How to manage diabetes by yourself

1. Teaching Diabetes Self-Management—in 4
Hours (or Less)
h=p://bit.do/b3SSy
Linda S Go*redson, PhD
School of Educa7on
University of Delaware
Kathy Stroh, MS, RD, CDE
Diabetes Preven7on and Control Program
Delaware Division of Public Health
1
CEHD Colloquium, University of Delaware, February 28, 2013

2. Juvenile Diabetes Maturity-onset Diabetes
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 no such thing as Borderline Diabetes
or a “Touch of Diabetes.”
Pre-diabetes is a diagnosis.
4

5. There is no such thing as
Borderline Diabetes
or a “Touch of Diabetes.”
5
Pre-diabetes

6. DM defects
6

7. Diabetes is a cardiovascular 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 International Diabetes 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” is not a noun 10

11. 11

12. 12

13. 13

14. As teacher educators,
how would you recommend
teaching diabetes self-management?
Here’s the challenge
14

15. Private schools
0.4 mil teachers
5.4 mil pupils
$673 billion
15
Federal
State
District
Federal
State
District
Regulation
s
Public schools
3 million
50 million
Diabetes
educa7on??

16. $673 billion
16
Federal
State
District
Federal
State
District
Regulation
s
Public schools
3 million
50 million
InstrucXon
Learning tasks
Private schools
0.4 mil teachers
5.4 mil pupils
Diabetes
educa7on??

17. Context: Exploding numbers
12012 Condi*on of Educa*on, Table A-3-1. h=p://nces.ed.gov/pubs2012/2012045_5.pdf
2 For 1970, All Ages is interpolated from 1968 and 1973. h=p://www.cdc.gov/diabetes/staXsXcs/diabetes_slides.htm.
3For 1990 and 2010, All ages and 65+ derived from h=p://www.cdc.gov/diabetes/staXsXcs/prev/naXonal/tnumage.htm, and 18+ from
h=p://www.cdc.gov/diabetes/staXsXcs/prev/naXonal/figadults.htm
4 Boyle et al (2010), ProjecXon of the year 2050 burden of diabetes in the US adult populaXon. Popula*on Health Metrics, 8(29).I averaged the results from their 4 models. Huang et al. (2009) esXmated 34.2M for
Type 2 alone: Using clinical informaXon to project federal health care spending. Health Affairs, 28(5), w978-990.
5CDC’s Diabetes Data & Trends. h=p://apps.nccd.cdc.gov/DDT_STRS2/NaXonalDiabetesPrevalenceEsXmates.aspx,
Just 5 years!
Public schools Diabetes cases
Number needing
instruc7on
Millions enrolled1 Millions diagnosed with diabetes Type 1 or 2
(non-insXtuXonalized civilians)
Fall of
Total
Elementary (preK-8)
HS (9-12)
1970
45.5
32.5
13.0
1990
41.2
29.9
11.3
2010
49.5
34.6
14.9
2020
52.7
37.3
15.4
All ages
Adults (18+)
Older (65+)
19702
3.6
19903
6.6
6.6
2.8
20103
20.9
20.7
7.8
20204
33.5
2004 % diagnosed adults > 20 years 5 2009
17

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

19. Total medical costs, by age & diabetes type, 2007
$ (billions)
25.3
105.7
11.0
10.5
Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars. 19
%
(prevalence)

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

24. Example of required task for all PWDs:
Glucose meters
and
lancet devices
24

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

31. UD survey:
CriXcality
rankings
31

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

34. *Revised 2001: Anderson, L. W., & Krathwohl,
D. R. (2001). A taxonomy for learning, teaching, and
assessing: A revision of Bloom's taxonomy of educa*onal
objec*ves. NY: Addison Wesley Longman.
To be or not to be,
that is the ques7on.
To be or not to be,
that is the ques7on.
To be or not to be,
that is the ques7on.
To be or not to be,
that is the ques7on.
To be or not to be,
that is the ques7on.
To be or not to be,
that is the ques7on.
“To be or not to be”
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
34

35. *Revised 2001: Anderson, L. W., & Krathwohl,
D. R. (2001). A taxonomy for learning, teaching, and
assessing: A revision of Bloom's taxonomy of educa*onal
objec*ves. NY: Addison Wesley Longman.
AnXcipate effect of
exercise & foods
on blood glucose.
Coordinate meds, diet,
and exercise.
Manage sick days.
Determine when & why
blood glucose is out of
control
Monitor symptoms; assess
whether acXon needed;
evaluate effecXveness of
acXons
Create daily and conXngency
plans that control blood
glucose
Recall effects
of exercise
on glucose.
Remember to take
BGs & Rx.
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
Remember to measure
foods, drinks & read labels.
35

36. What about reading nutriXon labels?
• How important?
• How complex?
Essen7al
Extremely
36

37. 37

38. Information
is better
because
it’s in
chart form
Amount per serving
But,
it contains a
confusing technical
symbol.
Can you spot it?
“Amount/serving”
38

39. What’s the problem here?
39

40. And here?
Organic
HealthyNo sugar
added
40

41. Pros:
• Fewer items
• Single vertical list
• Major headings
stand out
Cons:
• Lots of irrelevant
info
• Seemingly
inconsistent info
Be=er, but…
41

42. Food Label revision…
counXng carbohydrates
42

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 vs Fiber 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

47. Complexity & aging
47

48. g - Basic
informa7on
processing
(GF)
Basic
cultural
Knowledge
(GC)
Age-related cogniXve decline
Learning & reasoning ability Age
8
48
Age
80

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

51. 51

52. 52

53. Basic pedometer—just counts steps
53

54. Graduated Rx
Basic Rx
increases
speed
h=p://www.udel.edu/educ/gozredson/Rx 54

55. 55

56. Teaching the teacher: Script for CDE when prescribing “Rx for
Walking”
Provides the CDE with:
Educationally sound teaching strategy
• Key ideas
• Content, sequence, and pace of
instruction, etc.
Implicit training
• Be concrete, personalize,
use meaningful metaphors, etc.
56

57. 57

58. 58

59. 59

60. Lesson plan: Don’t assume they know what’s obvious to you
Can’t assume:
That patient will 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

62. 62

63. Thank you.
QuesXons?
Advice?
63

64. 64

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