insulin and then forgetting to eat the meal timely, hypoglycemia caused them to go the emergency department. To me this means that memory problems should be investigated, but there is no mention of people over 80 often having these problems. Even distractions could be a problem, but instead meal planning is the only culprit.

This is what the expert says, “It's essential for diabetes patient education to continue emphasizing the importance of meal planning, and encourage patients to pay close attention to the insulin product that they administer.” Even I have made that mistake, but not often and normally (only three times in ten years) I inject the rapid acting too close to the injection site for the long acting. This causes the long acting to be converted to short acting and hypoglycemia did result. Fortunately, I recognized the problem as soon as I took the syringe out. Therefore, I had glucose tablets at the ready and started testing in 30 minutes. I tested about every 15 minutes and took glucose tablets accordingly until my glucose levels were at the proper level.

Granted the Medscape article was written for doctors, but as a patient, I feel that the information given was fair, but missed several points and alerts that should have been covered.

Intensive BG Monitoring Is Useful

Granted, I have changed the title from a question to a positive statement. I firmly believe that if the study had been properly set up and too many variables not tracked that should have been accounted for, the results could have been much more positive.  Patients were eligible if they were 35 to 75 years of age, had type 2 diabetes not treated with insulin, and HbA1c levels between 7% and 9%.


Yes, the “experts” said, “They were not convinced the extra cost of SMBG (self-monitoring of blood glucose) was worth the marginal added benefit. Also, this approach may not be generalizable outside of a clinical-trial setting, they said, noting that patients tend to tire of such self-monitoring in the long run.” None of the “experts” participated in the study. The problem with most studies of this type is that no education is given to the participants beyond a minimal amount.


Yes, some are taught more, but many are not given enough practice to have this become a habit. And this is a must to make the desire become important and make a person want to manage their diabetes. No, I do not think that intensive blood glucose monitoring needs to be done long-term, but at diagnosis, the first six months are critical to determine how the different foods or food combinations affect your blood glucose. This is one way to know which foods may need to be eliminated or reduced in the meal plan.


Then over time, you will need to up the testing intensity again when you add new to your meal plan foods, when you are ill, and when you are having problems for which you have no easy answers. What the “experts” do not realize is that by cutting to testing supplies over the years, people are less likely to maintain A1c's below 7.0% and this is the reason many people end up with progressive diabetes. People do need the education and encouragement to test more than twice per day, but testing for most people with type 2 diabetes should not require more than five times per day once a routine has been established.


Yes, there will be days when more testing may be required, and there may be days when less testing may suffice. With education and support, many people should be able to prevent their diabetes from becoming progressive. Yet, the “experts” don't care about the desires of patients and look at diabetes as progressive when it does not need to be. Because of the pronouncements of the “experts”, the insurance companies are happy to increase their profits by limiting the testing supplies for diabetes.


Please read about the study here and make your own analysis.

Diabetes Type 2 Resources

As much as I rail against the American Diabetes Association (ADA) and their guidelines, it is still important to know what they are advocating. Their guidelines are not safe for managing type 2 diabetes and using their guidelines will generally allow for the progression of diabetes to the complications. The ADA guidelines will not allow you to be a long-term healthy survivor with a long-term A1c of 7%. Yet this is what they promote. Even the American Association of Clinical Endocrinologists (AACE) and their guideline of an A1c of 6.5% is not ideal.

Considering that the A1c range for prediabetes is a reading of 5.7% to 6.4%, it would be prudent to have an A1c reading of less than 5.5% or lower. This is the reason I do not follow the teachings of the ADA. They seem quite willing to allow and advocate for people to allow for the progression of diabetes. It is also true that the advice given is to prevent doctors from being sued because they encouraged patients to work to have A1c's that put their patients in jeopardy of hypoglycemia. It is also true that most physicians do not stay current with even these poor guidelines so the patient is the one that pays the price with poorer health and the complications of diabetes.

With the above in mind, I feel that since the AACE has chosen to eliminate the page of type 2 diabetes resources, that as a blogger, I should start listing some of the resources that people with type 2 diabetes can use to start educating themselves. I have used and still review the listings even though I am not following their guidelines, but I still have hope that someday, they may improve. I also feel that because many physicians use these and insist that their patients follow them, we need to know where they are obtaining their numbers they throw at us. Even the endocrinologists seem to become upset when you get A1c's that are below 6.5%.

Some of this I know is because of my age and the lack of research including people over the age of 65. Researchers love to discriminate against us and are literally afraid of people over the age of 65 because we may have multiple health problems and failing cognition. Yet we are asked to take medications for which no research has been tested as to how we handle the medications and whether the medication may increase our cognitive decline. Almost 100 percent of studies and trials exclude persons over the age of 65. Rarely, and I mean rarely will you find a study that includes people up to the age of 70 or 75. Even the Food and Drug Administration does not seem concerned that people in the age group that will be heavily prescribed the medication are the ones excluded from the trials.

The following is a starter list for beginning your education: (Note: I have not listed them in any particular order as each has its positives and negatives.)

#1. www.diabetes.org This is the home page for the American Diabetes Association.

#2. http://www.cdc.gov/diabetes Centers for Disease Control and Prevention (CDC)

I find this more helpful for living with diabetes, but still follows many of the tenets of the ADA.

#3. http://ndep.nih.gov National Diabetes Education Program (NDEP), This site is a partnership of the National Institutes of Health (NIH), the CDC, and over 200 public and private organizations.

#4. http://www.nlm.nih.gov/medlineplus/diabetes.html Medline Plus, This is presented by the National Library of Medicine, and features many links to other helpful resources.

#5. http://diabetes.niddk.nih.gov National Diabetes Information Clearinghouse, This is presented by the National Institutes of Health (NIH), the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). My go to page in this site is http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez/index.aspx for the diabetes medications, both oral and insulin. See my blog here for other sites not on this list.

#6. http://www.everydayhealth.com/type2diabetes Everyday Health, This is generally an excellent site and at the same time a very aggravating site and pulling your cursor across the advertisements activates them and they are very intrusive and about the only way to avoid them is to restart the site and make sure that you keep the cursor away from them. It provides excellent news and information about diabetes and also provides links to MedPage Today’s trusted sister site.

One of the favorites on this site is this, http://www.everydayhealth.com/health- report/type-2-diabetes-control/why-your-type-2-diabetes-treatment-plan-is- unique.aspx

It talks about treatment being individualized and this is because each patient is unique. This is in conflict with the dogma of ADA which tries to make everything into a one-size- fits-all treatment plan.

#7. http://www.mayoclinic.com/health/diabetes/DS01121 The Mayo Clinic, and http://www.mayoclinic.com/health/diabetes/DS01121/TAB=expertblog

#8. http://blog.joslin.org/ The Joslin Diabetes Center Blog, and http://www.joslin.org/ The Joslin Diabetes Center

#9. http://www.medscape.com/resource/diabetes-type2 Medscape Today News, This requires a membership which is free to patients and the articles are often very interesting.

The above list is just a few of my sources that I enjoy reading. If you find them useful, you may wish to bookmark them to check them on a regular basis. Where the above sites have newsletters. I have subscribed to make sure I catch the latest news and research articles.

Being Asked to Speak to Another Group

The weekend after our meeting with the doctor, a group from another town about 20 miles distant, asked Tim and I to speak to them on insulin. Because of the doctor involved, we decided not to accept. We had a suspicion of what may have been behind this and as such, I was thankful I already had another commitment. Tim said he agreed with me and agreed we should not become involved in this since this doctor had the reputation of not wanting his patients on oral medications to test.

Tim sent the regrets explaining that I had a commitment and he would not do this by himself. Tim called me the next day saying something that was a total surprise. This doctor was asking for our help on insulin and testing for all patients with diabetes. He was realizing that he was in the wrong and felt that since our group was having so much success and had in fact converted several of his patients to testing, that he needed to learn about us and to get his patients started in testing. Tim added that he felt we should accept the challenge. I stated that I was committed to my meeting and that he should talk to the local doctor and maybe he could attend with him. I said that maybe Allen should go as well.

The following day, Tim called again to say the local doctor had called this doctor and said that he could come if allowed along with Allen and Tim. Tim said the doctor was happy with this and that yes, he wanted this very much. I said this was great. I then explained my commitment of a late afternoon medical appointment and a speaking engagement in the same town to a diabetes group that had been scheduled a month ago. Tim said this sounds good as three of us were involved in spreading the word. I suggested to Tim that Allen should raise the issue of vitamin and mineral testing on their way there so that if necessary, they could sound out the doctor before the meeting about raising this in the meeting as well. Tim said they would be traveling in the same car and he felt this was worth exploring. I said good, and that we should have a meeting the day following to cover both meetings and learn from each other. Tim agreed and asked about including the doctor and I thought why not and told Tim to explore this.

So the day following our meetings, we met after hours at the doctor's office and had a good discussion. This doctor had forgot there were three groups in our town and the size of the groups. The third group was now at six members and hoping to add more members. The group the local doctor led was now at 10 members and he felt that would be more in the coming months. The group that I had spoken to was 18 members attending and they were hoping to grow. The two doctors leading this group were confident the number would grow. Tim stated that the group they had met with was 9 members and that they were shocked that there were so many groups. The doctor commented that this doctor realized that his diabetes patients were being spread out in different groups and knew he was being called out about not testing. He just did not have the knowledge he should about diabetes. At first, he was angry at what was happening. Then he realized that it was him causing his own problem and he needed to learn.

The doctor from our town said this was good for several reasons. He continued that we were being asked to speak for the next several months and now that this doctor was aware of my blog, he wanted me to speak about that. Allen said he had been asked by several of the people there if I was for real and a few had read some of my blogs, but wanted to know if I meant what I was saying. Allen was happy to say that he was the one I had written about in the testing for B12 and Vitamin D and yes, I was interested in people and helping to educate people about diabetes.

The doctor had discussed vitamin and mineral testing with this doctor before hand and had given Allen permission to bring up the topic. He knew there were tests, but had not taken them seriously, so he would also need to learn more about them. The doctor with us said he will be working with this doctor over the next few months until he can get to some continuing education courses and felt that this was a step in the right direction. We all agreed and Tim said he was surprised that this doctor was actually transferring a few patients to our town that needed insulin. The local doctor confirmed this and said there was too much for him to learn for the patients he had and had asked if this would be possible.

This was why the doctor wanted us back for more talks to his group since we knew insulin and this might help make the transition for these patients easier. I commented that none of us were patients of his.  Our local doctor admitted to having only a couple type 2 patients on insulin, but he would look to us for assistance. I suggested that since the three of us all were at the same diabetes clinic, maybe he could talk to them as well. I pulled out the card I had and photocopied it for him. He looked at it and said thank you, as he was not aware of the clinic being so close. He knew of the one in another larger city south of us, but not this one. He then said that he recognized the doctor's name, but did not realize where he was practicing.

He said he had the permission to refer the patients to our group for education if we were willing. After a short discussion about location, he said he would rather use video and have them learn this mode so they could email us when they had questions and use video if needed at any time. We agreed that would work for us and I explained I was already doing this for several doctors in other states. The doctor wanted to learn more and asked if I would email the contact information so that he could check how this was working. When I said yes, he handed me a card of his with an email address on it. He explained that was the office email address and for this purpose only. Then he added his home email address and said this was the one Tim had. I said I also do some peer-to-peer work for the doctor on the card and he said good. That would give him a good reason to call him and asked other questions.

Then he surprised all three of us and thanked us for our being up front in our recent conversation. He had approached us with other motives and when we had been up front with him, he realized that we were more interested in education than taking patients from doctors. He as very appreciative in being asked to go to the other doctor and felt this was a real help in getting this doctor on the right path. He said this proved to him that we wanted to help more that hurt those doctors that were not as knowledgeable about diabetes. He said that talking about the diversity of topics that Allen and Tim had covered during the meeting even showed that doctor you were more interested in education than pushing patients away from him.

Allen then asked if he knew the doctor he named. He said yes and was there a problem. Allen said this was the doctor he had left because he would not test him for vitamin and mineral shortages. That if it had not been for Tim and I taking him to see their doctor and the tests proving he needed shots and vitamin and mineral supplements, he might not be alive today. The doctor said he would get this corrected if possible, but it may not be easy. He asked us if this is what we do when a doctor does not step up when asked. Allen said yes, and he had not planned to leave this doctor, but when the test were done and he was asked to surrender his license because he was severely deficient in Vitamin B12 and D, he knew that it was severe. He had not liked having his license taken, but after considering the alternative of having to surrender it to the state, and then having so much on record, he said that that made him feel better. He stated that when his levels were normal they had given his license back and that made him feel even better about it. Allen said that our aggressive nature after the doctor refused to do the tests probably saved his life and for that, he was grateful.

The doctor looked at us and said that you normally give the doctor the opportunity to make the mistake first. I said that the doctor they were now working with had a reputation and it was the pharmacist that sent them to another doctor. He said either way, we are not trying to divert patients away without cause, and we all said yes. He then said we could consult any time with him and if we had a doctor that refused to step up, to bring the patient to him and he would see that they were taken care of and what needed to be done. If we were correct in our thinking like we seemed to be, then he would attempt to get the situation corrected. He said even if this meant loosing a friend and colleague which he then told Allen that the doctor was that he had left. He said that yes, he was aware of his position on vitamins and minerals, but for him to let someone on metformin become that deficient was inexcusable and he agreed with our actions.

We concluded and went our way home. Yes, several emails followed, but we wanted to think more about what had transpired.

National Standards for DSME and DSMS - Part 5

Part 5 of 6 Parts

The eighth standard states, “The participant and instructor(s) will together develop a personalized follow-up plan for ongoing self-management support. The participant’s outcomes and goals and the plan for ongoing self-management support will be communicated to other members of the health care team.”

If the seventh standard is not completed, chances are this standard will go by the way also. The setting of goals is important for the patient and knowledge of the goals is also important for the healthcare team. This helps communications and lets all members of the healthcare team know what the others are working on. While DSME can be effective for short periods of time, it needs DSMS to reinforce the information and help the patient understand the importance of daily management away from the clinic or doctor's office.

While the primary responsibility for diabetes education belongs to the provider(s) of DSME, participants benefit by receiving reinforcement of content and behavioral goals from their entire health care team. It should not matter that the support (DSMS) comes from the trained peers, community health workers, or community-based programs. Because self-management takes place in participants’ daily lives and not in clinical or educational settings, patients should be assisted to formulate a plan to find community-based resources that may support their ongoing diabetes self-management.

Hopefully, DSME and DSMS providers will work with participants to identify such services and, when possible, track those that have been effective with patients, communicating with providers of community-based resources in order to better integrate them into patients’ overall care and ongoing support. This will be especially important in many rural areas where CDEs are in short supply and are not present on an every day basis.

The ninth standard states, “The provider(s) of DSME and DSMS will monitor whether participants are achieving their personal diabetes self-management goals and other outcome(s) as a way to evaluate the effectiveness of the educational intervention(s), using appropriate measurement techniques.”

For diabetes self-management to become the contributor to long-term, positive outcomes, the provider(s) of DSME and DSMS will need to assess each patient's personal self-management goals and the progress in achieving these goals. At least the AADE has their AADE7 list (found here) that outlines seven behavior changes that everyone needs to consider how they apply to them individually. Differences in behaviors, health beliefs, and culture as well as their emotional response to diabetes can have a significant impact on how participants understand and view their illness and engage in self-management. DSME providers who account for (properly assess) these differences when collaborating with participants on the design of personalized DSME or DSMS programs can improve participant outcomes.

Although this is not feasible yet, for people in rural areas may benefit in the future from telemedicine. At present, assessments of patients may be difficult in rural areas, but attempts must still be made. In some areas, guidelines from professional organizations or government agencies may prevail for time frames of this assessment.

The tenth standard states, “The provider(s) of DSME will measure the effectiveness of the education and support and look for ways to improve any identified gaps in services or service quality using a systematic review of process and outcome data.”

This could be a most important standard if this could be reviewed by a third party, but having a CDE review this is like letting the fox guard the chicken coop. Will the CDE be responsible? Will new advances in knowledge, treatment strategies, education strategies, psychosocial interventions, and the changing healthcare environment be incorporated into the ongoing education and support? If they are responsible, they will identify areas of improvement and make the necessary adjustments.

This should be in their mind at all times. “The Institute for Healthcare Improvement suggests three fundamental questions that should be answered by an improvement process:

1. What are we trying to accomplish?

2. How will we know a change is an improvement?

3. What changes can we make that will result in an improvement?

Once areas for improvement are identified, the DSME provider (CDE) must designate time lines and important milestones including data collection, analysis, and presentation of results. Process measures are often targeted to those processes that typically impact the most important outcomes and these must be properly assessed.

If you have read the standards, you should agree that this is putting a lot on the plate for the AADE and their CDEs. Unless they change their way of doing business, these standards will not become a reality for many people with diabetes and the people with prediabetes will continue to be ignored.

To this point, I have not mentioned the shortcomings of the ADA 2013 Guidelines. I can see many things left out of the ADA Guidelines that may impact the National Standards for Diabetes Self-Management Education and Support.

First, the ADA Guidelines totally ignore any mention of telemedicine, which could be an advantage for CDEs providing education and support for rural patients with diabetes. Second, while the group of patients who are at risk for diabetes are mentioned and some overall guidance is mentioned, this group of people need a name more descriptive than prediabetes and specific treatments need to be part of the guidelines. This could make it possible for the CDEs to be reimbursed for time spent on education in this group of patients. Under current ADA guidelines, reimbursements are very difficult for time spent on education, which discourages CDEs from even attempting education for this group.

 This information is from the National Standards for DSME and DSMS.

Group Diabetes Education One Time Not Good

Do you feel stressed, irritated, or downright angry when you read some of medical news headlines? I do and I have to read something else to get control of my run-a-way feelings. One of my favorite things to read is the introduction titled “Joyful?” by Will Ryan for his blogs. Then I go into my positive attitude routine and soon I am feeling like tackling the offending article again.

Such was the case of this article. I could see all sorts of negatives when I first read the title “Doubts Over Long Term Impact Of Group Education For Diabetes Patients.” I had visions of more studies like many of the rigged studies of self-monitoring of blood glucose (SMBG) where they purposely excluded anyone interested in SMBG. I could see this as a rigged study as well.

I feel better about the study after reading it completely. The first paragraph helped when it stated, “that there are no long term benefits from type 2 diabetes group education programs that only take place once.” That is totally understandable as most education is so loaded with information that most people do have trouble absorbing it in one session, to say nothing of retaining it all even with two sessions.

Then they raised some more questionable reasoning about how the study may have been pulled together. You also need to question what the level and detail of education may have been that would cause the following statement to be made - “Lifestyle and biomedical results at 3 years were the same with the intervention group and the control group, but the patients’ beliefs about illness seemed to have improved.”

I may be in total error, but if the patients in the intervention group were given quality education and reinforcement for the three years, they should have been much more efficient and knowledgeable in their management of their diabetes than the control group. Of course, the well-trained healthcare professionals may not have been quality instructors capable of educating the intervention group.

The article does quote from “an accompanying editorial that the outcome of the trial is discouraging and that we should focus again on the setting of appropriate targets by professionals who care for patients with diabetes and the patients themselves." This seems to nail the crux of the problem and properly put the results on the professionals who may have known the topic, but were not able to communicate with the patients.

This seems to be true in so many cases where the professionals may know the material, but lack the essential communication skills to assist patients.

The Challenges in Self-Management of Diabetes

Even though this is a small UK study, it could apply to any developed country and fit the conditions found in this study. This study highlights many of the problems people with diabetes face on a daily basis. These problems include prejudice, ignorance, and stereotyping not only by medical professionals, but also by the society in general.

It is no wonder that even with a trend toward having individuals manage their own health; individuals are ready and able to do this, but need more support. Even in the USA, many doctors are not supporting having individuals manage their diabetes. They often feel that education is wasted on uncaring individuals and many doctors use fear to force people to use oral medications when insulin may make the individuals task of managing their diabetes easier. Plus many in the medical profession feel that for type 2 diabetes, insulin should be the medication of last resort.

If you are a person with type 2 diabetes, you invest time and effort in managing your diabetes. This includes self-monitoring of your blood glucose levels, managing your medications, and carefully following a restricted diet. On top of this, there are the challenges of not offending relatives who think they have your interests at heart. Then we all have the food police that can be rude and offensive in their instructions about what you may consume. Lastly, we have the diabetes police that want to tell you when to test and want to know what the reading is so they can advise you. If you thought life was difficult, then consider the doctors that use fear to motivate you or doctors that belittle you for not having followed orders that were never that specific in the first place.

Since the doctor cannot be with you but only 15 to 30 minutes per appointment approximately four times per year, we must learn to manage our diabetes on a daily basis. This means that for over 99 percent of the time, you are on your own in managing your diabetes.

What is interesting about this study compared to many studies, is that the researchers shadowed the participants for several periods of two to five hours while they were living their lives. They took notes of how they managed their diabetes and the challenges they faced. Trisha Greenhalgh, Professor of Primary Health Care at Queen Mary, University of London, led the study. She said, “Until now there has been very little research on what people with diabetes do and how they cope when health professionals aren’t around. We have shown that self-management of diabetes is hard work both practically and emotionally, and that many but not all people with diabetes are skilful at undertaking and co-ordinating all the different tasks involved."

It is interesting that this part was examined and the participants praised for the efforts they put into managing diabetes. They did say that for those not managing their diabetes well, it was understandable since many were cycled in family responsibilities, some had other illnesses, and some were struggling financially, or even had a combination of these factors. The researchers correctly state that these factors can limit opportunities to manage diabetes and that those who could benefit the most from self-management were the ones least able to achieve it.

The researchers did acknowledge that more needs to be known about how patients manage diabetes outside the clinic. In reality, doctors should be more aware of the efforts patients expend to self-manage their diabetes and understand the many factors that will influence how successful patients are. Until doctors are better able to assess patients and their ability to manage their diabetes, little will be acknowledged in the value of education patients receive. Doctors will continue to resist educating patients.

Patients Lack Knowledge About Hypoglycemia

I have to take my hat off to the endocrinologists. They took a survey which puts them in a bad light and published it. Most organizations would have put this information through the shredder. Few in the medical profession are willing to to look problems in the eye and address it head on. Will they succeed? – that remains to be seen. There are a lot of hurdles to over come, the biggest is our medical insurance industry, Medicare, and the complexities of the new healthcare law.

Why are patients with diabetes unaware of hypoglycemia and what causes hypoglycemia? To me the broader implication is the lack of time by the medical community at large. Many primary care physicians and doctors in family medicine do not have the time or resources to educate patients. Many are in rural areas, small towns, and even many small city settings that do not have diabetes educators available. Many do not even have diabetes support groups to get support from.

Then add to this our medical insurance industry led by Medicare, that is cutting costs where ever possible and we have a situation ripe for failure. Many patients when they are newly diagnosed are in shock, causing very few to listen carefully to what they are being told by the doctor. Therefore, the doctors should be able to schedule another appointment shortly thereafter to do some education, but most of our insurance companies will not reimburse for the time.

The results of a survey conducted by the American College of Endocrinology therefore does not surprise me. This also shows just how reluctant our medical professionals are to recommend good web sites and help their patients get the information needed.  One site listed here has some information; however, there could be a better presentation and one that is more patient oriented and not so sterile and written for doctors. The information is presented in PDF files that can be downloaded and printed for reference.

The other part of the survey, not mentioned, is where the survey was taken. If it was taken from a cross sample, then good. Otherwise from only rural areas, or only large metropolitan areas could also greatly affect the outcome of the survey. National online surveys can be notoriously misleading and little reliance should be placed on them.

The only real part of this survey is that the numbers, regardless of the method of obtaining them, show that the USA has a serious problem and needs to find a way to educate people with diabetes. Read a doctors interpretation of the survey here and the news release here. The PDF file for low blood sugar is here and the PDF file for high blood sugar is here.