All education efforts should be patient-centered. Patients should be active participants in managing their diabetes. Nearly all patients with diabetes are the daily managers of their disease.
Explaining the Diagnosis
Education efforts should begin the moment the patient is found to have elevated blood or urine glucose. Once hyperglycemia is confirmed, then a concise and clear explanation of the diagnosis should occur. Complications of the disease should be discussed along with the importance of available therapies.Adherence studies have found that patient’s health beliefs are more important than inadequate knowledge of the disease. Providers should make time to ask patients open-ended questions about how they think diabetes works. Culturally responsive reading materials that are appropriately tailored to the patient’s health literacy level can help reinforce discussion points. Referral to a specialized diabetes education center may be appropriate if office or hospital teaching resources do not meet the patient’s needs. Group education classes, if amenable to the patient, can be cost effective and are reimbursed by many insurance plans. Some select excellent education resources are listed below:
Self-Monitoring of Blood Glucose
All diabetic patients should be taught to check their own blood glucose. Blood glucose levels can decide if immediate therapeutic interventions must be made. Daily self-monitoring of blood glucose (SMBG) is advised for patients on multiple-dose insulin (MDI) or insulin pump therapy: at least prior to meals and snacks, occasionally at other times as well (e.g. bedtime, post-prandial, prior to exercise, symptoms of low glucose). SMBG results can guide patients in quick management decisions; longer term patterns of blood glucose levels can be used by the patient and doctor to make adjustments to therapy over time. In general, the frequency and timing of SMBG should be tailored to an individual patient’s needs and goals.
The utility of SMBG in patients who are using insulin less frequently, or using oral medications, is most likely to be of benefit when patient is attempting better control, or when the patient wants to confirm their treatment plan is working. Evidence that SMBG in these patients affects quality of life or long-term clinically important outcomes is limited.
Patients taking oral medications should be counseled on dosage and frequency instructions, potential side effects, and the treatment goals. Patients receiving insulin should be counseled on instructions on self-administration, avoiding exercise-induced hypoglycemia, and the use of glucagon in hypoglycemia.
All diabetic patients should receive instruction on managing brief illnesses (e.g. viral syndromes). Recommendations during a brief illness include:
Counseling on Acute and Chronic Complications
Diabetic patients should be advised to wear medic alert bracelets, particularly when they use medications that put them at risk for hypoglycemia. They should be taught about acute complications including infections, hyperosmolar coma, ketoacidosis, hyperglycemia, and hypoglycemia.
|Causes: Taking too much diabetes medicine, missing a meal or snack, exercising too much, and drinking alcohol may cause hypoglycemia.
|Causes: Forgetting to take medicines on time, eating too much and getting too little exercise may cause hyperglycemia. Being ill also can raise blood glucose levels.
|The signs of hypoglycemia:
|The signs of hyperglycemia:
|Plan: If you experience these symptoms, test your blood glucose. If it is 70 or less, eat one of the following right away, in order to ingest 15-30 g of glucose:
Check blood glucose again 15 minutes after glucose intake.
|Source: National Institute of Diabetes and Digestive and Kidney Diseases
Diabetes patient education also includes counseling on chronic complications. Patients should be taught to monitor the signs of long-term damage of the eye, cardiovascular, skin, renal, nervous, gastrointestinal, and vascular systems, and psychological issues. Foot care including self-inspection and hygiene should be encouraged. The ADA provides an excellent overview of chronic complications of diabetes for patients at: http://www.diabetes.org/living-with-diabetes/complications/.
Exploring how a patient understands their disease is a vital listening skill for a physician (e.g. What is diabetes? What made it happen? What makes it better? What makes it worse? How does treatment work?). Making the time to listen to a patient with diabetes can provide important information on how to tailor your counseling, the likelihood of adherence to treatment, and how the patient is experiencing the “illness” of diabetes rather than the “disease.” Many people living with diabetes can benefit from support groups that can provide suggestions for coping with stress and daily living challenges.
Twenty to 25% of diabetic patients suffer from depression at some point in their lives. The ADA recommends screening for depression during a new diabetes diagnosis, during regular visits, or if adherence issues arise. Integrating psychosocial care into routine care is better rather than waiting for deterioration of psychological status.
Some risk factors for depression in diabetic patients include:
- Age <65
- Previous history of depression
- Unmarried status
- Poor physical health
- Poor mental health
Diabetes Self-Management Education Programs (DSME)
Diabetes self-management education programs (DSME) are important elements of diabetes care. There has been a progressive shift over the past decades from didactic approaches of DSME to skill-based, patient-centered, and longitudinal approaches in DSME. Research has found that DSME is associated with better knowledge of diabetes, better self-management decisions, and better clinical outcomes. DSME programs are reimbursed by Medicare and Medicaid programs. The ADA has national standards for DSME programs. In order to receive an ADA certification, a DSME program must include registered nurses and nutritionist staff; must cover all areas of diabetes management in the curriculum; and have continuous quality improvement projects as part of their assessment of effectiveness.
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