The Role of The Certified Diabetes Educator

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The Role ofThe Certified Diabetes Educator
The Certification Process

• Brenda Jagatic, BSN, RN, CDE

2
Objectives

• Overview of Diabetes in America
• Role of the Certified Diabetes Educator
• The Certification Process

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Who Has Diabetes in the U.S.?

• 20.8 million people have diabetes
• 70 are diagnosed
• 30 do not know they have diabetes

ADA 2008
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Who Has Diabetes in the U.S.?

• 14.6 million diagnosed with diabetes
• Type 1 5-10
• Type 2 90-95

ADA 2008
5
Types of Diabetes

• Type 1 Diabetes
• Pre-Diabetes
• Type 2 Diabetes
• Gestational Diabetes

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Type 1 Diabetes

• Causes
• Genetics loads the gun
• and environment
• pulls the trigger
• Treatment
• Need insulin for life
• Lifestyle

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Basal/Bolus/Correction

• Basal- the amount of insulin to run the
• body 24 hours a day
• Bolus- the amount of insulin needed to
• cover food eaten
• Correction- the amount of insulin needed
• to correct high blood glucose

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Delivery of Basal/Bolus/Correction

• MDI-Multiple Daily Injections
• At bedtime injection of long-acting insulin
• Before meals injection of rapid-acting insulin
• CSII-Continuous Subcutaneous Insulin Infusion (
  insulin pump)
• Uses rapid-acting insulin.
• Basal given continuously, around the clock
• Bolus for food with meals and snacks.

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Insulin Delivery

• syringe insulin
  insulin
• and vial pens
  pump

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The History of Insulin Pumps
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• And now

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Types of Pumps
Medtronic-Minimed Animas Deltec Cozmo Accu-Chek
Spirit Omni-pod
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Pre-Diabetes Blood glucose greater than normal
but not in diabetic range

• Causes
• Genetic
• Lifestyle
• Other
• Treatment
• Lifestyle changes
• Medication

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Who Has Pre-Diabetes in the U.S.?

• 54 million people have pre-diabetes
• Unless these individuals make significant
  lifestyle changes, many will develop type 2
  diabetes

ADA 2008
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Goals for Pre-Diabetes

• 30 minutes of exercise/day and a
• 5-10 weight loss reduced the risk
• of developing diabetes by 58
• Diabetes Prevention Program Research Group
• New England Journal of Medicine 2002393-403

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Type 2 Diabetes

• Causes
• Genetic
• Lifestyle
• Treatment
• Lifestyle changes
• Medication

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Whos at Risk for Type 2?

• High cholesterol
• High blood pressure
• Diabetes during pregnancy
• Inactivity
• Overweight
• Family history of diabetes
• African American, American Indian, Hispanic,
  Asian, Alaska Native, Native Hawaiian or Pacific
  Islander

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Obesity and Type 2 Diabetes

• The increase in Type 2 Diabetes in
• the United States correlates with the
• epidemic of obesity
• 85 type 2 patients are overweight

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Obesity Trends Among U.S. AdultsBRFSS, 1985
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
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Obesity Trends Among U.S. AdultsBRFSS, 1990
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
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Obesity Trends Among U.S. AdultsBRFSS, 1995
Source Mokdad A H, et al. J Am Med Assoc 1999
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Obesity Trends Among U.S. AdultsBRFSS, 2001
Source Mokdad A H, et al. J Am Med Assoc 1999
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How Type 2 Diabetes Develops and Changes Over Time
Insulin Resistance
Insulin Production
Blood Glucose
Source IDC, 2000
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Type 2 Diabetes

• Insulin resistance
• Initially may have high insulin production
• Lifestyle and Oral agents initial treatment
• Most patients will eventually need insulin
• Type 2 diabetes is a progressive disease
• Important to be aggressive in getting A1c less
  than 7 to reduce risks of complications
• N. Emanuele, MD and G. Moto, MD 9/28/07

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Gestational Diabetes

• Occurs around 24th-28th week
• Hormones produced by placenta block the effect of
  insulin in the mothers body leading to insulin
  resistance
• Managed by diet and exercise in most cases
• Resolves at delivery, but there is
  risk for type 2 diabetes for mother
  2 - 15 years later
  in life
• Source Core Curriculum for Diabetes Education
  Diabetes
• In the Life Cycle and Research Ch 5 Gestational
  Diabetes

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The Role of a Certified Diabetes Educator

• provide diabetes
• self-management
• education training

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The Empowerment Model

• Interactions are based on the patients agenda
• Important to listen to patients concerns/goals
• Adopt a nonjudgmental attitude- key for patient
  to discuss problems without fear of being
  criticized
• Develop a plan that is formulated with the
  patient
• The educator and the patient work as a team
• Source Susan Cornell, BS, PharmD, CDE, CDM
  Assistant Professor, Midwestern University,
  Clinical Pharmacy Consultant 1/19/08

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Author James S Hirsch, in Cheating Destiny
Living with Diabetes, Americas Biggest Epidemic

• The most important provider for any chronic
  disease is the patient himself, which places the
  highest priority on education and trainingI
  believe most diabetics, given the tools and
  training, are willing to discipline themselves to
  stay healthy

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AADE 7 Self-Care Behaviors

• Healthy Eating
• Being Active
• Blood Glucose Monitoring
• Medication
• Problem-Solving
• Reduce Risks of Complications
• Healthy Coping
• Source The Diabetes Educator Volume 33, Number 6
  Nov/Dec 2007

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1. Healthy Eating

• Nutritional counseling
• Healthy eating most of the time
• Moderate carbohydrate intake
• Heart healthy eating
• No forbidden foods
• Maintain pleasure of eating
• Source The Diabetes Educator Volume 33, Number
  6,
• Nov/Dec 2007
• Diabetes and Healthy Eating A Commentary
  Elswick,B et al

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2. Being Active
Possible Benefits 1. Better BG control 2.
Reduced risks of complications 3. Increased
insulin sensitivity 4. Facilitate weight loss 5.
Stress management 6. Improve depression 7.
Improve cardiovascular fitness 8. Improve lipid
and BP control Source The Diabetes Educator
Volume 33, Number 6 Nov/Dec 2007. Interventions
for Being Active Among Individuals with Diabetes
Kavookjian, J et al
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2. Being Active (cont.)

• Using Motivational Counseling the CDE can help
  the individual
• Design, implement and evaluate plan for regular
  physical activity
• Select activities patient enjoys
• Identify barriers
• Set realistic goals
• Integrate regular physical activity into
  lifestyle
• Source The Diabetes Educator Volume 33, Number
  6, November/December 2007
• Interventions for Being Active Among
  Individuals with Diabetes Whetsel et al.

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3. Blood Glucose Monitoring

• Self-monitoring of Blood Glucose (SMBG)
• Hemoglobin A1c (HgbAlc)
• Continuous Blood Glucose Sensors

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SMBG Teaching how to use a Blood Glucose Meter

• How to use a meter
• When to test and why
• Blood glucose targets
• Evaluating blood glucose readings
• What to do when BG high or low
• Analysis what effects your BG?(food, activity,
  stress, pain, illness, meds)

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SMBG Key points to review

• Be objective
• Be a detective
• Highs lows can happen sometimes, even when you
  do everything right
• Data collection-identifies areas needing some
  work
• Why some patients stop testing
• Source The Diabetes Educator Volume 33, Number
  6, November/December 2007
• Self-monitoring of Blood Glucose A Commentary
  Martha Mitchell Funnell, MS,RN, CDE

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Approximate comparison of blood glucose and A1c
values
Blood Glucose Levels
Percentage
Yellow Zone 6.5 -7.0
Normal 4-6
Normal 60 135 mg/dl
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Continuous Blood Glucose Sensor

• Gain insight into blood glucose patterns for
  optimal diabetes care
• Formerly only available to people wearing insulin
  pumps

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4. Medication

• Teach patient about their diabetes meds
• How to take meds
• How they work
• How to evaluate effectiveness of drug
• Possible side effects
• What to do when a dose is missed

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Medications Adherence to medical regimen can

• Improve blood glucose control
• Reduce morbidity
• Reduce mortality
• Reduce health care costs
• Source Ho PM, et al. Effect of medication
  nonadherence on
• Hospitalizations and mortality among patients
  with diabetes
• Mellitus. Arch Intern Med. 2006. 166 1836-1841.

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Adherence to Medical RegimenPossible Barriers

• Cost
• Complex regimen
• Frequency of dosing
• Self-confidence
• Inadequate education on treatment
• Depression
• Side effects or fear of side effects
• Fear of weight gain
• Inconvenience
• Inadequate supports

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Insulin therapy in type 2 diabetes

• Under-used! Under-prescribed!
• Insulin therapy has a unique set
• of challenges education,
• follow-up and monitoring
• Source The Diabetes Educator Volume 33,
  Number 6, Nov/Dec 200
• Medication Taking and Diabetes Odegard,
  P et al.

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Reasons for avoidance of insulin therapy when
indicated

• Sense of personal failure
• Pain of injection
• Needle phobia
• Belief that insulin leads to an increase in
  severity of diabetes
• Permanence-on insulin for the rest of your life
• Hypoglycemia
• Source Polonsky,WH et al. Psychological insulin
  resistance in patients with type 2 diabetes the
  scope of the problem. Diabetes Care 200528(1)
  2543-2546

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Insulin pump therapy

• Patient with type 2 diabetes for 20 years
• Insulin dependent
• Next slide pump download after first week on
  insulin pump

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5. Problem solving

• Help patient to know what to do if
• Has hypoglycemia
• Has hyperglycemia
• Has lows after exercise
• Feels sick and not wanting to eat
• Type 1 diabetes and has large ketones
• Pump failure

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6. Reducing Risks of Complications

• High blood glucose levels can cause serious
  health complications.
• But, damage can be prevented, slowed or delayed
  with good control.
• Research demonstrates keeping HgbA1c less than 7
  can reduce risks of complications.

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Complications that can occur

• Heart disease and stroke
• Retinopathy
• Nephropathy
• Neuropathy
• Infections
• Depression

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Informing patients how to reduce risks of
complications

• Resources for smoking cessation
• Yearly dilated eye exam
• Learning the signs of a stroke
• Apply lotion to feet daily

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7. Healthy coping

• From the outside, diabetes looks like it should
  be fairly simple. After all, all you have to do
  is take your insulin or oral meds every day at
  the right time and in the right amount, eat
  perfectly without ever cheating, check your
  blood glucose regularly and exercise frequently.
  Balance these tasks with each other so that your
  blood glucose never gets too low or too high.
  Stay vigilant at all times in case anything goes
  wrong
• 
  William Polonsky

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Depression

• 2X greater in patients with chronic disease like
  diabetes
• Very difficult to look after diabetes if you are
  depressed
• Screening for depression important part of
  assessment

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• Becoming a
• Certified Diabetes
• Educator

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What Career Opportunities are Available?

• In-Hospital Diabetes Management
• Outpatient Diabetes Education Center
• School nurse
• Corporate Health
• Education
• Research/Development
• Sales (pharmaceutical companies)
• Government
• CDE in Primary Care
• CDE in Endocrinologist office setting

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Criteria to write certification exam

• Hold a current, active unrestricted license from
  the United States as RN, RD,MD, PharmD, OT, PT
• 1,000 paid hours of documented diabetes education
  submitted to NCBDE a minimum of 2 years (to the
  day) within the past 5 years
• Current employment in a defined role as a
  diabetes educator at time of application

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For more information contact

• National Certification Board for Diabetes
  Educators
• Phone [phone]
• Fax [phone]
• www.ncbde.org
• info_at_ncbde.org

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Professional Memberships

• American Association of Diabetes Educators (AADE)
• subscription to The Diabetes Educator
• purchase the 4 book series The Core Curriculum
• consider attending the annual meeting
• Diabetes Educators of Chicago chapter of AADE
  (DECAADE)
• consider attending monthly educational meetings
• American Diabetes Association(ADA)
• professional journals as well as Diabetes Forecast

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Recommended Web Sites

• American Association of Diabetes
  Educatorsaadenet.org
• American Diabetes Associationdiabetes.org
• American Dietetic Associationeatright.org
• National Diabetes Education Programndep.nih.gov
• Centers for Diabetes Control and
  Preventioncdc.gov/diabetes
• National Institute of Healthnih.org

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Additional Recommendations

• Volunteer at one of the ADAs camps
• dLife program on CNBS Sundays 6pm
• Volunteer at a free clinic to get additional
  experience
• To obtain a full copy of this power-point
  presentation, go to www.decaade.org