Caring for people with diabetes: A fresh look at an old disease.

ABSTRACT: This article describes current evidence-based approaches to the care and education of adults living with diabetes. It also highlights revisions in the 2022 Standards of Care and evidence-based strategies nurses can use to be more effective.

One size does not fit all: Nutrition strategies for people with diabetes.

Several nutrition strategies and eating patterns can help support self-management among persons with diabetes. This article details the effectiveness of popular eating patterns and nutrition strategies, as well as the role of nurses in facilitating informed patient choices and decisions.

Diabetes: Changing the conversation.

Nurses can make a difference by carefully considering the language they use to talk to or about patients with diabetes. This article discusses the importance of words and messages in healthcare, particularly in diabetes education.

Keeping up-to-date with diabetes care and education.

The American Diabetes Association publishes standards of care that are updated annually by a panel of experts in nursing, education, behavior, psychology, nutrition, pharmacology, and medicine. This article describes current evidence-based approaches to care and education for adults and highlights revisions in the 2018 Standards of Care that are relevant to nurses and patients with type 2 diabetes.

Effect of a patient decision aid (PDA) for type 2 diabetes on knowledge, decisional self-efficacy, and decisional conflict.

BACKGROUND: Patients with type 2 diabetes (T2DM) often have poor glycemic control on first-line pharmacologic therapy and require treatment intensification. Intensification decisions can be difficult because of many available options and their many benefits and risks. The American Diabetes Association recommends patient-centered, evidence-based tools supporting shared decision-making between patients and clinicians. We developed a patient decision aid (PDA) targeting decisions about treatment intensification for T2DM. Our objective was to determine the effectiveness of this PDA for patients with T2DM on metformin who require treatment intensification. METHODS: This study was a pragmatic randomized controlled trial conducted in 27 US primary care and endocrinology clinics. Subjects were English-speaking adults with T2DM receiving metformin with persistent hyperglycemia who were recommended to consider medication intensification. Subjects were randomized to receive either the PDA or usual care (UC). Main outcome measures were change in knowledge, decisional self-efficacy, and decisional conflict. RESULTS: Of 225 subjects enrolled, 114 were randomized to the PDA and 111 to UC. Mean [SD] age was 52 [1] years, time since T2DM diagnosis was 6 [+/-6] years, 45.3% were male, and most (55.5%) were non-Caucasian. Compared to UC, PDA users had significantly larger knowledge gains (35.0% [22.3] vs 9.9% [22.2]; P < 0.0001) and larger improvements in self-efficacy (3.7 [16.7] vs-3.9 [19.2]; P < 0.0001) and decisional conflict (-22.2 [20.6] vs-7.5 [16.6]; P < 0.0001). CONCLUSIONS: The PDA resulted in substantial and significant improvements in knowledge, decisional conflict and decisional self-efficacy. Decisional conflict scores after PDA use were within the range that correlates with effective decision-making. This PDA has the potential to facilitate shared-decision-making for patients with T2DM. TRIAL REGISTRATION: NCT02110979.

Role of Emerging Insulin Technologies in the Initiation and Intensification of Insulin Therapy for Diabetes in Primary Care.

In Brief This article explores some of the reasons for the delay in insulin initiation in primary care and evaluates new approaches to insulin therapy that may address these barriers and, therefore, improve insulin use by primary care providers.

Peer-Led, Empowerment-Based Approach to Self-Management Efforts in Diabetes (PLEASED): A Randomized Controlled Trial in an African American Community.

PURPOSE: We compared a 3-month diabetes self-management education (DSME) program followed by a 12-month peer support intervention with a 3-month DSME program alone in terms of initial and sustained improvements in glycated hemoglobin (HbA1c). Secondary outcomes were risk factors for cardiovascular disease (CVD), diabetes distress, and social support. METHODS: We randomized 106 community-dwelling African American adults with type 2 diabetes to a 3-month DSME program followed by 12 months of weekly group sessions and supplementary telephone support delivered by peer leaders or to a 3-month DSME program with no follow-up peer support. Assessments were conducted at baseline, 3, 9, and 15 months. RESULTS: No changes in HbA1c were observed at 3 months or at 15 months for either group. The peer support group either sustained improvement in key CVD risk factors or stayed the same while the control group worsened at 15 months. At 15 months, the peer-support group had significantly lower low-density lipoprotein cholesterol levels (-15 mg/dL, P = .03), systolic blood pressure (-10 mm Hg, P = .01), diastolic blood pressure (-8.3 mm Hg, P = .001), and body mass index (-0.8 kg/m(2), P = .032) than the DSME-alone group. CONCLUSIONS: In this population of African American adults, an initial DSME program, whether or not followed by 12 months of peer support, had no effect on glycemic control. Participants in the peer-support arm of the trial did, however, experience significant improvements in some CVD risk factors or stay approximately the same while the control group declined.

The Michigan Men's Diabetes Project Randomized Clinical Control Trial: A Pilot/Feasibility Study of a Peer-Led Diabetes Self-Management and Support Intervention for Black Men With Type 2 Diabetes.

Black men are disproportionately affected by type 2 diabetes (T2D) and experience higher diabetes-related complications than non-Hispanic White men. To address the complex barriers in diabetes self-management for Black men, we implemented a 3-month peer-led and empowerment-based Diabetes Self-Management Education (DSME) and Support (DSMS) intervention in Metro Detroit. Twenty-five Black men ≥55 years of age with self-reported T2D were randomized to the intervention group (n=12)-10 hr of DSME and 9 hr of DSMS-or enhanced usual care (EUC) group (n=13)-10 hr of DSME. Peer leaders (n = 3) were trained by certified diabetes care and education specialists (CDCESs) to cofacilitate the support sessions. Outcomes (hemoglobin A1c [HbA1c], diabetes self-care activities, and diabetes distress) were assessed preintervention and postintervention. In the intervention and EUC groups, mean HbA1c decreased by 0.20% (p = .52, SD = 0.99) and 0.13% (p = .68), respectively. General diet (p = .03, M change: 1.32, SD = 1.71) and blood glucose monitoring (p < .05, M change: 0.50, SD = 0.74) scores improved among those in the intervention group. General diet scores also improved in the EUC group: mean change: 1.77, p = .08, although changes were not statistically significant. Changes in diabetes distress scores differed based on the number of sessions attended, with a significant decrease in those attending 7 to 12 sessions (n = 7), >50%, (p = .003, M change: -5.71, SD = 3.20). Implementing a peer-led DSMS program for Black men was feasible, adopted, and led to positive changes in outcomes. Scaling up the intervention and assessing sustainability is warranted.

Improving nurses' perceptions of competency in diabetes self-management education through the use of simulation and problem-based learning.

Nurses who provide case management can improve care practice and outcomes among patients who have type 2 diabetes through appropriate training and systems of care. This study was conducted to improve ambulatory care nurses' perceptions of competency in empowerment-based skills required for diabetes self-management education after participation in a multifaceted educational session that included problem-based learning and simulation. After participation in the multifaceted educational session, nurses (n = 21) perceived that the education provided an excellent opportunity for knowledge uptake and applicability to their respective work settings. The learning strategies provided opportunities for engagement in a safe and relaxed atmosphere. The simulation experience allowed participants to deliberately practice the competencies. These nurses considered this a very effective learning activity. Through the use of problem-based learning and simulation, nurses may be able to more efficiently and effectively develop the necessary skills to provide effective case management of chronic disease.

The AH-HA! Project: Transforming Group Diabetes Self-Management Education Through the Addition of Flash Glucose Monitoring.

Background: The majority of individuals referred to diabetes self-management education and support (DSMES) programs do not access this resource. Of those who do, attrition is high, with anecdotal reports pointing to the didactic and impersonal nature of these programs contributing to low utilization and completion rates. In an effort to develop a more engaging form of DSMES for adults with type 2 diabetes (T2D), we constructed a nondidactic "discovery learning"-based DSMES program centered on real-time flash glucose monitoring (FGM). Methods: In this single-arm pilot study, 35 adults with T2D duration 1-5 years, ages 21-75 years, not using insulin and HbA1c ≥8.0% were introduced to FGM and participated in five weekly group sessions. DSMES content was personalized, emerging from the concerns and questions arising from participants' FGM discoveries. The primary outcome was glycemic change as assessed by blinded FGM at baseline and month 3. Secondary outcomes included psychosocial and behavioral measures. Results: There was a significant gain in percentage time in range (% TIR) 70-180 mg/dL from baseline (55%) to month 3 (74%), and a parallel drop-in percentage time above range (TAR) >180 mg/dL from 44% to 25% (Ps = 0.01). Overall well-being rose significantly (P = 0.04), whereas diabetes distress showed a nonsignificant drop. Participants reported improvements in healthy eating (P < 0.001) and physical activity, although the latter did not reach statistical significance. Conclusions: These findings support a new approach to DSMES, a method that integrates FGM with a highly interactive and engaging patient-driven "discovery learning" approach to education.

Standards of care for diabetes: what's new?

Each year, the American Diabetes Association (ADA) publishes standards of medical care for people with diabetes. The ADA updates these standards based on the latest evidence so that healthcare professional scan incorporate this evidence into their care. The standards also summarize and rate the levels of evidence on which the recommendations are based. This article describes new recommendations in the 2010 Standards of Medical Care in Diabetes (the 2010 Standards).

The therapeutic role of incretin mimetics and DPP-4 inhibitors.

PURPOSE: Gastric inhibitory peptide (GIP) and glucagon-like peptide-1 (GLP-1) stimulate the secretion of insulin when blood glucose levels are elevated and inhibit the postprandial release of glucagon. An increased understanding of the role of these incretin hormones in insulin and blood glucose regulation has resulted in the development of new types of medications for managing diabetes. GLP-1 agonists and dipeptidyl peptidase-IV (DPP-4) inhibitors are 2 classes of medications that have been shown to offer benefits for patients with type 2 diabetes. To use and teach patients how to use these medications effectively, educators need to understand their mechanisms of action, indications and contraindications, side effects, and effectiveness. Expanding the number of options available has increased the complexity of providing care and education, but also offers new opportunities to help our patients achieve better outcomes. CONCLUSION: This article provides an overview of the physiology of insulin regulation and the roles of GIP, GLP-1, and DPP-4; discusses how the action of incretin hormones is affected by diabetes; and describes the therapeutic agents in these classes and their potential use by people with diabetes.

Access to diabetes self-management education: results of national surveys of patients, educators, and physicians.

PURPOSE: To examine factors related to access to diabetes self-management education (DSME), including services delivered and sought; patient, physician, and program barriers to access; educator outreach and expansion efforts; and perceptions of alternative DSME delivery strategies. METHODS: Internet surveys were completed by 1169 adults with diabetes (661 with prior DSME, 508 with no prior DSME) from a national community survey panel, 1871 educators who were AADE members, and 629 physicians (212 diabetes specialists, 417 primary care practitioners) from a national physician survey panel. RESULTS: Physicians want patients to receive more self-management support, but some report that patients are told to do things with which the physician does not agree. Provider (physician and educator)-delivered DSME is more highly regarded among those who have received it than among those who have not received it. Physicians generally have positive perceptions of provider-delivered DSME, and educators see physicians as key to encouraging DSME use in patients. Some physicians are concerned about losing patients sent to DSME, and 11% of patients report changing physicians as a result of DSME. Most DSME programs have grown recently as a result of recruiting efforts and adding new programs/services; most programs plan more such efforts. Patients prefer traditional DSME sources/settings and are moderately accepting of media sources. CONCLUSIONS: Additional efforts are required to guarantee that all people with diabetes receive the DSME they need. This will require increased referral by physicians, increased follow-through by patients, and increased availability of DSME in forms that make it appealing to patients and physicians.