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Teaching Diabetes Self-Management
Teaching diabetes self-management effectively requires addressing complex patient needs over a lifetime. Public schools face challenges in providing diabetes education due to limited resources, competing priorities, and lack of specialized training for teachers. Diabetes self-management education (DSME) programs have more flexibility but struggle with variable funding, voluntary attendance, and lack of age-appropriate curricula and differentiated instruction. Both systems would benefit from identifying best practices for efficiently educating the growing number of students and patients needing diabetes self-management skills.
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Teaching Diabetes Self-Management
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- 2. Juvenile Diabetes Maturity-onsetDiabetes Insulin dependent Non-insulin dependent Diabetes (IDD) Diabetes (NIDD) Type I Diabetes Type II Diabetes Type 1 Diabetes Type 2 Diabetes Types of Diabetes 2
- 3. Types of Diabetes(DM) Type 1 β-cell destruction; autoimmune disease; complete lack of insulin 5-10% of total patients Type 2 β-cell dysfunction and insulin resistance Gestational β-cell dysfunction and insulin resistance during pregnancy 3
- 4. There is nosuch thing as Borderline Diabetes or a “Touch of Diabetes.” Pre-diabetes is a diagnosis. 4
- 5. There is nosuch thing as Borderline Diabetes or a “Touch of Diabetes.” 5 Pre-diabetes
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- 7. Diabetes is acardiovascular disease. The Burden of Diabetes in Delaware, 2009. Diabetes Prevention and Control Program People with diabetes are twice as likely to suffer a heart attack or stroke compared to people without diabetes. 7
- 8. Natural history of Type 2 diabetes Adapted from InternationalDiabetes Center (IDC), Minneapolis, Minnesota. Obesity Diabetes Uncontrolled Hyperglycemia 50 100 150 200 250 300 350 50 100 150 200 250 Glucose (mg/dL) Relative Function(%) -10 -5 0 diagnosis 5 10 15 20 25 30 Years of Diabetes Post-meal Glucose Fasting Glucose Insulin Resistance Insulin Level β-cell Failure Insulin ResistanceFamily History Prediabetes
- 9. Why teach self-management? • PaXents must control their blood glucose (BG) levels to avoid complicaXons • Controlling BG is a complex, 24/7, life-long task – Rx’s change, increase; may not insure opXmal BG control – Changes in dietary intake & physical acXvity necessary – And more… • So much to learn and do (or stop doing) 9
- 10. PWD’s* everyday reality * “Diabetic” isnot a noun 10
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- 14. As teacher educators, howwould you recommend teaching diabetes self-management? Here’s the challenge 14
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- 16. $673 billion 16 Federal State District Federal State District Regulation s Public schools 3 million 50million InstrucXon Learning tasks Private schools 0.4 mil teachers 5.4 mil pupils Diabetes educa7on??
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- 18. Average $/person2 4,310 7,925 10,694 (2008) 11,093 6,745 1,834 466 Context: Exploding costs 12011 Digest of Educa*on Sta*s*cs, Table 28, h=p://nces.ed.gov/programs/digest/d11/tables/dt11_028.asp. Table reports costs in current dollars, so inflaXon calculator used to bring up to 2010 values. 22011 Digest of Educa*on Sta*s*cs, Table 194, h=p://nces.ed.gov/programs/digest/d11/tables/dt11_194.asp 3 Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. Used inflaXon calculator to translate dollars from 2007 to 2010. h=p://www.usinflaXoncalculator.com 4Huang et al. (2009) Using clinical informaXon to project federal health care spending. Health Affairs, 28(5), w978-990. Includes Type 2 only. Type 1 would be <5% of cases but higher per capita cost. InflaXon calculator used to change costs from 2007 to 2010 dollars. 5 No 2020-2030 projecXons available for school expenditures, so just repeated % GDP from the prior 2 decades. Used Huang et al.’s total diabetes medical costs for 2007, together with 2007 GDP, to calculate costs as % GDP in that year (1.1%). Then used their Exhibit 3 (projected real growth as mulXple of GDP) to esXmate % GDP in 2010, 2020, and 2030. No data prior to 2007, so just took line toward asymtope . Students in public schools , K-12 Diabetes cases, diagnosed and undiagnosed Total expenditures (2010 dollars) Medical costs only (2010 dollars) 1970 1990 2010 20073 20204 Total $ (billions)1 270 415 673 Type 1 11 Type 2 111 Undiag 12 Pre-diab 27 Total 160 Type 2 237 0.0 5.0 10.0 15.0 1970 1980 1990 2000 2010 2020 2030 Costs as % of GDP1,5 Diabetes Schools 18
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- 20. 3,567 4,775 6,387 8,198 11,722 3,837 3,714 4,561 5,077 5,359 9,061 5,425 1,374 2,327 2,063 4,763 579 210 305 391 488 537 716 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 18–34 35–44 45–54 55–59 60–64 65+ Type 1 Type 2 Undiagnosed Pre-diabetes Ages: Average 35,365 Average cost ($) Average medical costs per person by age & diabetes type, 2007 Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars. 20
- 21. Context: InsXtuXonal resources Public schools Diabetes self-management educa7on Dedicated space Permanent buildings Varies; hospitals, medical offices, community sites Guaranteed funding 100% tax-supported1 (local, state, federal) Varies by health plan; free community classes provided by DPH/DPCP. Mandatory a_endance 10-14 years None, all voluntary. ~ 24% of Medicare paXents a=ended DSMT class. Teaching force: Trained in content area CerXfied to teach Classroom teachers All (N=3.1 million) 1 99%1 Many staff do DSME: medical (e.g., MD, RN, RD, NP, PA, RPh); non-medical (e.g., CHW, CHES, peer educators). DSMP classes given by lay trainers. Trained in disease management: MD, RN, RPh, RD, NP, CDE. Trained to educate: Only CDEs (N=8710), naXonal credenXal; possible state licensure too. Curriculum content & Teacher lesson plans State naXonal standards (CCSS2) Always. Vary by teacher common planning Curriculum content: ADA and AADE cerXfy Recognized Programs. DSMP has evidence-based curriculum. Lesson plans: vary with ADA & AADE programs. Fidelity agreement for DSMP. 12012 Condi*on of Educa*on, Tables A-19-1 (2008-2009), A-17-1 & A-17-2 (2007-2008) 2 h=p://www.corestandards.org/ = trend towards 21 More variable for DSME
- 22. 5 levels of diabetes educators* o Level 1, non-healthcare professional, o Level 2, healthcare professional non-diabetes educator, o Level 3, non-credenXaled diabetes educator, v Level 4, credenXaled diabetes educator, and v Level 5, advanced level diabetes educator/clinical manager. *American AssociaXon of Diabetes Educators (AADE) (2011). Scope of Prac*ce, Standards of Prac*ce, and Standards of Professional Performance for Diabetes Educators, p. 4. h=p://www.diabeteseducator.org/export/ sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf 22
- 23. Context: InstrucXonal resources op0 Public schools Diabetes self-management educa7on Hours of instruc7on in content area (average per year) State/district-mandated minimum hours:1 G1-4: 418 read/write 194 math 292 science Varies greatly by health plan & site - Classes: 10-15 hrs - Individual DSME: varies Instruc7onal strategies SystemaXc use of pedagogical principles For individual paXents: CDE’s assessment of paXent’s needs. For groups: scripts for some non-medical educators (e.g., DSMP) Pace, sequencing, Bloom level not always considered. Special needs students Established protocols? Yes, legal obligaXon (IDEA) Currently, no DSME materials or curricula specifically for elderly or persons with disabiliXes. Age- and ability-differen7ated instruc7on & materials Age grouping, preK-12 Elem: reading/math groups within or between classrooms, all with different lessons HS: Tracks None. Growing concern over low “health literacy” & age-related cogniXve decline with PWDs, but -Diabetes educaXon materials vary widely; content, but not complexity, matched to PWD’s learning needs. - PWDs are given pre-determined meters and supplies, regardless of their abiliXes. 1Data for 2003-2004. Source: “Changes in InstrucXonal Hours in Four Subjects by Public School Teachers of Grades 1 Through 4,“ May 2007, NCES report 2007-305 h=p://www.eric.ed.gov/PDFS/ED497041.pdf/ 2h=p://www.cdc.gov/diabetes/staXsXcs/prevenXve/tNewDEduAgeTot.htmwww.eric.ed.gov/PDFS/ED497041.pdf 23 Li_le differen7a7on Limited 7me Materials too complex
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- 25. Our efforts 1. Describe job of self-care from pa7ent’s perspec7ve. – Collabora7on with CDS: AUCD Conference – AADE Conference: “Cogni7ve Demands of DSME” – NACDD Teleconference: “Cogni7ve Demands of DSME” – AADE Conference 2013: “Psychometrics of DSME in the Elderly” 2. IdenXfy the job’s most criXcal tasks 3. Trace (and limit) cogniXve complexity of learning tasks 4. DifferenXate instrucXon by ability (“literacy”) level 5. Provide scripts for providers that minimize complexity 6. Provide paXent handout that reinforces learning 25
- 26. AADE’s descripXon of DSM* Living well with diabetes requires acXve, diligent, effecXve self-management of the disease. It is a process that: • Requires making and acXng on choices, on a regular and recurring basis, that affect one’s health • Includes Ø learning the body of knowledge relevant to the disease state, Ø defining personal goals, weighing the benefits and risks of various treatment opXons, Ø making informed choices about treatment, Ø developing skills (both physical and behavioral) to support those choices, Ø evaluaXng the efficacy of the plan toward reaching self-defined goals. *American AssociaXon of Diabetes Educators (AADE) (2011). Scope of Prac*ce, Standards of Prac*ce, and Standards of Professional Performance for Diabetes Educators, pp. 1-2. h=p://www.diabeteseducator.org/export/sites/aade/ _resources/pdf/research/ScopeStandards_Final2_1_11.pdf 26
- 27. AADE’s descripXon of DSM* Living well with diabetes requires acXve, diligent, effecXve self-management of the disease. It is a process that: • Requires making and acXng on choices, on a regular and recurring basis, that affect one’s health • Includes Ø learning the body of knowledge relevant to the disease state, Ø defining personal goals, weighing the benefits and risks of various treatment opXons, Ø making informed choices about treatment, Ø developing skills (both physical and behavioral) to support those choices, Ø evaluaXng the efficacy of the plan toward reaching self-defined goals. *American AssociaXon of Diabetes Educators (AADE) (2011). Scope of Prac*ce, Standards of Prac*ce, and Standards of Professional Performance for Diabetes Educators, pp. 1-2. h=p://www.diabeteseducator.org/export/sites/aade/ _resources/pdf/research/ScopeStandards_Final2_1_11.pdf What Bloom level would you assign to each? • Remember • Understand • Apply • Analyze • Evaluate • Create 27 AADE7TM curriculum content 1. Healthy eaXng 2. Being acXve 3. Monitoring 4. Taking medicaXon 5. Problem solving 6. Reducing risks 7. Healthy coping
- 28. Objec7ve: Maintain blood glucose within healthy limits to avoid complica7ons • Learn about diabetes in general (At “entry’) – Physiological process – Interdependence of diet, exercise, meds – Symptoms & correcXve acXon – Consequences of poor control • Apply knowledge to own case (Daily, Hourly) – Implement appropriate regimen – ConXnuously monitor physical signs – Diagnose problems in Xmely manner – Adjust food, exercise, meds in Xmely and appropriate manner • Coordinate with relevant par7es (Frequently) – NegoXate changes in acXviXes with family, friends, job – Enlist/capitalize on social support – Communicate status and needs to pracXXoners • Update knowledge & adjust regimen (Occasionally) – When other chronic condiXons or disabiliXes develop – When new treatments are ordered – When life circumstances change • Condi7ons of work—24/7, no days off, no re7rement Our more paXent-centered job descripXon Self- management Training 28
- 29. Objec7ve: Maintain blood glucose within healthy limits to avoid complica7ons • Learn about diabetes in general (At “entry’) – Physiological process – Interdependence of diet, exercise, meds – Symptoms & correcXve acXon – Consequences of poor control • Apply knowledge to own case (Daily, Hourly) – Implement appropriate regimen – ConXnuously monitor physical signs – Diagnose problems in Xmely manner – Adjust food, exercise, meds in Xmely and appropriate manner • Coordinate with relevant par7es (Frequently) – NegoXate changes in acXviXes with family, friends, job – Enlist/capitalize on social support – Communicate status and needs to pracXXoners • Update knowledge & adjust regimen (Occasionally) – When other chronic condiXons or disabiliXes develop – When new treatments are ordered – When life circumstances change • Condi7ons of work—24/7, no days off, no re7rement Our more paXent-centered job descripXon Self- management Training 29 It is NOT just following a plan. It is also thinking and acXng to minimize problems.
- 30. Our efforts 1. Describe job of self-care from paXents’ perspecXve 2. Iden7fy the job’s most cri7cal tasks 3. Trace (and limit) cogniXve complexity of learning tasks 4. DifferenXate instrucXon by ability (“literacy”) level 5. Provide scripts for providers that minimize complexity 6. Provide paXent handout that reinforces learning 30
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- 32. Our efforts 1. Describe job of self-care from paXents’ perspecXve 2. IdenXfy the job’s most criXcal tasks 3. Trace (and limit) cogni7ve complexity of learning tasks 4. DifferenXate instrucXon by ability (“literacy”) level 5. Provide scripts for providers that minimize complexity 6. Provide paXent handout that reinforces learning 32
- 33. Bloom’s Taxonomy of Learning ObjecXves Latest (2001) revision Bloom levels =continuum of cognitive complexity Not just readability!! 33
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- 38. Information is better because it’s in chartform Amount per serving But, it contains a confusing technical symbol. Can you spot it? “Amount/serving” 38
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- 41. Pros: • Fewer items • Single vertical list • Major headings stand out Cons: • Lots of irrelevant info • Seemingly inconsistent info Be=er, but… 41
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- 43. Bloom’s taxonomy of educaXonal objecXves (cogniXve domain) Simplest tasks 1. Remember recognize, recall, IdenXfy, retrieve 2. Understand paraphrase, summarize, compare, predict, infer, 3. Apply execute familiar task,, apply procedure to unfamiliar task 4. Analyze disXnguish, focus, select, integrate, coordinate 5. Evaluate check, monitor, detect inconsistencies, judge effecXveness 6. Create hypothesize, plan, invent, devise, design Most complex tasks Distractors: CHOs vsFiber vs Fat Carb vs non-carb ?? Sequence of label Total CHOs important, “Sugars” not Grams as volume vs wt Part of meal vs snack OK? CHOs in intended serving? CHOs vs Fat/Chol vs Na Location of relevant CHO (carb) gms How many CHO gms in 1 serving? Subtract fiber gms from CHO gms Plan a meal or snack 43
- 44. Our efforts 1. Describe job of self-care from paXents’ perspecXve 2. IdenXfy the job’s most criXcal tasks 3. Trace (and limit) cogniXve complexity of learning tasks 4. Differen7ate instruc7on by ability (“literacy”) level 5. Provide scripts for providers that minimize complexity 6. Provide paXent handout that reinforces learning How different in ability can adults be? 44
- 45. Typical literacy items, by difficulty level NaXonal Adult Literacy Survey (NALS), 1993 NALS difficulty level (& scores) % US adults(age 65+) peaking at this level Simulated everyday tasks 5 (375-500) 3% ~0% § Use calculator to determine cost of carpet for a room § Use table of information to compare 2 credit cards 4 (325-375) 15% 4% § Use eligibility pamphlet to calculate SSI benefits § Explain difference between 2 types of employee benefits 3 (275-325) 31% 16% § Calculate miles per gallon from mileage record chart § Write brief letter explaining error on credit card bill 2 (225-275) 28% 33% § Determine difference in price between 2 show tickets § Locate intersection on street map 1 (0-225) 23% 47% § Total bank deposit entry § Locate expiration date on driver’s license Daily self-maintenance in modern literate societies 45
- 46. NALS difficulty level (& scores) % US adults(age 65+) peaking at this level Simulated everyday tasks National Adult Literacy Survey (NALS), 1993) 5 (375-500) 3% ~0% § Use calculator to determine cost of carpet for a room § Use table of information to compare 2 credit cards 4 (325-375) 15% 4% § Use eligibility pamphlet to calculate SSI benefits § Explain difference between 2 types of employee benefits 3 (275-325) 31% 16% § Calculate miles per gallon from mileage record chart § Write brief letter explaining error on credit card bill 2 (225-275) 28% 33% § Determine difference in price between 2 show tickets § Locate intersection on street map 1 (0-225) 23% 47% § Total bank deposit entry § Locate expiration date on driver’s license § level of inference (“connecting the dots”) § abstractness of info § distracting information § number of features to match Not reading per se, but “problem solving” Typical literacy items, by difficulty level NaXonal Adult Literacy Survey (NALS), 1993 46
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- 49. Our efforts 1. Describe job of self-care from paXents’ perspecXve 2. IdenXfy the job’s most criXcal tasks 3. Trace (and limit) cogniXve complexity of learning tasks 4. DifferenXate instrucXon by ability (“literacy”) level 5. Provide scripts for providers that minimize complexity 6. Provide paXent handout that reinforces learning 49
- 50. “Rx for Physical Ac7vity” for a Rural Community Health Center Linda S. Gottfredson,PhD School of Education University of Delaware Kathy Stroh, MS, RD, CDE Diabetes Prevention & Control Program Delaware Division of Public Health Presented at the 2009 Diabetes Translation Conference of the Centers for Disease Control & Prevention (CDC). Long Beach, CA, April 24, 2009 50
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- 56. Teaching the teacher: Script for CDE when prescribing “Rx for Walking” Provides the CDEwith: Educationally sound teaching strategy • Key ideas • Content, sequence, and pace of instruction, etc. Implicit training • Be concrete, personalize, use meaningful metaphors, etc. 56
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- 60. Lesson plan: Don’t assume they know what’s obvious to you Can’t assume: That patientwill know: • What a pedometer is • How to wear it • The exact regimen of the Rx • i.e., extra steps That the educator will know specific learning steps for: • Aim of script (e.g., extra steps) • How to adjust regimen 60
- 61. Our efforts 1. Describe job of self-care from paXents’ perspecXve 2. IdenXfy the job’s most criXcal tasks 3. Trace (and limit) cogniXve complexity of learning tasks 4. DifferenXate instrucXon by ability (“literacy”) level 5. Provide scripts for providers that minimize complexity 6. Provide pa7ent handout that reinforces learning 61
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- 65. 5 levels of diabetes educators* o Level 1, non-healthcare professional, o Level 2, healthcare professional non-diabetes educator, o Level 3, non-credenXaled diabetes educator, v Level 4, credenXaled diabetes educator, and v Level 5, advanced level diabetes educator/clinical manager. *American AssociaXon of Diabetes Educators (AADE) (2011). Scope of Prac*ce, Standards of Prac*ce, and Standards of Professional Performance for Diabetes Educators, p. 4. h=p://www.diabeteseducator.org/export/ sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf 65