Diabetes Management and Insulin Administration

Summary of Teaching Plan

In recent years, an increase in demand for expansion of education programs for diabetes patients as also for Federal Government or third party payers to support these programs has been observed. A survey by Veterans Administration Hospital conducted a survey to evaluate the capability of patient for diabetes management reported lack of formal training in over 35% of patients interviewed (Miller, Goldstein & Nicolaisen, 1978, p. 275). Therefore, some recommendations for training patients to administer insulin therapy, which reflect best practices, are as follows:

• The therapy should be initiated after a thorough patient assessment, including numeracy skills and health literacy. Therapy initiation should be followed by follow-up phone calls.

• Treatment adherence should be measured during follow-up visits to recognize adherence issues, changing barriers or other problems due to poor recall of instructions etc. Injection practice should also be observed and re-trained, if required.

• They should be well-instructed about the site rotation and its importance; also sites inspection is crucial for any signs of lipohypertrophy or lipoatrophy during all follow-up visits.

• Appropriate language should be used while teaching injection technique avoiding terms like “spearing” or “throwing a dart.” Moreover, psychological discomfort can be reduced by minimizing delay in injecting.

• Dose should be prepared by insulin inspection, manufacturer’s directions for rolling to suspend insulin and evading air bubbles.

• Insulin-mixing should follow the prescription laid down by American Diabetes Association.

• Different creative strategies in insulin storage like applying colored dots or rubber bands, or colored vial sleeves to insulin vials, may be helpful in avoiding patient’s confusion about different insulin types.

• Risk stratification table can be used to identify patient’s target blood glucose level.

• Vials unused needs to be refrigerated. Recapping is critical while reusing the needles, while needles should be removed in extreme climates (Siminerio et al., 2011, pp. 5-6).

Epidemiological rationale

Timely intervention and delay or evasion of development of type 2 diabetes proves enormously beneficent for patients, in terms of improving their quality of life and increasing life expectancy; and possibly for health-care payers and society in economic terms. The International Diabetes Federation (IDF) Taskforce organized a consensus workshop in 2006 on Epidemiology and Prevention of diabetes. The resulting consensus paper launched in Barcelona in April 2007 at the 2nd International Congress on Prediabetes and the Metabolic Syndrome, published in Diabetic Medicine in the May 2007 issue, reflected significant changes in the health of a large percentage of population brought about by IDF population approach for the prevention of type-2 diabetes. The approach for its prevention must be systematic and continued for a long time (IDF, 2015).

Therefore, not just the education but a conducive environment and condition must be created for maintaining and attaining an active and healthy lifestyle and eating habits. The governments of all countries need to develop and implement a National Diabetes Prevention Plan according to IDF population strategy. This plan would include many groups including communities (namely ethnic and religious groups); schools; workplace (health promotion in the working environment); and the industry (investment policy, marketing, product development) (IDF, 2015).

Evaluation of teaching experience

A survey was conducted on Australian adults with Type 1 diabetes (T1D), aged 18-35 years. Diabetes consumer-organizations recruited participants (n= 150) through advertisements and asked them to rate features of clinician-led diabetes education and identify their self-education sources for the evaluation. At initial diagnosis, 77.3% from a diabetes educator, while 74.7% of all participants/family members attained diabetes education through a specialist physician or endocrinologists. However, 58.0% received education from a dietician, and 26.7% from a GP, whereas 2% due to age were unaware of provision of any diabetes education (Wiley et al., 2014).

The results reported that 56% of respondents were satisfied with the extent of continuing diabetes education received from their health-care group. 76.6% were found confident about calculating bolus insulin requirements for meals, while 64.0% for calculating basal insulin requirements. 66.0% agreed about receiving adequate explanation to manage their diabetes when sick, 66.7% agreed about same when exercising, and 76.7% agreed about proper explanation of alcohol’s effect on their diabetes. 96.6% of the respondents accessed additional resources of diabetes education and 73.3% stated that they obtained more diabetes information than the overall amount provided by their health-care team (Wiley et al., 2014).

Community response to teaching

The American Association of Diabetes Educators (AADE) declares that diabetes education is effective in delivering results. However, less than 60% of people affected with diabetes have acquired any formal diabetes education, but increasing that percentage has become a priority for Healthy People 2020, as research indicates that people who received diabetes education are more inclined and motivated to:

• Take medicine/treatment as prescribed.

• Use precautionary services and primary care.

• Experience lower health costs.

• Better control their blood pressure, blood glucose and cholesterol levels.

Training and education about diabetes self-management is a benefit covered by most health plans like Medicare etc. when provided in an accredited/recognized program through a diabetes educator. (AADE, 2016) Diabetes self-management education and support (DSME/S), on the other hand, provides the base to support people with diabetes and improve health outcomes. It’s not only cost-effective reducing hospital admissions and readmissions, but also reduces lifetime health-care costs and a lower risk for complications. DSME/S also improves haemoglobin A1c (HBA1c) to the extent of 1% in people with type 2 diabetes. Moreover, it has a positive effect on other psychosocial, clinical, and behavioural aspects of diabetes. It also reduces the onset and advancement of complications pertaining to diabetes; improves the quality of life and routine activities such as healthful eating pattern, regular physical activity; enhances self-efficiency and empowerment; increases healthy coping abilities and decreases diabetes-related depression and distress. Such improvements reaffirm the significance and value-added benefit of imparting DSME/S and necessity of acquiring it (Powers et al., 2015).

Areas of strengths and areas of improvement

As per the recommendation of National Institute for Health and Care Excellence (NICE), well-designed and well-implemented education programmes are expected to be very beneficent and cost-effective for people with diabetes. The potential aids of an effective education programme:

• Improves knowledge, changes lifestyle, and health beliefs.

• Improves patients’ results — for example, haemoglobin A1c (HBA1c), weight, smoking, lipid levels, and psychosocial changes like quality of life and depression levels.

• Reduces the need for medication and other articles like blood testing strips etc.

• Improves physical activity levels (Tidy, 2014).

Well-constructed and well-implemented structured education programs as mentioned below demonstrate the strength of these diabetes education programs, which not just improve their knowledge, confidence, and skills, but also enables them to take increased control of their condition and incorporate effective self-management into their routine life. Some examples of such programs are as follows:

• DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) program, • DAFNE (Dose Adjustment for Normal Eating and Exercise) program, • X-PERT Diabetes program, • X-PERT Insulin program, and • Bournemouth Type 1 Intensive Education (BERTIE) programme exclusively for T1D patients, etc. (Tidy, 2014)

While, the survey conducted by Wiley et al. indicated that apart from clinician — led education, peer-led education and support serves as a vital component to improve self-management abilities of young adults with T1D. Studies also suggest that diabetes education with peer involvement leads to improved results. However, many participants considered peer involvement as an essential element in diabetes management; many others asserted that peer involvement in the process offers chances for reality-based clarifications or solutions for problems in managing diabetes on their own, often unlikely to achieve otherwise, while some others were cautious of the reliability of peer-led information. Participants also informed that a practical basis of education is diabetes consumer organizations and that knowledge acquisition can be improved through technological interventions but that as an instrument for teaching, technology has been underutilized by not only clinicians but also consumer- diabetic organizations (Wiley et al., 2014).

To improve health literacy, participants incorporated various ways to establish peer-networks as: meeting other diabetic patients at diabetes support-group functions or hospital-based clinics; creating Internet chat-rooms and Facebook groups; instituting specialized-service care associations particularly linked to exercise. These peer-led discussions not just made a base available for learning but, in addition, provided reassurance that experienced events of active management of diabetes on their own commonly differs from educational set-ups based in theory, which was not accentuated in education imparted by clinicians. Participants asserted that many clinicians are technophobic and do not begin patient education regarding new technologies to help with self-management which is in contrast with T1D affected communities’ reported needs to be kept well-informed with knowledge of latest technologies. Therefore, education imparted by clinicians should include such subjects and promote education based on latest technology (Wiley et al., 2014).

Conclusion

Individuals with diabetes, health care providers and systems, and professional organizations all recognize the importance of diabetes education in preventing long-term complications, but achievement of optimal control over situation remains elusive to many. Continued efforts to simplify daily diabetes and insulin management and provide access to adequate education and support to enable successful self-management are required. Prevention from diabetes remains the ideal. At the same time, decreasing the onset and advancement of long-term problems is critical to preserve quality of life and lasting health in persons with type 1 diabetes (Nathan et al., 2013).

References

American Association of Diabetes Educators. (2016). The Benefits of Diabetes Education. Retrieved 11 August 2016 fromhttps://www.diabeteseducator.org/practice/provider-resources/benefits-of-diabetes-education

International Diabetes Federation. (2015). Epidemiology and Prevention. Retrieved 11 August 2016 from http://www.idf.org/diabetes-prevention/population-approach

Miller, L. V., Goldstein, J. &Nicolaisen, G. (Sep-Oct. 1978). Patients’ Knowledge of Diabetes Self-Care. Diabetes Care, 1(5), 275-280.Retrieved 11 August 2016 fromhttp://care.diabetesjournals.org/content/1/5/275

Nathan, D. M., Bayless, M., Cleary, P., Genuth, S., Gubitosi-Klug, R., Lachin, J. M., Lorenzi, G., Zinman, B., for the DCCT/EDIC Research Group. (Dec 2013). Epidemiology of Diabetes Interventions and Complications Study at 30 Years: Advances and Contributions. Diabetes, 62(12), 3976-3986. http://dx.doi.org/10.2337/db13-1093.

Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., Maryniuk, M. D., Siminerio, L. & Vivian, Eva. (Jul 2015). Diabetes Self-Management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes care, 38(7), 1372-1382. http://dx.doi.org/10.2337/dc15-0730. Retrieved 11 August 2016 fromhttp://care.diabetesjournals.org/content/38/7/1372

Siminerio, L., Kulkarni, K., Meece, J., Williams, A., Cypress, M., Haas, L., Pearson, T., Rodbard, H. & Lavernia, F. (2011). Strategies for Insulin Injection Therapy in Diabetes Self-Management. American Association of Diabetes Educators. Retrieved 11 August 2016 fromhttps://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/research/aade_meded.pdf?sfvrsn=2

Tidy, C. (Jul 2014). Diabetes Education and Self-Management Programmes. Patient. Doc. ID: 1593 (v26). Retrieved 11 August 2016 from http://patient.info/doctor/diabetes-education-and-self-management-programmes

Wiley, J., Westbrook, M., Long, J., Greenfield, J. R., Day, R. O. & Braithwaite, J. (Jun 2014). Diabetes Education: The Experiences of Young Adults with Type 1 Diabetes. Diabetes Therapy, 5(1), 299-321. doi: 10.1007/s13300-014-0056-0