AADE 2008 PEARLS
This was another fun, fact-filled, useful AADE event. It was the first international conference with many attendees from various countries, and presidents of diabetes educator associations from Spain, Mexico, Canada, Australia, Taiwan, European Nurses, India, and New Zealand. Notes listed in order of programs attended with my reactions listed in blue.

The theme put forward by our President, Amparo Gonzales—embrace change! Our landscape has and will continue to change. There are 12,000 AADE members, 15,000 CDEs, or 1 CDE per 2,000 patients in the US. We need to diversify our delivery system into primary care settings, community/employer-based wellness, and disease management.

#1 pearl: knowledge is just that—knowledge. It does not translate into action.
It doesn’t matter what the patient knows about diabetes. The question is what will inspire the patient to make behavior change. Polonsky used a quote from William Butler Yeats to make the point we need to light the fire of inspiration of diabetes care and education, “Education is not the filling of a pail, but the lighting of a fire.”

Diabetes education effectiveness in the US and abroad
Polonsky reviewed diabetes education (DE) effectiveness and had many brilliant points about goal setting. According to the Cochrane review of 11 studies of DE in the US shows many patients do well in the short term, but many don’t demonstrate improvement in diabetes outcomes (used A1C to measure – decreased 1.4% in 4-6 months, and 0.8% at 12 months).

In Italy, reviewed groups over 5 years and measured A1Cs (42 pts in control and intensive arms). The control group had A1C at baseline of 7.3, and 5 years later climbed to 9.0. The intensive group had a baseline of 7.4, and 5 years later stayed at 7.3. How?

1. Kept program simple. Curriculum kept to a minimum of essential components via hands on activities, group work, problem solving, real live situations.
2. Made it real.
3. Avoided shaming. Mistakes not criticized, but used as a source of positive learning.

In Sweden, 2 groups over 9 months. The control group had an average A1C at baseline of 5.8, and 5 years later, climbed to 7.1.The intensive group had a baseline of 5.7, and 5 years later stayed at 5.7. How?

1. Everything in the program was personally meaningful.
2. No agenda, no curriculum.

5.7 at baseline? Let’s tell our patients to move to Sweden!

In the United Kingdom with the X-PERT Programme, 6 two hour sessions, 300 people. The control group had A1C at baseline of 7.7, and 14 months later climbed to 7.8. The intensive group had a baseline of 7.7, and 14 months later stayed at 7.8. How?

1. Kept it simple.
2. Didn’t overwhelm pts with structure.
3. Patient received and examined their personal health results (A1C, etc), reviewed the implications of them and acceptable ranges.

EVOLUTION OF DSME
(Still Polonsky)
Late 20^th Century-targeted knowledge.
Strategies were to provide more info, but it didn’t change behavior. Knowledge is never enough.

Early 21^st century – targeted behavior change.
Focusing on behavior is problematic. May not focus on the most critical behavior. Knowing what to do and even planning what to do, may not lead to long term behavior change. Goal setting may potentially be de-motivating if it’s not clear which one to focus on that gives the most bang for their buck. (He gave the example of a pt that set a goal of increasing water consumption – with an A1C of 12. Although pts need to choose what to focus on, it is our job to provide them with info on the efficacy of their choices. In the list of 100 things that will help bring down your A1C, drinking water may be the 100^th thing. As long as you know this, you are making an informed decision. What do you think is at the top of the list? Taking medicine, exercise, eating.) 

2008 – targeting belief systems.
In particular, if we promote what he termed “worthwhileness”, we can help our patients believe that diabetes management is worth their effort, then everything else will follow.
Contributors to perceived worthwhileness:
1.      Personally meaningful. Is participation worth their effort? Are they awake and interested? Strategies: follow pts agenda, provide personal metabolic feedback. ADA website has a “Personal Health Decision” tool where you enter in current and target A1C values, you get nifty color charts for pts to see how their risk for MI, stroke, dialysis, eye/foot problems improves with better care.

2.      Hope. Positive long-term outcomes are possible. Strategies: provide clear, data driven messages of hope. Use true or false questions. For example, diabetes is the leading cause of adult blindness, amputation and kidney failure. Then say FALSE. It’s POORLY controlled diabetes. Well controlled diabetes is the cause of …nothing. He asks the question, “How do you think diabetes will get you?” and “What so you think your odds are of getting that complication?” Many pts have fatalistic belief systems wherein they believe their fate is that of their parents, etc, and may not bother trying if they don’t know their efforts will change their risk. (He gave the example of a woman who thought she had an 80% chance of dialysis. When he showed her risk that by lowering her A1C her risk of kidney problems dropped from 20% to 5%, she was relieved, only to become worried about her 50% risk of MI.)

He also showed a photo of Joslin 50-year medalists and explained the percentage of the 326 type 1s without complications were:
No retinopathy=52.1%
No neuropathy=49.7%
No macrovascular complications at all=46.6%

3.      Treatment efficacy. Believe treatment works. If you don’t, why would you continue? And if you’re not seeing tangible results, why bother? Strategies: show BG values of pre and post 30 minutes of walking for just one week. The example his patient gave showed an average of 40 mg/dl drop.

4.      Self-efficacy. “If I put out the effort will it work?” Have to believe that self care is doable. If you don’t, you’ll give up. If you don’t have the confidence, it predicts glycemic control.
Strategy: Before you leave, I want you to make an informed change. There are millions of ways to help control your diabetes; not all are equal. If it’s too small of a change, you might not see enough benefit. (I termed this the Goldilocks approach.) If it’s too much, you might get discouraged and give up. It’s got to feel right. Remember you can’t be perfect. Are you ready to make a change?

It’s not as powerful to focus on what you’re stopping doing. What are you going to start to do? (Allows the pt to feel less overwhelmed and more enthusiastic when we avoid focusing on deprivation behaviors. 

Goal setting

1. Meaningful for you. Know why you are bothering. Ask the pt why do you want to_____?
2. Realistic. Small, achievable targets.
3. Action oriented. To begin, not old actions to stop.
4. Implimentable. Plan your first steps. Is it doable?

The conceptual evolution of diabetes education:

08/11/08 by Theresa Garnero
Click here for a PDF version of this information

10/16/08