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Teaching Diabetes Self-Management—in 4 Hours (or Less)

Teaching Diabetes Self-Management—in 4 Hours (or Less). Kathy Stroh, MS, RD, CDE Diabetes Prevention and Control Program Delaware Division of Public Health. Linda S Gottfredson, PhD School of Education University of Delaware. CEHD Colloquium, University of Delaware, February 28, 2013.

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Teaching Diabetes Self-Management—in 4 Hours (or Less)

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  1. Teaching Diabetes Self-Management—in 4 Hours (or Less) Kathy Stroh, MS, RD, CDE Diabetes Prevention and Control Program Delaware Division of Public Health Linda S Gottfredson, PhD School of Education University of Delaware CEHD Colloquium, University of Delaware, February 28, 2013

  2. Types of Diabetes Juvenile Diabetes Maturity-onset Diabetes Insulin dependent Non-insulin dependent Diabetes (IDD) Diabetes (NIDD) Type I Diabetes Type II Diabetes Type 1 DiabetesType 2 Diabetes

  3. Types of Diabetes (DM) Type 1 -cell destruction; autoimmune disease; complete lack of insulin 5-10% of total patients Type 2 -cell dysfunction and insulin resistance Gestational -cell dysfunction and insulin resistance during pregnancy

  4. There is no such thing as Borderline Diabetes or a “Touch of Diabetes.” Pre-diabetes is a diagnosis.

  5. Pre-diabetes There is no such thing as Borderline Diabetes or a “Touch of Diabetes.”

  6. DM defects

  7. Diabetes is a cardiovascular disease. People with diabetes are twice as likely to suffer a heart attack or stroke compared to people without diabetes. The Burden of Diabetes in Delaware, 2009. Diabetes Prevention and Control Program

  8. 350 300 250 200 150 100 50 Natural history of Type 2 diabetes Family History Insulin Resistance Uncontrolled Hyperglycemia Diabetes Obesity Prediabetes Post-meal Glucose Glucose (mg/dL) Fasting Glucose 250 Insulin Resistance 200 Relative Function (%) 150 Insulin Level 100 -cell Failure 50 0 diagnosis -10 -5 5 10 15 20 25 30 Years of Diabetes Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.

  9. Why teach self-management? • Patients must control their blood glucose (BG) levels to avoid complications • Controlling BG is a complex, 24/7, life-long task • Rx’s change, increase; may not insure optimal BG control • Changes in dietary intake & physical activity necessary • And more… • So much to learn and do (or stop doing)

  10. PWD’s* everyday reality * “Diabetic” is not a noun

  11. As teacher educators, how would you recommend teaching diabetes self-management? Here’s the challenge

  12. Private schools 0.4 mil teachers 5.4 mil pupils Regulations • Federal • Federal • District • District • State • State $673 billion Diabetes education?? 3 million 50 million Public schools

  13. Private schools 0.4 mil teachers 5.4 mil pupils Regulations • Federal • Federal • District • District • State • State $673 billion Diabetes education?? Instruction Learning tasks 3 million 50 million Public schools

  14. Context: Exploding numbers 2004 % diagnosed adults >20 years 52009 Just 5 years! 12012 Condition of Education, Table A-3-1. http://nces.ed.gov/pubs2012/2012045_5.pdf 2 For 1970, All Ages is interpolated from 1968 and 1973. http://www.cdc.gov/diabetes/statistics/diabetes_slides.htm. 3For 1990 and 2010, All ages and 65+ derived from http://www.cdc.gov/diabetes/statistics/prev/national/tnumage.htm, and 18+ from http://www.cdc.gov/diabetes/statistics/prev/national/figadults.htm 4Boyle et al (2010), Projection of the year 2050 burden of diabetes in the US adult population. Population Health Metrics, 8(29).I averaged the results from their 4 models. Huang et al. (2009) estimated 34.2M for Type 2 alone: Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990. 5CDC’s Diabetes Data & Trends. http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx,

  15. Context: Exploding costs Diabetes Schools • 12011 Digest of Education Statistics, Table 28, http://nces.ed.gov/programs/digest/d11/tables/dt11_028.asp. Table reports costs in current dollars, so inflation calculator used to bring up to 2010 values. • 22011 Digest of Education Statistics, Table 194, http://nces.ed.gov/programs/digest/d11/tables/dt11_194.asp • 3Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. Used inflation calculator to translate dollars from 2007 to 2010. http://www.usinflationcalculator.com • 4Huang et al. (2009) Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990. Includes Type 2 only. Type 1 would be <5% of cases but higher per capita cost. Inflation calculator used to change costs from 2007 to 2010 dollars. • 5 No 2020-2030 projections available for school expenditures, so just repeated % GDP from the prior 2 decades. Used Huang et al.’s total diabetes medical costs for 2007, together with 2007 GDP, to calculate costs as % GDP in that year (1.1%). Then used their Exhibit 3 (projected real growth as multiple of GDP) to estimate % GDP in 2010, 2020, and 2030. No data prior to 2007, so just took line toward asymtope .

  16. Total medical costs, by age & diabetes type, 2007 $ (billions) 25.3 105.7 11.0 10.5 % (prevalence) Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars.

  17. 35,365 Average medical costs per person by age & diabetes type, 2007 Average cost ($) Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars.

  18. Context: Institutional resources More variable for DSME = trend towards 12012 Condition of Education, Tables A-19-1 (2008-2009), A-17-1 & A-17-2 (2007-2008) 2http://www.corestandards.org/

  19. 5 levels of diabetes educators* • Level 1, non-healthcare professional, • Level 2, healthcare professional non-diabetes educator, • Level 3, non-credentialed diabetes educator, • Level 4, credentialed diabetes educator, and • Level 5, advanced level diabetes educator/clinical manager. *American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, p. 4. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf

  20. Context: Instructional resources Limited time Materials too complex Little differentiation 1Data for 2003-2004. Source: “Changes in Instructional Hours in Four Subjects by Public School Teachers of Grades 1 Through 4,“ May 2007, NCES report 2007-305 http://www.eric.ed.gov/PDFS/ED497041.pdf/ 2http://www.cdc.gov/diabetes/statistics/preventive/tNewDEduAgeTot.htmwww.eric.ed.gov/PDFS/ED497041.pdf

  21. Example of required task for all PWDs: Glucose meters and lancet devices Demonstration !!

  22. Our efforts • Describe job of self-care from patient’s perspective. • Collaboration with CDS: AUCD Conference • AADE Conference: “Cognitive Demands of DSME” • NACDD Teleconference:“Cognitive Demands of DSME” • AADE Conference 2013: “Psychometrics of DSME in the Elderly” • Identify the job’s most critical tasks • Trace (and limit) cognitive complexity of learning tasks • Differentiate instruction by ability (“literacy”) level • Provide scripts for providers that minimize complexity • Provide patient handout that reinforces learning

  23. AADE’s description of DSM* Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that: • Requires making and acting on choices, on a regular and recurring basis, that affect one’s health • Includes • learning the body of knowledge relevant to the disease state, • defining personal goals, weighing the benefits and risks of various treatment options, • making informed choices about treatment, • developing skills (both physical and behavioral) to support those choices, • evaluating the efficacy of the plan toward reaching self-defined goals. *American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf

  24. AADE’s description of DSM* Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that: • Requires making and acting on choices, on a regular and recurring basis, that affect one’s health • Includes • learning the body of knowledge relevant to the disease state, • defining personal goals, weighing the benefits and risks of various treatment options, • making informed choices about treatment, • developing skills (both physical and behavioral) to support those choices, • evaluating the efficacy of the plan toward reaching self-defined goals. *American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf AADE7TM curriculum content • Healthy eating • Being active • Monitoring • Taking medication • Problem solving • Reducing risks • Healthy coping • What Bloom level would you assign to each? • Remember • Understand • Apply • Analyze • Evaluate • Create

  25. Our more patient-centered job description Training Self- management Objective: Maintain blood glucose within healthy limits to avoid complications • Learn about diabetes in general (At “entry’) • Physiological process • Interdependence of diet, exercise, meds • Symptoms & corrective action • Consequences of poor control • Apply knowledge to own case (Daily, Hourly) • Implement appropriate regimen • Continuously monitor physical signs • Diagnose problems in timely manner • Adjust food, exercise, meds in timely and appropriate manner • Coordinate with relevant parties (Frequently) • Negotiate changes in activities with family, friends, job • Enlist/capitalize on social support • Communicate status and needs to practitioners • Update knowledge & adjust regimen (Occasionally) • When other chronic conditions or disabilities develop • When new treatments are ordered • When life circumstances change • Conditions of work—24/7, no days off, no retirement

  26. Our more patient-centered job description Training It is NOT just following a plan. It is also thinking and acting to minimize problems. Self- management Objective: Maintain blood glucose within healthy limits to avoid complications • Learn about diabetes in general (At “entry’) • Physiological process • Interdependence of diet, exercise, meds • Symptoms & corrective action • Consequences of poor control • Apply knowledge to own case (Daily, Hourly) • Implement appropriate regimen • Continuously monitor physical signs • Diagnose problems in timely manner • Adjust food, exercise, meds in timely and appropriate manner • Coordinate with relevant parties (Frequently) • Negotiate changes in activities with family, friends, job • Enlist/capitalize on social support • Communicate status and needs to practitioners • Update knowledge & adjust regimen (Occasionally) • When other chronic conditions or disabilities develop • When new treatments are ordered • When life circumstances change • Conditions of work—24/7, no days off, no retirement

  27. Our efforts • Describe job of self-care from patients’ perspective • Identify the job’s most critical tasks • Trace (and limit) cognitive complexity of learning tasks • Differentiate instruction by ability (“literacy”) level • Provide scripts for providers that minimize complexity • Provide patient handout that reinforces learning

  28. UD survey: Criticality rankings

  29. Our efforts • Describe job of self-care from patients’ perspective • Identify the job’s most critical tasks • Trace (and limit) cognitive complexity of learning tasks • Differentiate instruction by ability (“literacy”) level • Provide scripts for providers that minimize complexity • Provide patient handout that reinforces learning

  30. Bloom’s Taxonomy of Learning ObjectivesLatest (2001) revision Not just readability!! Bloom levels = continuum of cognitive complexity

  31. Bloom’s taxonomy of educational objectives (cognitive domain)* Simplest tasks 1. Remember recognize, recall, Identify, retrieve 2. Understand paraphrase, summarize, compare, predict, infer 3. Apply execute familiar task,, apply procedure to unfamiliar task 4. Analyze distinguish, focus, select, integrate, coordinate 5. Evaluate check, monitor, detect inconsistencies, judge effectiveness 6. Create hypothesize, plan, invent, devise, design Most complex tasks “To be or not to be” To be or not to be, that is the question. To be or not to be, that is the question. To be or not to be, that is the question. To be or not to be, that is the question. To be or not to be, that is the question. To be or not to be, that is the question. *Revised 2001: Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman.

  32. Bloom’s taxonomy of educational objectives (cognitive domain)* Simplest tasks 1. Remember recognize, recall, Identify, retrieve 2. Understand paraphrase, summarize, compare, predict, infer 3. Apply execute familiar task,, apply procedure to unfamiliar task 4. Analyze distinguish, focus, select, integrate, coordinate 5. Evaluate check, monitor, detect inconsistencies, judge effectiveness 6. Create hypothesize, plan, invent, devise, design Most complex tasks Remember to measure foods, drinks & read labels. Remember to take BGs & Rx. Recall effects of exercise on glucose. Anticipate effect of exercise & foods on blood glucose. Coordinate meds, diet, and exercise. Manage sick days. Determine when & why blood glucose is out of control Monitor symptoms; assess whether action needed; evaluate effectiveness of actions Create daily and contingency plans that control blood glucose *Revised 2001: Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman.

  33. What about reading nutrition labels? • How important? • How complex? Essential Extremely

  34. Amount per serving Information is better because it’s in chart form • But, • it contains a • confusing technical symbol. • Can you spot it? • “Amount/serving”

  35. What’s the problem here?

  36. And here? Organic No sugar added Healthy

  37. Better, but… • Cons: • Lots of irrelevant info • Seemingly inconsistent info • Pros: • Fewer items • Single vertical list • Major headings stand out

  38. Food Label revision… counting carbohydrates

  39. Bloom’s taxonomy of educational objectives (cognitive domain) • Simplest tasks • 1. Remember • recognize, recall, • Identify, retrieve • Understand • paraphrase, summarize, compare, predict, infer, • 3. Apply • execute familiar task,, apply procedure to unfamiliar task • 4. Analyze • distinguish, focus, select, integrate, coordinate • 5. Evaluate • check, monitor, detect inconsistencies, judge effectiveness • 6. Create • hypothesize, plan, invent, • devise, design • Most complex tasks Location of relevant CHO (carb) gms Carb vs non-carb ?? Sequence of label Total CHOs important, “Sugars” not Grams as volume vswt How many CHO gms in 1 serving? Subtract fiber gms from CHO gms Distractors: CHOs vs Fiber vs Fat Part of meal vssnack OK? CHOs in intended serving? CHOs vs Fat/Cholvs Na Plan a meal or snack

  40. Our efforts • Describe job of self-care from patients’ perspective • Identify the job’s most critical tasks • Trace (and limit) cognitive complexity of learning tasks • Differentiate instruction by ability (“literacy”) level • Provide scripts for providers that minimize complexity • Provide patient handout that reinforces learning How different in ability can adults be?

  41. Typical literacy items, by difficulty levelNational Adult Literacy Survey (NALS), 1993 Daily self-maintenance in modern literate societies

  42. Typical literacy items, by difficulty levelNational Adult Literacy Survey (NALS), 1993 Not reading per se, but “problem solving” • number of features to match • level of inference (“connecting the dots”) • abstractness of info • distracting information

  43. Complexity & aging

  44. Age-related cognitive decline Basic cultural Knowledge (GC) Learning & reasoning ability Age 8 Age 80 g - Basic information processing (GF)

  45. Our efforts • Describe job of self-care from patients’ perspective • Identify the job’s most critical tasks • Trace (and limit) cognitive complexity of learning tasks • Differentiate instruction by ability (“literacy”) level • Provide scripts for providers that minimize complexity • Provide patient handout that reinforces learning

  46. “Rx for Physical Activity” for a Rural Community Health Center 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

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