Teaching Diabetes Self-Management

TeachingDiabetesSelf-Management—in4Hours(orLess)

h=p://bit.do/b3SSy

LindaSGo*redson,PhD

SchoolofEduca7onUniversityofDelaware

KathyStroh,MS,RD,CDEDiabetesPreven7onandControlProgram

DelawareDivisionofPublicHealth

1

CEHDColloquium,UniversityofDelaware,February28,2013

Juvenile Diabetes Maturity-onset Diabetes Insulin dependent Non-insulin dependent Diabetes (IDD) Diabetes (NIDD)

Type I Diabetes Type II Diabetes Type 1 Diabetes Type 2 Diabetes

Types of Diabetes

2

Types of Diabetes (DM)

Type 1 β-cell destruction; autoimmune disease; complete lack of insulin 5-10% of total patients

Type 2 β-cell dysfunction and insulin

resistance Gestational β-cell dysfunction and insulin

resistance during pregnancy

3

There is no such thing as Borderline Diabetes

or a “Touch of Diabetes.”

Pre-diabetes is a diagnosis.

4

There is no such thing as Borderline Diabetes

or a “Touch of Diabetes.”

5

Pre-diabetes

DM defects

6

Diabetes is a cardiovascular disease.

The Burden of Diabetes in Delaware, 2009. Diabetes Prevention and Control Program

People with diabetes are

twice as likely

to suffer a heart attack

or stroke

compared to people without diabetes.

7

NaturalhistoryofType2diabetes

Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.

Obesity Diabetes Uncontrolled Hyperglycemia

50 100 150 200 250 300 350

50

100

150

200

250

Glu

cose

(m

g/dL

) R

elat

ive

Func

tion

(%)

-10 -5 0 diagnosis

5 10 15 20 25 30 Years of Diabetes

Post-meal Glucose

Fasting Glucose

Insulin Resistance

Insulin Level β-cell Failure

Insulin Resistance Family History

Prediabetes

Whyteachself-management?

•  PaXentsmustcontroltheirbloodglucose(BG)levelstoavoidcomplicaXons

•  ControllingBGisacomplex,24/7,life-longtask–  Rx’schange,increase;maynotinsureopXmalBGcontrol–  Changesindietaryintake&physicalacXvitynecessary–  Andmore…

•  Somuchtolearnanddo(orstopdoing)

9

PWD’s*everydayreality

* “Diabetic” is not a noun 10

11

12

13

As teacher educators, how would you recommend

teaching diabetes self-management?

Here’s the challenge

14

Privateschools

0.4milteachers5.4milpupils

$673 billion

15Federal

State

District

Federal

State

District

Regulations

Publicschools

3 million 50 million

Diabeteseduca7on??

$673 billion

16Federal

State

District

Federal

State

District

Regulations

Publicschools

3 million 50 million

InstrucXonLearningtasks

Privateschools

0.4milteachers5.4milpupils

Diabeteseduca7on??

Context:Explodingnumbers

12012Condi*onofEduca*on,TableA-3-1.h=p://nces.ed.gov/pubs2012/2012045_5.pdf2For1970,AllAgesisinterpolatedfrom1968and1973.h=p://www.cdc.gov/diabetes/staXsXcs/diabetes_slides.htm.3For1990and2010,Allagesand65+derivedfromh=p://www.cdc.gov/diabetes/staXsXcs/prev/naXonal/tnumage.htm,and18+fromh=p://www.cdc.gov/diabetes/staXsXcs/prev/naXonal/figadults.htm4Boyleetal(2010),ProjecXonoftheyear2050burdenofdiabetesintheUSadultpopulaXon.Popula*onHealthMetrics,8(29).Iaveragedtheresultsfromtheir4models.Huangetal.(2009)esXmated34.2MforType2alone:UsingclinicalinformaXontoprojectfederalhealthcarespending.HealthAffairs,28(5),w978-990.5CDC’sDiabetesData&Trends.h=p://apps.nccd.cdc.gov/DDT_STRS2/NaXonalDiabetesPrevalenceEsXmates.aspx,

Just5years!

Publicschools DiabetescasesNumberneedinginstruc7on

Millionsenrolled1 MillionsdiagnosedwithdiabetesType1or2(non-insXtuXonalizedcivilians)

FallofTotal

Elementary(preK-8)HS(9-12)

197045.532.513.0

199041.229.911.3

201049.534.614.9

202052.737.315.4

Allages

Adults(18+)Older(65+)

197023.6

199036.66.62.8

2010320.920.77.8

2020433.5

2004%diagnosedadults>20years52009

17

Average$/person2 4,310 7,925 10,694(2008)

11,093 6,745 1,834 466

Context:Explodingcosts

12011DigestofEduca*onSta*s*cs,Table28,h=p://nces.ed.gov/programs/digest/d11/tables/dt11_028.asp.Tablereportscostsincurrentdollars,soinflaXoncalculatorusedtobringupto2010values.22011DigestofEduca*onSta*s*cs,Table194,h=p://nces.ed.gov/programs/digest/d11/tables/dt11_194.asp3Dalletal.(2010).Theeconomicburdenofdiabetes.HealthAffairs,29(2),exhibit4.UsedinflaXoncalculatortotranslatedollarsfrom2007to2010.h=p://www.usinflaXoncalculator.com4Huangetal.(2009)UsingclinicalinformaXontoprojectfederalhealthcarespending.HealthAffairs,28(5),w978-990.IncludesType2only.Type1wouldbe<5%ofcasesbuthigherpercapitacost.InflaXoncalculatorusedtochangecostsfrom2007to2010dollars.5No2020-2030projecXonsavailableforschoolexpenditures,sojustrepeated%GDPfromtheprior2decades.UsedHuangetal.’stotaldiabetesmedicalcostsfor2007,togetherwith2007GDP,tocalculatecostsas%GDPinthatyear(1.1%).ThenusedtheirExhibit3(projectedrealgrowthasmulXpleofGDP)toesXmate%GDPin2010,2020,and2030.Nodatapriorto2007,sojusttooklinetowardasymtope.

Studentsinpublicschools,K-12 Diabetescases,diagnosedandundiagnosedTotalexpenditures(2010dollars)

Medicalcostsonly(2010dollars)

1970 1990 2010 20073 20204

Total$(billions)1

270

415

673

Type111

Type2111

Undiag12

Pre-diab27

Total160

Type2237

0.0

5.0

10.0

15.0

1970 1980 1990 2000 2010 2020 2030

Costsas%ofGDP1,5

Diabetes

Schools

18

Totalmedicalcosts,byage&diabetestype,2007

$(billions)

25.3

105.7

11.0

10.5

Dalletal.(2010).Theeconomicburdenofdiabetes.HealthAffairs,29(2),exhibit4.2007currentdollars. 19

%(prevalence)

3,567

4,775

6,387

8,198

11,722

3,837 3,7144,561

5,077 5,359

9,061

5,425

1,3742,327 2,063

4,763

579210 305 391 488 537 716

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

18–34 35–44 45–54 55–59 60–64 65+

Type1Type2UndiagnosedPre-diabetes

Ages:

Average

35,365

Averagecost($)

Averagemedicalcostsperpersonbyage&diabetestype,2007

Dalletal.(2010).Theeconomicburdenofdiabetes.HealthAffairs,29(2),exhibit4.2007currentdollars.20

Context:InsXtuXonalresources

Publicschools Diabetesself-managementeduca7onDedicatedspace Permanentbuildings Varies;hospitals,medicaloffices,communitysites

Guaranteedfunding 100%tax-supported1(local,state,federal)

Variesbyhealthplan;freecommunityclassesprovidedbyDPH/DPCP.

Mandatorya_endance 10-14years None,allvoluntary.~24%ofMedicarepaXentsa=endedDSMTclass.

Teachingforce:

TrainedincontentareaCerXfiedtoteach

ClassroomteachersAll(N=3.1million)199%1

ManystaffdoDSME:medical(e.g.,MD,RN,RD,NP,PA,RPh);non-medical(e.g.,CHW,CHES,peereducators).DSMPclassesgivenbylaytrainers.Trainedindiseasemanagement:MD,RN,RPh,RD,NP,CDE.Trainedtoeducate:OnlyCDEs(N=8710),naXonalcredenXal;possiblestatelicensuretoo.

Curriculumcontent&

Teacherlessonplans

StatenaXonalstandards(CCSS2)Always.Varybyteachercommonplanning

Curriculumcontent:ADAandAADEcerXfyRecognizedPrograms.DSMPhasevidence-basedcurriculum.Lessonplans:varywithADA&AADEprograms.FidelityagreementforDSMP.

12012Condi*onofEduca*on,TablesA-19-1(2008-2009),A-17-1&A-17-2(2007-2008)2h=p://www.corestandards.org/

=trendtowards

21

MorevariableforDSME

5levelsofdiabeteseducators*o  Level1,non-healthcareprofessional,o  Level2,healthcareprofessionalnon-diabeteseducator,o  Level3,non-credenXaleddiabeteseducator,

v Level4,credenXaleddiabeteseducator,andv Level5,advancedleveldiabeteseducator/clinicalmanager.

*AmericanAssociaXonofDiabetesEducators(AADE)(2011).ScopeofPrac*ce,StandardsofPrac*ce,andStandardsofProfessionalPerformanceforDiabetesEducators,p.4.h=p://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf 22

Context:InstrucXonalresourcesop0 Publicschools Diabetesself-managementeduca7on

Hoursofinstruc7onincontentarea(averageperyear)

State/district-mandatedminimumhours:1G1-4:418read/write194math292science

Variesgreatlybyhealthplan&site-Classes:10-15hrs-IndividualDSME:varies

Instruc7onalstrategies SystemaXcuseofpedagogicalprinciples

ForindividualpaXents:CDE’sassessmentofpaXent’sneeds.Forgroups:scriptsforsomenon-medicaleducators(e.g.,DSMP)Pace,sequencing,Bloomlevelnotalwaysconsidered.

SpecialneedsstudentsEstablishedprotocols?

Yes,legalobligaXon(IDEA)

Currently,noDSMEmaterialsorcurriculaspecificallyforelderlyorpersonswithdisabiliXes.

Age-andability-differen7atedinstruc7on&materials

Agegrouping,preK-12Elem:reading/mathgroupswithinorbetweenclassrooms,allwithdifferentlessonsHS:Tracks

None.Growingconcernoverlow“healthliteracy”&age-relatedcogniXvedeclinewithPWDs,but-DiabeteseducaXonmaterialsvarywidely;content,butnotcomplexity,matchedtoPWD’slearningneeds.-PWDsaregivenpre-determinedmetersandsupplies,regardlessoftheirabiliXes.

1Datafor2003-2004.Source:“ChangesinInstrucXonalHoursinFourSubjectsbyPublicSchoolTeachersofGrades1Through4,“May2007,NCESreport2007-305h=p://www.eric.ed.gov/PDFS/ED497041.pdf/2h=p://www.cdc.gov/diabetes/staXsXcs/prevenXve/tNewDEduAgeTot.htmwww.eric.ed.gov/PDFS/ED497041.pdf

23

Li_ledifferen7a7on

Limited7me

Materialstoocomplex

ExampleofrequiredtaskforallPWDs:

Glucosemeters

andlancetdevices

24

Ourefforts

1.   Describejobofself-carefrompa7ent’sperspec7ve.–  Collabora7onwithCDS:AUCDConference–  AADEConference:“Cogni7veDemandsofDSME”

–  NACDDTeleconference:“Cogni7veDemandsofDSME”

–  AADEConference2013:“PsychometricsofDSMEintheElderly”

2.  IdenXfythejob’smostcriXcaltasks

3.  Trace(andlimit)cogniXvecomplexityoflearningtasks

4.  DifferenXateinstrucXonbyability(“literacy”)level

5.  Providescriptsforprovidersthatminimizecomplexity

6.  ProvidepaXenthandoutthatreinforceslearning

25

AADE’sdescripXonofDSM*LivingwellwithdiabetesrequiresacXve,diligent,effecXveself-managementofthedisease.Itisaprocessthat:

•  RequiresmakingandacXngonchoices,onaregularandrecurringbasis,thataffectone’shealth

•  IncludesØ  learningthebodyofknowledgerelevanttothediseasestate,Ø  definingpersonalgoals,weighingthebenefitsandrisksofvarioustreatmentopXons,Ø  makinginformedchoicesabouttreatment,Ø  developingskills(bothphysicalandbehavioral)tosupportthosechoices,Ø  evaluaXngtheefficacyoftheplantowardreachingself-definedgoals.

*AmericanAssociaXonofDiabetesEducators(AADE)(2011).ScopeofPrac*ce,StandardsofPrac*ce,andStandardsofProfessionalPerformanceforDiabetesEducators,pp.1-2.h=p://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf 26

AADE’sdescripXonofDSM*LivingwellwithdiabetesrequiresacXve,diligent,effecXveself-managementofthedisease.Itisaprocessthat:

•  RequiresmakingandacXngonchoices,onaregularandrecurringbasis,thataffectone’shealth

•  IncludesØ  learningthebodyofknowledgerelevanttothediseasestate,Ø  definingpersonalgoals,weighingthebenefitsandrisksofvarioustreatmentopXons,Ø  makinginformedchoicesabouttreatment,Ø  developingskills(bothphysicalandbehavioral)tosupportthosechoices,Ø  evaluaXngtheefficacyoftheplantowardreachingself-definedgoals.

*AmericanAssociaXonofDiabetesEducators(AADE)(2011).ScopeofPrac*ce,StandardsofPrac*ce,andStandardsofProfessionalPerformanceforDiabetesEducators,pp.1-2.h=p://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf

WhatBloomlevelwouldyouassigntoeach?•  Remember•  Understand•  Apply•  Analyze•  Evaluate•  Create 27

AADE7TMcurriculumcontent

1.  HealthyeaXng2.  BeingacXve3.  Monitoring4.  TakingmedicaXon5.  Problemsolving6.  Reducingrisks7.  Healthycoping

Objec7ve:Maintainbloodglucosewithinhealthylimitstoavoidcomplica7ons

•  Learnaboutdiabetesingeneral(At“entry’)–  Physiologicalprocess–  Interdependenceofdiet,exercise,meds–  Symptoms&correcXveacXon–  Consequencesofpoorcontrol

•  Applyknowledgetoowncase(Daily,Hourly)–  Implementappropriateregimen–  ConXnuouslymonitorphysicalsigns–  DiagnoseproblemsinXmelymanner–  Adjustfood,exercise,medsinXmelyandappropriatemanner

•  Coordinatewithrelevantpar7es(Frequently)–  NegoXatechangesinacXviXeswithfamily,friends,job–  Enlist/capitalizeonsocialsupport–  CommunicatestatusandneedstopracXXoners

•  Updateknowledge&adjustregimen(Occasionally)–  WhenotherchroniccondiXonsordisabiliXesdevelop–  Whennewtreatmentsareordered–  Whenlifecircumstanceschange

•  Condi7onsofwork—24/7,nodaysoff,nore7rement

OurmorepaXent-centeredjobdescripXon

Self-

management

Training

28

Objec7ve:Maintainbloodglucosewithinhealthylimitstoavoidcomplica7ons

•  Learnaboutdiabetesingeneral(At“entry’)–  Physiologicalprocess–  Interdependenceofdiet,exercise,meds–  Symptoms&correcXveacXon–  Consequencesofpoorcontrol

•  Applyknowledgetoowncase(Daily,Hourly)–  Implementappropriateregimen–  ConXnuouslymonitorphysicalsigns–  DiagnoseproblemsinXmelymanner–  Adjustfood,exercise,medsinXmelyandappropriatemanner

•  Coordinatewithrelevantpar7es(Frequently)–  NegoXatechangesinacXviXeswithfamily,friends,job–  Enlist/capitalizeonsocialsupport–  CommunicatestatusandneedstopracXXoners

•  Updateknowledge&adjustregimen(Occasionally)–  WhenotherchroniccondiXonsordisabiliXesdevelop–  Whennewtreatmentsareordered–  Whenlifecircumstanceschange

•  Condi7onsofwork—24/7,nodaysoff,nore7rement

OurmorepaXent-centeredjobdescripXon

Self-

management

Training

29

ItisNOTjustfollowingaplan.

ItisalsothinkingandacXngtominimizeproblems.

Ourefforts

1.  Describejobofself-carefrompaXents’perspecXve

2.   Iden7fythejob’smostcri7caltasks





30

UDsurvey:CriXcalityrankings

31

Ourefforts



3.   Trace(andlimit)cogni7vecomplexityoflearningtasks




32

Bloom’sTaxonomyofLearningObjecXvesLatest(2001)revision

Bloom levels = continuum of cognitive complexity

Notjustreadability!!

33

*Revised 2001: Anderson,L.W.,&Krathwohl,D.R.(2001).Ataxonomyforlearning,teaching,and

assessing:ArevisionofBloom'staxonomyofeduca*onalobjec*ves.NY:AddisonWesleyLongman.

Tobeornottobe,thatistheques7on.






“Tobeornottobe”Bloom’staxonomyofeducaXonalobjecXves(cogniXvedomain)*Simplesttasks1.Remember

recognize,recall,IdenXfy,retrieve

2.Understand

paraphrase,summarize,compare,predict,infer

3.Applyexecutefamiliartask,,

applyproceduretounfamiliartask

4.AnalyzedisXnguish,focus,select,

integrate,coordinate

5.Evaluatecheck,monitor,detect

inconsistencies,judgeeffecXveness

6.Createhypothesize,plan,invent,

devise,design

Mostcomplextasks

34

*Revised 2001: Anderson,L.W.,&Krathwohl,D.R.(2001).Ataxonomyforlearning,teaching,and

assessing:ArevisionofBloom'staxonomyofeduca*onalobjec*ves.NY:AddisonWesleyLongman.

AnXcipateeffectofexercise&foodsonbloodglucose.

Coordinatemeds,diet,andexercise.

Managesickdays.

Determinewhen&whybloodglucoseisoutof

control

Monitorsymptoms;assesswhetheracXonneeded;evaluateeffecXvenessof

acXons

CreatedailyandconXngencyplansthatcontrolblood

glucose

Recalleffectsofexerciseonglucose.

RemembertotakeBGs&Rx.

Bloom’staxonomyofeducaXonalobjecXves(cogniXvedomain)*Simplesttasks1.Remember


2.Understand

paraphrase,summarize,compare,predict,infer








devise,design

Mostcomplextasks

Remembertomeasurefoods,drinks&readlabels.

35

WhataboutreadingnutriXonlabels?

• Howimportant?• Howcomplex?

Essen7al

Extremely

36

37

Information is better because it’s in chart form

Amount per serving

But, it contains a confusing technical symbol. Can you spot it?

“Amount/serving”

38

What’stheproblemhere?

39

And here?

Organic

Healthy No sugar

added 40

Pros: •  Fewer items •  Single vertical list •  Major headings

stand out

Cons: •  Lots of irrelevant

info

•  Seemingly inconsistent info

Be=er,but…

41

FoodLabelrevision…counXngcarbohydrates

42

Bloom’staxonomyofeducaXonalobjecXves(cogniXvedomain)Simplesttasks1.Remember


2.   Understandparaphrase,summarize,

compare,predict,infer,








devise,design

Mostcomplextasks

Distractors: CHOs vs Fiber vs Fat

Carb vs non-carb ?? Sequence of label Total CHOs important, “Sugars” not Grams as volume vs wt

Part of meal vs snack OK? CHOs in intended serving? CHOs vs Fat/Chol vs Na

Location of relevant CHO (carb) gms

How many CHO gms in 1 serving? Subtract fiber gms from CHO gms

Plan a meal or snack

43

Ourefforts




4.   Differen7ateinstruc7onbyability(“literacy”)level



Howdifferentinabilitycanadultsbe?

44

Typicalliteracyitems,bydifficultylevelNaXonalAdultLiteracySurvey(NALS),1993

NALS difficulty level (& scores)

% US adults (age 65+)

peaking at this level

Simulated everyday tasks

5 (375-500)

3%

~0%

§  Use calculator to determine cost of carpet for a room §  Use table of information to compare 2 credit cards

4 (325-375)

15% 4%

§  Use eligibility pamphlet to calculate SSI benefits §  Explain difference between 2 types of employee benefits

3 (275-325)

31% 16%

§  Calculate miles per gallon from mileage record chart §  Write brief letter explaining error on credit card bill

2 (225-275)

28% 33%

§  Determine difference in price between 2 show tickets §  Locate intersection on street map

1 (0-225)

23% 47%

§  Total bank deposit entry §  Locate expiration date on driver’s license

Daily self-maintenance in modern literate societies

45

NALS difficulty level (& scores)

% US adults (age 65+)

peaking at this level

Simulated everyday tasks National Adult Literacy Survey (NALS), 1993)

5 (375-500)

3%

~0%

§  Use calculator to determine cost of carpet for a room §  Use table of information to compare 2 credit cards

4 (325-375)

15% 4%

§  Use eligibility pamphlet to calculate SSI benefits §  Explain difference between 2 types of employee benefits

3 (275-325)

31% 16%

§  Calculate miles per gallon from mileage record chart §  Write brief letter explaining error on credit card bill

2 (225-275)

28% 33%

§  Determine difference in price between 2 show tickets §  Locate intersection on street map

1 (0-225)

23% 47%

§  Total bank deposit entry §  Locate expiration date on driver’s license

§  level of inference (“connecting the dots”)

§  abstractness of info

§  distracting information

§  number of features to match

Not reading per se, but “problem solving”

Typicalliteracyitems,bydifficultylevelNaXonalAdultLiteracySurvey(NALS),1993

46

Complexity&aging

47

g-Basicinforma7onprocessing(GF)

BasicculturalKnowledge(GC)

Age-relatedcogniXvedecline

Learning&reasoningabilityAge8

48

Age80

Ourefforts





5.   Providescriptsforprovidersthatminimizecomplexity


49

“RxforPhysicalAc7vity”foraRuralCommunityHealthCenter

Linda S. Gottfredson, PhD School of Education University of Delaware Kathy Stroh, MS, RD, CDE Diabetes Prevention & Control Program Delaware Division of Public Health

Presented at the 2009 Diabetes Translation Conference of the Centers for Disease Control & Prevention (CDC). Long Beach, CA, April 24, 2009

50

51

52

Basicpedometer—justcountssteps

53

GraduatedRxBasic Rx

increases

speed

h=p://www.udel.edu/educ/gozredson/Rx54

55

Teachingtheteacher:ScriptforCDEwhenprescribing“RxforWalking”

Provides the CDE with:

Educationally sound teaching strategy •  Key ideas •  Content, sequence, and pace of

instruction, etc. Implicit training •  Be concrete, personalize,

use meaningful metaphors, etc.

56

57

58

59

Lessonplan:Don’tassumetheyknowwhat’sobvioustoyou

Can’t assume: That patient will know:

•  What a pedometer is •  How to wear it •  The exact regimen of the Rx

•  i.e., extra steps

That the educator will know specific learning steps for: •  Aim of script (e.g., extra steps) •  How to adjust regimen

60

Ourefforts






6.   Providepa7enthandoutthatreinforceslearning

61

62

Thankyou.

QuesXons?Advice?

63

64

5levelsofdiabeteseducators*o  Level1,non-healthcareprofessional,o  Level2,healthcareprofessionalnon-diabeteseducator,o  Level3,non-credenXaleddiabeteseducator,

v Level4,credenXaleddiabeteseducator,andv Level5,advancedleveldiabeteseducator/clinicalmanager.

*AmericanAssociaXonofDiabetesEducators(AADE)(2011).ScopeofPrac*ce,StandardsofPrac*ce,andStandardsofProfessionalPerformanceforDiabetesEducators,p.4.h=p://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf 65

Healthcare

Teaching Diabetes Self-Management