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First of all, there is a difference between skill acquisition and comprehensive diabetes self-management training. Effective education is essential for long-term improved health status. Diabetes self-management education goes beyond the passive relay of information and basic skill acquisition to a more intense coaching and understanding that results in behavior change and improved health status. The goal of diabetes education is to provide knowledge and skill training, as well as to help individuals identify barriers, facilitate problem solving, and develop effective coping skills to achieve sustainable health outcomes.
AADE has defined the health care outcomes continuum, which establishes that the unique outcome of diabetes education is behavior change. The steps in that continuum focus on four key areas. The initial step is immediate outcomes such as basic knowledge and skill acquisition. The intermediate outcome is behavior change. The post-immediate outcome is improved clinical indicators, and the final outcome is sustainability of lifestyle change and long-term improved health status. Diabetes education encompasses all four of these areas.
Insulin therapy initiation requires more comprehensive training than the simple skill acquisition of pen use. These include problem solving around meal planning and exercise, as well as managing hypo- and hyperglycemia.
All individuals with diabetes have the right to comprehensive patient education. Education is hardly a burden, but an essential component of diabetes care. Physicians and health care providers must recognize the urgent need to help individuals effectively self-manage their disease. Patients are the ones in control 24/7.
Today, there is an epidemic of diabetes in our country, and the level of control is sub-optimal. The missing link is comprehensive diabetes education. Literature supports the premise that informed, proactive individuals impact their care and sustain positive health outcomes. The medical community must embrace the future of health care and provide opportunities for individuals to live effectively with their disease if we are ever going to impact this epidemic.
Diabetes education is an essential component of diabetes management that needs to be respected and recognized if we are ever going to move the needle of chronic disease care in the U.S.
Donna Rice, MBA, RN, CDE
President, American Association of Diabetes Educators
Chicago
In his guest editorial, Dr. James Chamberlain does a good job of encouraging earlier use of insulin and supporting the use of pen delivery systems right up to the last line, where he ends with, "Gone are the days of burdensome patient education...."
What was he thinking? That the 5-minute pen demo is all the patient needs and we are "burdening" the patient with information about how insulin works, covering food, preventing and managing hypoglycemia?
Diabetes educators are almost an endangered species, and it is this attitude that is going to spell the end of the availability of effective self-management education for our patients. I am equally disappointed in the editorial staff of DOC News who selected this offending line to highlight in the middle of the article. Doesn't the American Diabetes Association (ADA) support the self-management education process for people with diabetes?
I know you support the use of educators and promote availability of diabetes education, but unfortunately, this is not true in the majority of primary care physicians, where much of diabetes care rests.
Virginia Valentine, CNS, BC-ADM, CDE
Diabetes Network, Inc.
Albuquerque, N.M.
I was sorry to read the closing statement in the recent, otherwise excellent editorial on insulin pens. While diabetes is certainly a burdensome disease, most patients find that diabetes education actually eases the burden by helping them better understand their illness, deal with their emotional issues and concerns, and accomplish the myriad behaviors needed to manage their illness.
This past year, a task force was jointly convened by ADA and the American Association of Diabetes Educators to revise the National Standards for Diabetes Self-Management Education (DSME), and considerable effort was made to increase accessibility to diabetes education.1
We believe that we were able to accomplish this goal, and I am very disheartened to see the myth that diabetes education is burdensome is still being promulgated.
Martha M. Funnell, MS, RN, CDE
Michigan Diabetes Research and Training Center
Ann Arbor, Mich.
RESPONSE FROM DR. CHAMBERLAIN:
I appreciate the responses from passionate diabetes educators. I certainly did not mean to imply that diabetes education is "burdensome." A better phrase might have been, "Gone are the days of burdensome and time-consuming teaching of injection therapy with vial and syringe."
I continue to maintain, however, that with the advent of pen devices, the teaching of injection therapy can be done and should be done quite easily, and in only a few minutes, in the primary care setting. The persistent misconception that the initiation of injection therapy is overly time-consuming and difficult needs to be dispelled. All too often, the argument that starting injection therapy in primary care is too difficult and requires formal diabetes education seems to be used as an excuse to not offer appropriate therapy in a timely manner.
In fact, a study presented at the ADA Scientific Sessions in 2006 showed that progressing from basal to intensive basal-prandial insulin therapy can most likely be accomplished efficiently and safely with the use of a simple algorithm used by providers to adjust mealtime insulin doses weekly, with results equivalent to those of intensive diabetes education using insulin-to-carbohydrate ratios.1 While this study does not imply that diabetes education is not important, it does imply that the use of appropriate, intensive insulin therapy can and should be implemented in the primary care setting.
Not all primary care providers have the ability to get their patients diabetes education in a timely manner. This should not preclude the timely, aggressive, and appropriate use of injection therapy, especially given the relative ease of teaching the use of pen delivery devices.
Know also that my belief that diabetes educators are "worth their weight in gold" will never change.
For many patients with type 2 diabetes, starting a fixed mealtime glulisine dose and adjusting to target with a simple algorithm is as safe and effective as using an insulin-to-carbohydrate ratio.
Correction
Regarding the article, "A Provider Primer on Omega-3" (DOC
News, September 2007, page 6), it should be noted that the drug
discussed—Omacor (omega-3-acid ethyl esters, Reliant)—has since
undergone a name change to Lovaza. Also, on first mention, the triglyceride
level for the drug dose was incorrectly listed as >500 mg/dl. The correct
triglyceride level is 
500 mg/dl, as noted in the second mention.
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