Education, Motivation and Collaboration in San Antonio
by joseph shivers
We recently traveled to the annual meeting of the American Association of Diabetes Educators (AADE) in San Antonio, where 3,300 educators gathered and shared their fellowship and warmth (something we notice even when the conference isn’t held in the Texas heat). As always at AADE, speakers focused on self-management and patient-provider interactions: the often-neglected, more practical sides of diabetes therapy. This year, particular attention was focused on self-motivation versus instruction and preventive versus interventional care – two distinctions that will be important for government, industry, and health care providers alike. Below, we highlight some of the conference’s major themes.
an uphill, team effort
Every year, the AADE conference is among our favorites, and this year was no exception. We were especially inspired by the overwhelming sense of community among the CDEs and their message about the importance of collaboration among health care providers, researchers, payers, and industry giants. Calling the audience to action during day two’s keynote address, Dr. Eduardo Sanchez of the Blue Cross and Blue Shield of Texas proclaimed that diabetes prevention is the key to improving the health of America. Listing the vast public health benefits of a comprehensive prevention program (and the enormous costs of failure), he urged every physician, educator, and researcher to find common cause and band together. As Dr. Sanchez put it, “There will be no shortage of people for whom to provide care…there’s plenty of business for all of us.” In his own keynote address, Dr. John Agwunobi, the Senior Vice President of Wal-Mart Stores, encouraged the audience to partner with big clinics and companies that have the resources to help millions of people. While we found these and other speeches powerful, one presentation in particular stood out above the rest. It was a panel discussion of advanced duration diabetes, featuring three clinicians and a motivational speaker, all of whom have lived with diabetes for over 30 years. The majority of the packed audience were themselves individuals with diabetes, and the question-and-answer session took on a support-group feel with the crowd applauding at each patient/educator’s declaration “I have had diabetes for X years.” “It was truly eye-opening to see diabetes educators with good glucose control personally battling complications from diabetes,” said Adam Brown, a diaTribe summer intern who has lived with type 1 for nearly a decade. “The outpouring of support and care from the talk’s attendees was certainly wonderful to see.” To us, the most amazing thing is that it isn’t only those with diabetes who are able to empathize with the disease’s burdens and teach people how to bear them. Indeed, that’s what being a CDE is all about.
motivation tools, techniques, and tips
Living with diabetes is a constant battle not only to keep blood sugar in range and weight stable, but also to stay motivated. Fortunately, healthcare providers are learning more and more about the role of personal motivation. Martha Funnell, a nurse and CDE at the University of Michigan (Ann Arbor, MI), summed up a critical lesson, recommending that providers frame diabetes management in terms of choices and consequences rather than rules and adherence. At the same time, new tools are making it less of a burden to stay on track. One welcome advance is WellDoc’s Diabetes Manager system, a mobile health program that provides real-time feedback on blood glucose trends and facilitates contact with doctors and educators (see New Now Next in this issue of diaTribe). Meanwhile, diaTribe’s editor-in-chief Kelly Close had the chance to moderate a panel about HealthSeeker, the Diabetes Hands Foundation’s Facebook game sponsored by Boehringer Ingelheim that rewards users for completing real-world lifestyle “missions” like taking the stairs instead of the escalator or trying one new type of fruit per week. Offering more general tips, CDE Jen Block (Stanford University School of Medicine, Stanford, CA) cited evidence that the most motivated users of continuous glucose monitoring tend to be those with lots of information, good problem-solving skills, and emotional support. Unfortunately, family and friends are not always the best influences on people with diabetes, as we were reminded by Dr. William Fisher (University of Western Ontario, London, Canada). Dr. Fisher noted that 60-67% of coworkers, 57% of children, 43-47% of friends, and 34-45% of spouses of individuals with diabetes do not believe there is a need to test blood glucose levels as often as providers recommend. We think that wider education can solve many of these discrepancies, however, and we remind our readers that they can find diabetes educators in their area from AADE at 1-800-TEAM-UP4 (1-800-832-6874).
benefits observed and anticipated from GLP-1 agonists
We heard a great deal about drugs at the conference, and speakers were especially vocal about GLP-1 agonists (like Amylin/Eli Lilly’s Byetta and Novo Nordisk’s Victoza). These injectable drugs, which stimulate beta cells to secrete insulin in response to food intake, are used to treat type 2 diabetes. For more information on GLP-1 agonists, please see What We're Reading in diaTribe issue #5. While the weight loss and A1c reductions associated with GLP-1 agonists have been well established, Dr. Robert Chilton (University of Texas Health Science Center, San Antonio, TX) highlighted that these drugs, unlike most other diabetes drugs, also improve factors associated with poor cardiovascular health, including lipids and blood pressure. While he and other speakers were optimistic about the use of GLP-1 agonists to improve cardiovascular risk in patients with diabetes, we point out that longer-term clinical trials to study these potential heart benefits have just begun. In another talk, Dr. Curtis Triplitt (University of Texas Health Science Center, San Antonio, TX) offered a separate reason to be excited about GLP-1 agonists: the drugs’ potential to slow or reverse the progression of diabetes through the preservation of beta cells. Although this effect has also not yet been proven in humans, each passing conference seems to bring additional information regarding therapeutic benefits for this drug class outside of their role in reducing blood sugar. We can’t wait to see human clinical data regarding these and other drugs in the future and are beginning to think more and more that that GLP-1 agonists could one day be regarded as the new gold standard for type 2 diabetes medications (we also hope to see testing in type 1 patients soon as we believe there is promise here as well).
monitoring reimbursement and health care reform
As health budgets tighten across the US, it only makes sense that the new Patient Protection and Affordable Care Act (PPACA, part of the healthcare reform bill) emphasizes preventive rather than interventional care. Although no one at the conference expected the healthcare system to change overnight, we were encouraged to hear from reimbursement expert Patty Telgener (Emerson Consultants, Golden, CO), who noted that many major insurance companies already reimburse for continuous glucose monitoring (CGM) systems for both professional (short-term, diagnostic) and personal (long-term) use. Unfortunately, Medicare does not currently support personal CGM, but we hope that this will change as the technology continues to improve and to be adopted by more individuals. Paying for traditional self-monitoring of blood glucose (SMBG) also remains a challenge for many, especially individuals with type 2 diabetes not on insulin. In cases where strips are in short supply, Christopher Parkin (CGParkin Communications, Carmel, IN) and CDE Mary Austin (The Austin Group, Shelby Township, MI) recommended that people test at many consistent times for a few days rather than once or twice every day. This way, it’s possible to identify patterns: helpful for self-management, and evidence for why the expense is worthwhile. For both CGM and SMBG, it usually seems that the best way to get reimbursed is by presenting data. If your health care provider makes a case using numbers, whether from clinical trials or (better yet) from you yourself, insurers tend to be more willing to confirm prescriptions with requested numbers of strips. Meanwhile, some employers are experimenting with other strategies to improve workers’ health. Michael Roizen, chief wellness officer at the Cleveland Clinic (Cleveland, OH), discussed a number of the Clinic’s interventions for its employees, including free gym access. Other public health efforts are starting even earlier, the most notable of which is Michelle Obama’s Let’s Move campaign against childhood obesity. Looking toward future government efforts, Roberta Friedman (Yale Rudd Center for Food Policy and Obesity, New Haven, CT) encouraged voters to support policy changes and not just short-term programs.
getting insulin right
Allen King (Diabetes Care Center, Salinas, CA) updated his dosing recommendations from last year with user-friendly formulas that relate everything to total basal dose (TBD, measured in units [U] of insulin). New pumpers can estimate TBD by multiplying their weight (in kilograms) by 0.2, or by multiplying their total multiple-daily-injection dose (assuming it was correct) by 0.4. This preliminary TBD value can then be plugged into a formula with parameters for insulin sensitivity: 100/TBD = ICR = CF/4.5, where ICR is insulin-carb ratio (the maximum amount of carbohydrate that one unit of insulin can offset within two-to-four hours, in g/U) and CF is correction factor (the drop in blood glucose per unit of insulin, in mg/dl/U). On the topic of multiple daily injections, former AADE President Amparo Gonzalez (Emory School of Medicine, Atlanta, GA) emphasized that nearly everyone’s skin thickness is equivalent, and she recommended that people stop using 8-mm-or-longer needles, given that 5-mm and new 4-mm needles work equally well and involve fewer risks of going too deep beneath the skin and into the muscle. The one drawback mentioned about the 4-mm needle is that it needs to be held in the skin for a second longer than other needles, to prevent leakage. (We note that the research on skin thickness was conducted with pens and needles only, and that we hope to hear similar data on cannulas soon).Ms. Gonzalez and several other speakers also pointed out that there is a general lack of nationwide guidelines on insulin injection techniques, and we hope that the AADE follows her suggestion and develops a consistent set of guidelines in the years to come. As we’re always reminded at this conference, a therapy is only as good as its implementation – one more reason that widespread diabetes education continues to be essential.
survey suggests health care providers positive on CGM, incretins, and pumps
As at several other major conferences each year, diaTribe conducted a survey of 136 healthcare providers (HCPs) during AADE 2010. Notably, 70% of the respondents expected to increase their use of CGM in the upcoming year, suggesting that interest in CGM continues to grow among HCPs. Another area of excitement for HCPs was the use of GLP-1 agonists for the treatment of type 2 diabetes. Of those surveyed, 81% responded as ‘likely’ or ‘highly likely’ to increase their use of Victoza in the upcoming year, and 85% expressed significant enthusiasm about Bydureon (the once-weekly GLP-1 agonist that is due for an FDA decision on October 22, 2010). Finally, 70% reported interest in using insulin pumps for individuals with type 2 diabetes. While our survey did have several limitations, including the small number of individuals surveyed, we find the results may indicate how current and future diabetes care products are perceived among HCPs.
