Elaine Massaro, MS, RN, CDE, American Association of Diabetes Educators (AADE) Educator of the Year, Shares Her Thoughts on Diabetes Care
by vincent wu, benjamin kozak, and kelly close
We recently had the pleasure of speaking with Ms. Elaine Massaro, recipient of the 2010 AADE Diabetes Educator of the Year Award, about her experiences, her insights on patient care, and her views on technology and pharmaceuticals. As a Clinical Nurse Specialist and Clinical Research Coordinator at Northwestern University, Ms. Massaro has been involved in a number of noteworthy trials, including managing her site for the international multi-site Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes (BARI 2D) trial .
Ms. Massaro also recently finished work in a trial on Calibra’s novel insulin patch-pen, the Finesse – in this interview, she shares her very positive reactions to this technology. Ms. Massaro brings a unique perspective to diabetes, as her initial clinical experience was in cardiovascular nursing, intensive care, and the cardiac care unit (CCU), allowing her to better synthesize experience and expertise in two closely related fields.
During the interview, Ms. Massaro emphasized the importance of behavior change as the most effective way to manage diabetes and to bring about weight loss, extolling the use of motivational interviewing by diabetes educators and other health professionals to bring about such behavior change. Ms. Massaro noted that ultimately knowledge, motivation, and confidence are the three essential factors for such change – easier said than done for many patients. Furthermore, Ms. Massaro expressed optimism for GLP-1s, new insulin delivery technologies, and CGM. Finally, she stressed the need for greater advocacy and awareness about diabetes education, urging readers to contact their local legislators to support S.3211/H.R.2425, the Diabetes Self-Management Training Act of 2010. If this initiative passes, Certified Diabetes Educators (CDEs) will finally be able to bill Medicare for their diabetes self-management training services. She stressed that ultimately, reimbursement to CDEs for their work may attract a greater number of qualified educators to the field. We agree this is a great initiative, and we urge you to rally behind AADE and contact your local Senate and House of Representatives members today to support the Diabetes Self-Management Training Act as soon as you can!
on personal experience and aade 2010
Kelly Close: Elaine, thank you so very much for taking the time to talk with us today. Congratulations on receiving AADE’s Educator of the Year Award! It really is a great privilege for us to be able to speak with you. I want to start off by asking a little bit about your personal background. How did you initially become involved in diabetes education?
Elaine Massaro: Well, it all began in upstate New York. My original clinical background was in cardiovascular nursing, intensive care, and the cardiac care unit (CCU). A job opportunity as a Nurse Manager involving both cardiovascular and endocrinology disciplines opened up, and I applied for the job without having extensive knowledge about diabetes at the time. Luckily, I got the job, and as I interacted more with people with diabetes, I became increasingly passionate about and involved in diabetes education and self-management. I really wanted to help people become healthier. Since I initially landed that first job, I’ve had so many incredible experiences working in the community and in the hospital setting to educate people to manage their diabetes better and reduce the likelihood of diabetes-related complications. At the end of the day, knowing that I really can make a difference in people’s lives for the better is what keeps me going.
Vincent Wu: What part of your work do you find the most fulfilling as well as the most challenging?
Elaine: By far, knowing that I can make a difference in people’s lives has been the most fulfilling part of my work. When I see people struggling to change their behavior, I do everything I can to help guide and support them. I have a passion to help people with their diabetes and to help them improve outcomes. When people come back and tell me they feel good about life again, I know I’m making a difference. That is by far the most gratifying part of my work. There isn’t a single day I go home thinking I didn’t make an impact in at least one person’s life.
I would have to say my involvement in the BARI 2D trial was the most challenging work experience I’ve had to date. It was a fantastic opportunity, but such a challenge because participants in the trial already had diabetes-related complications. Many had struggled with weight and diabetes management for a long time. They desperately wanted to better manage their diabetes and control their weight, but they just weren’t able to achieve their goals. That is the biggest challenge – wanting to make a change for the better, but struggling with behavior change. I am grateful to have been exposed recently to the new technique of motivational interviewing, as it provided me with a new and effective framework to encourage behavior change for the people I saw in BARI 2D.
On a related note, some of my friends and family members have been struggling with weight loss, and have tried everything in the way of pharmaceuticals to no avail. It all comes down to the way you live your life – your eating and exercise habits, your overall way of life. To change all of that at once can be overwhelming, and that is where the issue really is for a majority of individuals. We can’t focus solely on drugs or surgery alone – we need to focus more heavily on behavior change as well in order to help people achieve sustained weight loss. Now, the Lap-Band has been a huge breakthrough and has helped many people achieve initial weight loss, but ultimately, they still had to change their behavior to sustain it. They couldn’t go back to their old way of eating, and now had to adapt to a whole new way of life.
Kelly: Since BARI 2D ended, what research has interested you the most – that you can tell us about!
Elaine: I was quite excited when I found out that we were selected to be a clinical site for a study on Calibra’s Finesse, because I was able to case manage patients very closely and see what the pressing issues were in insulin delivery for both people with type 1 and people with type 2 diabetes. Approximately half of the people I saw had type 1 diabetes, while the other half had type 2 diabetes. All participants in the study had a baseline A1c greater than 7% and less than or equal to 10%. My role in the study was to provide participants with intensive counseling and education on carbohydrate counting, knowledge on how to figure out their sensitivity factor, and knowledge on how to adjust their correction factor after a meal. It was a huge eye-opener for some of the people with type 2 diabetes. We performed a seven-point check before and after each meal and bedtime with each participant, and then we recorded the bolus insulin dose for each meal and the daily basal dose to determine the optimal basal-bolus regime. Notably, one study participant with type 2 diabetes came in with an A1c of almost 10%, and he managed to reduce his A1c to under 7% by the end of the study. Near the end of the study, I met with him, and he was tearful because now he “felt good about life again”. To hear him say that really reaffirmed that I am able to make a difference in people’s lives, and that’s why I am in diabetes education to this day.
Vincent: Are there any specific upcoming initiatives at your practice that you are looking forward to?
Elaine: Most definitely! One of our physicians (a lipidologist) recently received a grant to set up a clinic focused on metabolic syndrome. I’m really excited about this upcoming multidisciplinary opportunity – in addition to our standard team, we have numerous other health professionals on board, including a cardiologist, an alternative medicine physician, an exercise physiologist, and a psychologist. After all, there is no one-size-fits-all solution for obesity. We hope that we’ll be able to help people who are struggling with weight loss to lose weight more effectively.
Vincent: What were your top takeaways from this year’s AADE meeting? Did you find any specific themes emerge over the course of the meeting?
Elaine: The overall theme of the meeting resonated well with me – we are indeed all part of the bigger picture. In particular, I’m excited about the increasing opportunities for AADE members to network with others throughout the nation. So many good resources and protocols are out there, but we just don’t know about them. Through this new network, all of the educators will be able to share resources and tips with each other, ultimately allowing us to expand our knowledge base and become even more effective educators. At AADE 2010, I certainly learned a lot about how to more effectively network within my own community as well as nationally.
Another takeaway I had was the need to develop AADE as a united force so that we have greater collective influence to shape policy that will allow us to provide the best care possible. We really need to make diabetes education and management a priority for hospitals and healthcare organizations around the country.
on patient care
Benjamin Kozak: At this year’s AADE meeting, we noticed a strong emphasis on patient self-management. Drawing from your personal experience, what do you think would help people to improve self-management of their diabetes?
Elaine: The three things that are necessary are knowledge, motivation, and confidence. First, people need to have the proper knowledge for self-management – they need to know what their blood glucose levels are and what factors cause fluctuations in their glucose levels, and they need to have the proper tools to be able to calculate and assess what is best for them in various situations. In addition to knowledge, people need to have the motivation to manage their diabetes. Lastly, they need to be confident that they can effectively achieve their goals. With enough education, motivation, and confidence, patients are in the driver’s seat and are able to make their own decisions, adjust their own medications, and evaluate their own care.
Benjamin: How do you encourage people to change their lifestyle behaviors?
Elaine: I have found motivational interviewing techniques to be quite effective in assisting people with goal setting and behavior change. These techniques allow educators to dive into what motivates people, what goals they want to set, how confident they are in achieving those goals, and how they will be able to successfully deal with the barriers that interfere with goal achievement. It’s really quite a powerful skill to be able to engage in these behavioral change strategies. We are currently in the process of developing a program that will train other healthcare professionals to communicate more effectively with these new skills. Ultimately, more effective communication will help people to become more motivated, confident, and empowered to better manage their diabetes.
on education and research
Benjamin: As we understand it, only about 20% to 30% of people with diabetes see educators, which we think is really unfortunate. Do you have any idea why this is? Do you think it is more of an awareness problem or a capacity problem?
Elaine: I definitely think it is a problem of both awareness and capacity. People simply just don’t know about diabetes educators. Right now, the AADE is making a huge push in Congress. I’d urge all readers to write letters or contact their legislators by other means to sponsor S.3211/H.R.2425, the Diabetes Self-Management Training Act. A lot of legislators have not signed for it, so we’re trying to get the word out through AADEnet.org. If this initiative is approved, diabetes educators will be officially recognized as providers of diabetes education, and thereby will be able to get reimbursed for their work by Medicare. Approval of this bill will encourage more people to become diabetes educators, which will allow us to provide more people with diabetes with support and education, ultimately bringing about greater competency in the self-management of diabetes and reducing the rate of diabetes-related complications. Currently, many healthcare facilities are downsizing, and sadly, diabetes educators are often the first to be cut because of the lack of reimbursement or funding. Because of that, it is hard to encourage healthcare professionals to go into the field.
Benjamin: What tools and resources would you recommend for diabetes educators and others involved in diabetes care?
Elaine: I have found that US Conversation Map tools are effective and engaging tools and have made it a lot easier to provide education to people with diabetes. In terms of online resources, I would recommend diabeteseducator.org, Present Diabetes, dLife, and mydiabeteseducator.org. There are several examples of high quality materials available on those sites, including research news and self-management techniques. The information on those sites is written and developed by various professionals involved in diabetes care and management, including nutritionists, psychologists, diabetes educators, and nurses. These are excellent resources for educators, because they are able to share information with others involved in the field through these social networking opportunities. Finally, I also wanted to say that I find your publication, diaTribe, quite impressive. It contains so much current and cutting edge information regarding research and product news for people with diabetes. I have been sharing copies with several of my colleagues and they too have been most impressed. Overall, I think it is a great resource for people with diabetes as well as health care professionals who specialize in diabetes management.
Vincent: What do you think are currently the most important areas of research in the field of diabetes? What specifically would you like to see funded?
Elaine: I definitely would like to see more studies related to cardiovascular disease because of the high incidence of diabetes and cardiovascular disease. In addition, I would also like to see more research on the prevention of diabetes-related complications. Currently, I’m involved in studies addressing the complications of diabetes and the results are very promising for individuals with type 1 diabetes. I would also like to see more funding directed at intensive case management programs. As a case manager, I saw that intensive case management made a big difference, and the doctors I worked with commented how they wished we could do this for all the people we see. Having someone there who can check in with them by phone and in person and who can guide them through goal setting and provide support would be ideal.
on pharmaceuticals
Benjamin: Switching gears, what are your thoughts on upcoming pharmaceutical products such as SGLT2 inhibitors, longer-acting GLP-1 agonists, Afrezza, Linjeta (formerly known as VIAject), and insulin degludec? How helpful do you think these products will be in future diabetes care? Is there a particular class of drugs you are excited about?
Elaine: In general, I am excited by the prospect of more therapeutic options for patients. However, more research still needs to be done to assess the safety and efficacy of the upcoming therapies before I can comment on how useful they will be in future diabetes care. The benefits of the drugs need to outweigh the side effects in order for it to be worth it for people to use. For example, with one of the longer-acting GLP-1s in development, there may be greater discomfort and some issues with administration of the product. We’ll have to see whether the efficacy of the drug can outweigh its potential side effects. Additionally, we’re finding that many therapeutic options are only applicable and effective for some populations and not others. Thus, we need to make sure that drugs are targeted at an appropriate population when they are introduced.
That being said, I am quite excited about the current GLP-1s on the market [Byetta and Victoza]. I think they have a lot of potential, and as I indicated earlier, Calibra’s patch-pen may actually make it easier for people to administer these drugs in the future. For SGLT2 inhibitors [dapagliflozin, canagliflozin], I think the safety of this class still needs to be assessed, especially when used in patients at risk for excessive diuretic effects due to chronic illness or interactions with other medications. Bone health needs to also be addressed since some patients experience large increases in parathyroid hormone levels with SGLT2s. I have also heard that some clinicians are quite concerned about the increased incidence of genital and urinary infections in women. The bottom line is that larger trials need to be done in order to determine if one or more of the SGLT2s will be safe for future use in the management of hyperglycemia.
In terms of insulins, degludec and degludec plus are two of the newer insulins currently being investigated in clinical trials. I am curious to see whether there will be any advantages in taking these basal insulins over existing products. Perhaps there may be more flexibilty with once-daily dosing either in the morning or evening. There may even be the possibility for three-times-weekly dosing with degludec. So far, the results seem promising, but we really need to see data from the larger phase 3 data before drawing conclusions and making recommendations.
Benjamin: We’re definitely interested in GLP-1s as well – at recent conferences we attended, they have (by a landslide) garnered the most attention out of all the current and upcoming drug classes. Could you talk a little bit more about your experience with GLP-1s? Also, we understand there is a once-monthly GLP-1 agonist in development. Do you think that a once-monthly GLP-1 agonist will be a significant improvement over the current GLP-1 agonists on the market and the upcoming once-weekly GLP-1s?
Elaine: When the first GLP-1 agonist [twice-daily Byetta] came out, we didn’t think it would perform as well as it is doing now, despite the slowdown due to Victoza. Many people with diabetes whom I saw, especially those with gastrointestinal issues, could not tolerate that particular drug. Others who initially experienced nausea with the drug ended up taking half the prescribed dose; that is, they ended up taking it once a day and did not ever realize the beneficial effects. Thus, quite a few people discontinued the medication because they experienced side effects without seeing any of the benefits – they could certainly have benefited from more education. Now, with more effective patient education, tolerance for the medication seems to have improved.
The newer GLP-1 on the market [Victoza] has a lot more potential, because it is taken once daily and can be dosed any time of day. With the drug, people start out with a smaller dose, gradually build up to the recommended dose, and see if they get the anticipated effects. I think the gradual increase in dose over time is a much safer and more effective dosing pattern than quickly advancing to the full dose. The latest developments in pen technology have also been a huge improvement, allowing for incremental dosing of GLP-1s.
Regarding the once-monthly GLP-1 in development, I just hope administration issues will not be too much of barrier to adherence. Once-monthly dosing is certainly more convenient, provided that the patient adjusts to the monthly routine. Also, I’d love to see how people with diabetes react to the administration of that drug, given that a monthly dose is injected all at once.
on technology
Kelly: Earlier you mentioned you were involved in a trial for Calibra’s Finesse. I had the chance to wear the device recently and was taken by how small it was. I am very happy with my “basal-bolus” pump but wondered what you thought of the potential for people with type 2 diabetes as well as those with type 1 diabetes who have ruled out using traditional or disposable pumps that are available, due to size.
Elaine: The device itself was very easy to use – unlike insulin pumps, there isn’t much calculation involved. All you have to know is how much insulin you have to administer with your meal. The Finesse is for bolusing, not for basal insulin – that is taken care of by Lantus or Levemir. Another great thing about the Finesse is, because basal insulin is taken care of through other means, this is a very small device that can easily be applied on the abdomen.
That being said, I think the Finesse will be great for both people with type 1 diabetes and people with type 2 diabetes. Some of the people I see (both type 1 and type 2) didn’t want to inject themselves in public, even if they had insulin pens. Others did not like the idea of wearing pumps because they thought it would remind them too much about their diabetes. They felt pumps were too bulky and did not think there was a way to conceal them well. Consequently, they would often omit bolusing at mealtimes. Even though they had been eating carbs and knew they needed insulin, they just couldn’t bring themselves to carry insulin around with them all the time. For the people I just described, the Finesse was a great solution. It was easy to use and inconspicuous – all people need to do is click the button and it injects insulin without any programming or even lifting up their shirts. They just had to count clicks to make sure they administered the proper amount of insulin.
Overall, I think Finesse is a real breakthrough because it’s small, and it’s easy to use. The reservoir can hold up to three days worth of insulin. Every single participant in the study I encountered thought it was a good device. The only negative side is the waste associated with the device because of all the disposable elements. That’s a major downside for the environment. I am waiting for the next phase of the device and look forward to new improvements.
Kelly: It’s great to get your views on insulin delivery. It sounds like Finesse might be most attractive to those who don’t pump at all today. Ultimately, do you think the Finesse will make the biggest impact because it is discreet, because it is small, or because providers can train people with diabetes easily about its use?
Elaine: I would say it’s a combination of the three factors you just mentioned. The Finesse is definitely easy to use – I am not a tech savvy person, and I was able to train others in its use. Everything about the device is pretty intuitive, although the reservoir can initially be difficult to fill. After people learn how to fill the reservoir, they need to fill it every three days, so it becomes a lot easier over time. Most people I talked to really like the fact that it was discreet and could easily be concealed underneath a T-shirt. So, in summary, I would say discreteness, size, and ease of use all contribute to the Finesse’s potential adoption upon introduction. I don’t know how much the device will cost, but I’m quite certain it will be more affordable than pumps, and there shouldn’t be a contract to sign either.
Vincent: Shifting gears a little bit again, can you tell us how you’re using CGM in your practice? There was definitely increased enthusiasm at this year’s meeting from many educators and we wondered how your own views fell.
Elaine: At our facility, we are very fortunate to have an endocrinologist who specializes in CGM. We run a CGM clinic every week, in which our certified diabetes educators provide intensive education that teaches people how to insert and use the device and how to maintain it for the week as blood glucose levels are being recorded. After a week, a physician interprets the readings and gives tips to people on how to better manage their diabetes. Our clinics are a real eye-opener for many people, especially those who have a lot of fluctuations in their glucose levels because they are able to see all the patterns in their daily highs and lows. Even though not all of these people buy CGM devices in the end, our clinic is able to provide patients with greater insight into their daily fluctuations, allowing for better management in and outside of the clinic setting.
Vincent: What are your thoughts broadly about CGM? Do you think there is a benefit for people with type 2 diabetes to use CGM?
Elaine: I definitely think CGM is valuable for both people with type 1 and people with type 2 diabetes. With CGM, people can potentially identify some elements in their daily lives that contribute to fluctuations in their blood glucose, ultimately allowing for them to manage their glucose levels better. By wearing CGM, people are able to see if they’re trending up or down in glucose levels, which they would not have been able to otherwise. Even though CGM marks great progress from SMBG, there are still some issues with CGM devices that need to be improved. At the onset of use, you need to calibrate CGM devices, and sometimes there are occasions when the device doesn’t provide glucose data, alerts, or trending information because of sensor irregularity. In particular, one device was problematic for some patients when they started using it because it gave a lot of false alarms. Furthermore, CGM devices require a lengthy initial start-up period of two to ten hours and then calibration.
final thoughts
Vincent: What final words of advice do you have for other diabetes educators?
Elaine: First of all, increase your knowledge base by looking at both online and print materials and by attending educational conferences and meetings. Education is the key to developing the skills that will increase your options and marketability in the future. It will also allow you to understand the specialty and where it is headed. Next, engage in advocacy initiatives to help make our voices heard – we need to draw greater attention to the importance of diabetes education and self-management in the public arena. Engaging in advocacy initiatives will enable you to become more aware of the issues facing our practice and the welfare of our patients. Lastly, network with colleagues around the country so that you can learn about new and different diabetes education teaching techniques, resources, and experiences that will ultimately help you become a more effective educator.
Benjamin: What final words of advice do you have for doctors?
Elaine: It must be very stressful for primary care providers in today’s environment. They face many pressures including increased patient demand and a reduction in the total number of providers. In order to meet these challenges, I noticed that some organizations are advocating for a new model of care called the “Medical Home”. This model is based on a team approach that focuses on collaboration with mid-level providers like diabetes educators and dietitians. I believe that the future of primary care will ultimately involve a team-based approach to reach out to high-risk patients, improve chronic disease care, and strengthen prevention efforts. Physicians should be aware of the value of diabetes educators since they provide evidence-based and patient-centered care. Diabetes educators have a unique skill set that centers on behavior change strategies and diabetes self-care management. Given how important diabetes self-management education is for improving the self-management skills and health of individuals with diabetes, the diabetes educator is an essential member of the care team and can provide the support that is so badly needed.
Kelly: Great question! What final words of advice do you have for people with diabetes?
Elaine: I would recommend that all individuals with diabetes engage in the “AADE7” self-care behaviors, which is a set of seven behaviors that can really help individuals with diabetes achieve the best health possible. These behaviors include: healthy eating, being active, monitoring, taking medications, problem solving, reducing risks, and healthy coping. Let me elaborate on a few of them. Healthy eating involves choosing healthy food options, understanding the importance of portion sizes, and timing food intake. Being active involves regular physical activity, which helps to keep blood sugar, blood glucose, and cholesterol in check. Monitoring provides valuable information that individuals with diabetes can use to make better decisions about their treatment, reducing the number of decisions made on best guesses. When taking medications, it is critical to know how the medications work, what their side effects are, and how to store and administer the drug. Participating in discussions with your diabetes educator can also help you solve issues in your diabetes management, reduce your risk of short-term and long-term complications, and learn various strategies for healthy coping to handle the emotional and social aspects of diabetes. I would definitely urge everyone with diabetes to discuss the AADE7 self-care behaviors with a diabetes educator to get the most out of their visits.
Kelly: Elaine, thank you so much for your time, and congratulations again on receiving the AADE Educator of the Year Award!
