Guest Commentary: Dietitians Are Health and Wellness Gatekeepers

July 2017 Issue

Diabetes Management & Nutrition Guide: Guest Commentary: Dietitians Are Health and Wellness Gatekeepers
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
Today's Dietitian
Vol. 19, No. 7, P. 35

"No one wants diabetes. But if you're going to be diagnosed with diabetes, now is a pretty good time." This is the mantra I share with my patients who are newly diagnosed with diabetes. Today, we have new therapeutic agents that target the pathology associated with diabetes, novel personalized dietary approaches, technical advances in glycemic monitoring, and closed-loop technology to automatically deliver insulin. We have a heightened awareness of individuals at risk of diabetes, and we know how to treat and halt the progression of diabetes complications.1

But despite the progress we've made and all the tools we have available, achieving diabetes metabolic goals still remains suboptimal—particularly in some minority groups.2 Since the initiation of the National Diabetes Education Program in 1997, the percentage of people achieving glycemic, blood pressure, or cholesterol control goals (ABC) has increased. However, more recent evidence suggests that 33% to 49% of patients still don't meet ABC targets, and only 14% meet targets for all three measures and nonsmoking status.2,3

I believe the dichotomy between what we know about managing diabetes and the suboptimal levels of achieving metabolic goals is due, in large part, to health care providers not referring patients for diabetes self-management education and support (DSMES). Physicians and other providers too often don't appreciate the efficacy of DSMES. They may be confused about when and how to make referrals, have a misunderstanding of reimbursement issues, and/or have a misconception that one or a few initial education visits are adequate to provide patients with the skills needed for lifelong self-management.4

Dietitians who counsel people with diabetes know that even people who seek and receive high-quality medical care often need additional information. For example, a physician may advise patients to lose weight, watch carb intake, and avoid sugar. Good advice, but it leaves patients with questions. "What does that mean? And how should I do it?" "Will the latest diet craze help or hurt?" Too often, physicians assume patients can figure it out. But when patients leave a physician's office, feeling overwhelmed from a diabetes diagnosis and clutching a handful of prescriptions, they need a way to digest the information and make sense of it. DSMES provides the guidance, direction, and support they need to confidently and effectively manage their condition.

In fact, a 2016 systematic review published in Patient Education and Counseling by Chrvala and colleagues found robust data demonstrating that engagement in DSMES improves hemoglobin A1c by as much as 1% and has a positive effect on other clinical, psychosocial, and behavioral aspects of diabetes. DSMES also is reported to reduce the onset and/or advancement of diabetes complications, improve quality of life and lifestyle behaviors (eg, having a more healthful eating pattern and engaging in regular physical activity), enhance self-efficacy and empowerment, increase healthful coping, and decrease the presence of diabetes-related distress and depression.4

As dietitians and diabetes educators, we often serve as health and wellness gatekeepers for our patients. Therefore, it's imperative that we advocate for and promote DSMES to physicians and other health care providers. In a joint position statement by the American Association of Diabetes Educators (AADE), the American Diabetes Association, and the Academy of Nutrition and Dietetics, Powers and colleagues identified four critical times for assessing the need for a person with diabetes to be referred for DSMES.4 The times were identified as follows: 1) at diagnosis, 2) on a yearly basis for health maintenance and prevention of complications, 3) when new complicating factors influence self-management, and 4) when transitions of care occur.4 In addition to providing the evidence for the need for education at these times, Powers and colleagues developed a diabetes education algorithm to offer an evidence-based visual depiction of when to identify and refer individuals with diabetes to DSMES. The algorithm also pinpoints areas of focus and action steps that health care providers, educators, and patients with diabetes should consider at each of these times.

I encourage all dietitians and diabetes educators to read and use the full Joint Position Statement and algorithm by Powers and colleagues to proactively communicate these recommendations and benefits to providers who currently refer patients for DSMES as well as those who do not. Better yet, download the DSMES Joint Position Statement Toolkit from AADE at www.diabeteseducator.org. The toolkit provides a Position Statement Users Guide, printable education algorithm, PowerPoint slides, template letter to providers, and much more.

The ultimate goal is to move DSMES from a recommendation to an expectation. Think about it. If you fail to follow through on a referral from your physician for a mammogram, a colonoscopy, or blood work, you'll definitely hear about it at your next visit. DSMES should be treated with the same urgency as any other medical referral. Education and ongoing support are critical to our patients achieving metabolic goals and living well with diabetes.

— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is a member of the board of directors for the American Association of Diabetes Educators; a past national spokesperson for the Academy of Nutrition and Dietetics, specializing in African American nutrition; and author of The African American Guide to Living Well With Diabetes and Eating Soulfully and Healthfully With Diabetes. Her latest book Diabetes Guide to Enjoying Foods of the World will be published in the fall of 2017 by the Academy of Nutrition and Dietetics.

References
1. Cefalu WT. "TODAY" reflects on the changing "faces" of type 2 diabetes. Diabetes Care. 2013;35(6):1732-1734.

2. Stark Casagrande S, Fradkin JE, Saydah SH, Rust KF, Cowie CC. The prevalence of meeting A1c, blood pressure, and LDL goals among people with diabetes, 1988–2010. Diabetes Care. 2013;36(8):2271-2279.

3. American Diabetes Association. Strategies for improving care. Diabetes Care. 2016;39(Suppl 1):S6-S12.

4. Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educ. 2015;41(4):417-430.