March 02, 2022
7 min read
Greenwood reports being an employee for Dexcom. Scheiner reports serving as a consultant and advisory board member for Adocia, Byram Healthcare, Capillary Biomedical, Companion Medical, Dexcom, Eli Lilly, Triple Jump Ltd. and YpsoMed; and receiving honoraria from Companion Medical, Dexcom, Insulet, MannKind, Xeris Pharmaceutical and YpsoMed. Scheiner also receives other research support and is a patient coach for Roche/mySugr. Weiner reports serving as a consultant/advisory board member for Insulet.
This year marks the 20th year of Endocrine Today. Over the past 2 decades of the publication’s reporting on diabetes, the field has undergone immense change — including in the diabetes education arena.
Now referred to as diabetes care and education specialists, these professionals still empower people with diabetes to take care of their own disease, but their role on the health care team and the tools they use have changed dramatically.
“Diabetes care and education specialists can really be helping primary care manage diabetes and not just ‘educate,’ but can actually provide insight and guidance,” Deborah Greenwood, PhD, RN, BC-ADM, CDCES, FADCES, an Endocrine Today Editorial Board Member and medical science liaison on the clinical education team at Dexcom, said. Greenwood was president of the American Association of Diabetes Educators in 2015. In 2020, that organization changed its name to Association of Diabetes Care and Education Specialists (ADCES).
“Diabetes care and education specialists can look at data, they can make recommendations, they know the guidelines and they know the medications better than most primary care doctors do because there are so many new diabetes medicagions now,” Greenwood told Healio.
Far from the days of teaching about finger sticks and carb counting in classrooms, diabetes care and education specialists now counsel individuals with diabetes on using continuous glucose monitors, insulin pumps and smart pens. They use the data from devices and apps to help users respond to conditions in the moment, and to help physicians develop customized management plans.
“Back in the ’90s and early 2000s, we were just teaching,” Gary Scheiner, MS, CDCES, owner and clinical director of Integrated Diabetes Services in Wynnewood, Pennsylvania, told Endocrine Today. “Now we’re involved in the management of diabetes. If we’re not helping patients adjust their insulin on their own, then we’re counseling their physician on what changes to make. Physicians are looking to us to do more of that now, and with good reason. We have the expertise, and we have the time to do it properly.”
From adjusting insulin to recommending medications
Over the past 20 years, the understanding of diabetes has expanded to include its relationship to other cardiometabolic conditions, according to Greenwood, and the purview of diabetes care and education specialists has expanded with it.
“We’ve moved from diabetes to diabetes and related cardiometabolic metabolic conditions,” Greenwood said. “We need to not be treating diabetes in a silo, but to really be looking at the overall complexity of care because most people have other potential cardiometabolic issues with hypertension and hyperlipidemia, kidney conditions and psychosocial issues.”
Medications besides insulin developed over the past 10 years can address other components in the cardiometabolic constellation of diseases. Although most diabetes care and education specialists do not prescribe, they can advise users of these drugs and suggest their physicians adopt them.
“We’re teaching the patient about the different options so they can have an intelligent conversation with their prescriber, or we might directly communicate with the prescriber what we would consider to be in the patient’s best interest,” Scheiner said. “We’re going from the age of sulfonylureas, which could cause weight gain and hypoglycemia and would cause the pancreas to burn out prematurely. Now, we have medications that have more impact on glucose, preserve the pancreas and contribute to weight loss.”
From logbook to real-time data sharing
Diabetes educators have always emphasized using data in diabetes self-management, but now those data come from advanced technology instead of finger-stick glucose monitoring, Greenwood said. This positions diabetes care and education specialists to be the go-to experts on the health care team for interpreting data.
“The vast majority of diabetes patients are still managed by primary care,” Scheiner said. “They certainly don’t know what to do with CGM data and all the other information that’s fed to them. We’re the ones who are breaking that stuff down. When I started, patients would come in with little logbooks that they’d write their blood sugars in — who knows if they were accurate.”
The availability of data in real time has changed the goals of diabetes care from hitting an HbA1c target to maximizing time in an ideal blood glucose range, Scheiner said. Maintaining an HbA1c goal can prevent diabetes complications, but limiting glucose swings can improve quality of life.
“Although we continue to stress the prevention of long-term complications, we’re now placing greater emphasis on the day-to-day effects of glucose levels — physical performance, mental and intellectual [performance], emotions, sleep quality,” Scheiner said.
All the data from CGMs, insulin pumps and smart pens, and also from step counters, digital nutrition logs and other apps — all this information has allowed for more personalized care that respects the needs of individuals, according to Susan Weiner, MS, RDN, CDN, CDCES, FADCES, an Endocrine Today Editorial Board Member and owner of Susan Weiner Nutrition PLLC in New York.
“Twenty years ago, diabetes education was not nearly as collaborative as it is now because information was just given to the person with diabetes,” Weiner told Healio. “It was a one-size-fits-all approach. They were given a list of foods, possibly a printed exchange list [that was] not culturally relevant. There was really no collaboration, no asking the person living with diabetes, ‘What’s going on with you? Where are we starting from?’”
Those questions are essential for encouraging people with diabetes to consider and become comfortable with technology, Weiner said.
“[Technology is] as individualized as food, exercise and nutrition programs,” she said. “We cannot assume that apps make life easier for everyone. For some people, they can be overwhelming and yet another thing to do. That doesn’t mean that 6 months from now we can’t approach it again, but at the beginning it may be challenging for some people. … There are some general practitioners who took a long time to even consider the possibility of offering pumps for people on multiple daily injections.”
This role requires diabetes care and education specialists to stay on top of technology more than ever. For Weiner, that means researching apps on DANAtech — a website developed by ADCES to assess diabetes technology and support access — and using them herself.
“We need to become familiar with more of the technologies and to listen to people who are living with diabetes about what they’ve heard about and what they’re interested in exploring.”
From expert to peer support
With the proliferation of social media over the past decade, more people with diabetes rely on support from their peers. They come to diabetes care and education specialists with knowledge, suggestions and ideas from other people living with the disease.
“There are a lot more resources for people who want them,” Greenwood said. “They have access to peers who can help them within the moment on Twitter. They hear from other peers about technology or about medications. If they don’t like something or the way they’re being treated, they’re supporting each other.”
Twenty years ago, only a few organizations, such as the American Diabetes Association and JDRF, advocated for people with diabetes. Now, organizations such as Diabetes Sisters, Beyond Type 1, Beyond Type 2 and many others have proliferated to provide targeted support, Greenwood said.
“People living with diabetes and health care professionals are sharing 24/7 globally,” Weiner said. “The latest technology, the news is immediate. ‘How did this work for you?’ ‘What do you do if your sensor malfunctions?’ ‘Where what are we doing about insulin affordability?’ That has changed the entire landscape of communication and education.”
Weiner said she believes it is vitally important for her to keep up with the online conversations and acknowledge the experience of the person with diabetes. At times, she also must counter misinformation, but for the most part, she believes peer support to be helpful.
“Peer support is a fantastic and necessary tool,” Weiner said. “Health care professionals can be lacking in understanding of what peer support is and how we can recommend where people can seek it out, and our support of it without overstepping. That’s not where we really belong unless we’re invited and want to learn about it. But that’s been incredibly helpful and supportive.”
From hospital to virtual access
Over the past 2 decades, diabetes care and education has expanded beyond the traditional hospital setting to industry programs and to a variety of private practice types. During the past 2 years, the COVID-19 pandemic has revealed that much of diabetes care can pivot from in-person to remote access.
Scheiner said he has been providing care remotely since 2005 with clients around the world.
“We beat the pandemic by a longshot. Initially, it was phone appointments, and then my kids taught me what Skype was, and now it’s Zoom,” he said. “With CGM technology, and also data sharing, we don’t have to bring people in and plug a device in. The data syncs up with a cloud-based server, so we can access reports and stats to be able to help fine tune.”
Weiner switched her practice to fully remote in 2020, beginning first with a phone call for skeptical clients, then FaceTime and Zoom, and eventually easing them onto HIPAA-compliant platforms.
But even with technologic advancements, diabetes care and education are not reaching all those who would benefit from it.
“People of color are much more impacted by type 2 diabetes, and the educated workforce still doesn’t resemble what the population looks like,” Greenwood said. “Even though we have all this technology and these new drugs, we’ve learned from COVID that some racial and ethnic groups still have worse outcomes and less use of technology. So, there are some issues that we need to work on.”
For more information:
Deborah Greenwood, PhD, RN, BC-ADM, CDCES, FADCES, can be reached at [email protected]; Twitter: @DebGreenwood.
Gary Scheiner, MS, CDCES, can be reached at [email protected]; Twitter: @Integ_Diabetes.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, can be reached at [email protected]; Twitter: @susangweiner.