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Diabetes self-management education

We've all heard that Bermuda has the highest rate of lower-limb amputations in the developed world. We have high rates of kidney disease and half of patients on dialysis here in Bermuda have diabetes. Why do we have such poor outcomes? In the United States, 45 per cent of adults with diabetes do not achieve blood sugar levels low enough to prevent diabetes-related complications (blindness, kidney failure, amputations, erectile dysfunction, heart attacks and strokes). Most likely, the story is similar in Bermuda.

We traditionally think of diabetes as a disease of old age but in Bermuda it is affecting younger, working people. And they're sick. This is so sad because diabetes does not have to be a death sentence. Complications are preventable.

In our new Acute Care Wing, 25 to 39 per cent of beds are occupied by people who have diabetes. The number of people with diabetes in the hospital aged 41-64 years old is equal to those with diabetes who are older than 65. The number of inpatients at Bermuda Hospitals Board with diabetes increased from 16.6 per cent to 19.7 per cent between 2010 and 2014. People with diabetes who are admitted to King Edward VII Memorial Hospital stay an average of 40 days compared with 16.5 days for those without diabetes, and they're twice as likely to be affected by MRSA and other drug-resistant organisms.

What can we do about it? In 2009 a task group produced the Bermuda diabetes guidelines, stating that a person diagnosed with diabetes should receive immediate referral for education and treatment, annual review of control and complications, an agreed and continually updated diabetes plan, and involvement of the multidisciplinary team (doctor, diabetes educators, nurses and dietitians) in delivering that plan, which should be centred around the person with diabetes.

In June 2015 the American Diabetes Association, The American Association of Diabetes Educators and the Academy of Nutrition and Dietetics released a joint position statement offering guidance for health professionals on diabetes self-management education and support.

Why self-management? In most chronic diseases (heart disease, stroke, cancer, chronic lung disease), you can visit your doctor every three to four months for maintenance. They check your blood pressure and blood tests, review your medications and, as long as you take your medications as prescribed, you may not need any additional treatment between those visits.

Diabetes is unlike any other chronic disease. An individual with diabetes must make management decisions every two to five hours. They are making decisions about what they eat, when they eat, whether they exercise etc. Every day. This means that most of the management of diabetes is not by the doctor/nurse or dietitian, not in a clinic, but by the individual living with the diabetes, at home and at work.

Diabetes self-management education helps people with diabetes to navigate these decisions and activities. As well as teaching about glucose, medications and diabetes complications, we teach coping skills, behaviours and abilities necessary for diabetes self-care.

DSME has been shown to be cost-effective; it reduces hospital admissions and readmissions, reduces development and progression of diabetes-related complications and has been shown to improve quality of life.

One complication of diabetes that we don't talk about very much is depression and diabetes-related distress. Up to 35 per cent of people living with diabetes report diabetes-related distress. This, added to other life stresses, anxiety and social factors can negatively affect health and increase resource use. DSME has been shown to reduce diabetes-related distress and depression by teaching healthy coping, stress management, and enhancing self-efficacy and empowerment.

How effective is DSME? The FDA will approve a drug for treatment of diabetes that reduces HbA1c (the measure of average blood glucose over three months) by 0.4 per cent. Any DSME has been shown to reduce HbA1c by an average of 0.57 per cent and the more time you spend with diabetes educators, the more effective the education is. Group classes such as those offered at the BHB Diabetes Centre can reduce HbA1c by 2 per cent! To put this into context, if a person with diabetes reduces their HbA1c by one per cent, their risk of having a heart attack drops by 20 per cent. DSME is therefore more effective and certainly less expensive than many drugs approved for use to treat diabetes.

The goals of the ADA position statement are to improve the patient experience of care and education, to improve the health of individuals and populations and to reduce diabetes-associated per-capita healthcare costs. The ADA has recommended that all individuals with diabetes should receive diabetes self-management education at diagnosis and as needed thereafter, just like the 2009 Bermuda diabetes guidelines.

So we know that DSME improves quality of life, reduces diabetes complications and is cost-effective so surely everyone is getting the opportunity to participate? In the United States, only 6.8 per cent of those with private insurance engage in diabetes education within 12 months of diagnosis and only four per cent of those with Medicare. No wonder people with diabetes don't do well.

Data from the Steps to a Well Bermuda Survey carried out last year suggests that 12.2 per cent of our adult population has type two diabetes. Other population studies have shown that for every two people who know they have diabetes, another person is undiagnosed, so it is likely that the true prevalence is more than 18 per cent. This would mean that Bermuda has at least 10,000 people living with diabetes. To ensure that everyone who has diabetes in Bermuda has the best chance of the best outcomes, all of these people need to have access to quality diabetes self-management education.

At the DREAM Centre, we have an asthma/chronic lung disease nurse educator and an endocrinologist/internal medicine physician. All our services are covered by HIP, FutureCare, and major medical by-insurance without co-pays to the patients. Our classes are run by certified diabetes educators who offer one-on-one sessions and group classes. We recommend that individuals with diabetes do the 12-hour course initially. The longer an individual spends with diabetes educators, the more impact the education has to improve outcomes. Spending more than ten hours with educators is much more effective than one-on-one sessions, but some education is better than nothing!

If people diagnosed with diabetes understand their condition, and feel empowered to control their blood sugars, they can expect to live long and healthy lives despite their diagnosis. We at the DREAM Centre look forward to helping more people with their diabetes care. Ask your doctor for a referral!

• Dr Fountain is BHB's director of endocrinology. This article is part of a series organised by Bermuda Hospitals Board in honour of Diabetes and Chronic Obstructive Pulmonary Disease Awareness Month.

Not a death sentence: we traditionally think of diabetes as a disease of old age but in Bermuda it is affecting younger, working people

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Published December 02, 2015 at 8:00 am (Updated December 01, 2015 at 8:13 pm)

Diabetes self-management education

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