Episode 4: Diabetes Self-Management

Rita Kalyani:    Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes.  I’m your host, Dr. Rita Kalyani, at Johns Hopkins.  We developed this podcast as a companion to our Patient Guide to Diabetes website.  If you want a trusted and easy to understand resource for diabetes, or to listen to previous podcasts, please visit Hopkins Diabetes Info dot org.

On today’s podcast, I’m pleased to welcome Gene Arnold.  In our last episode, Gene spoke with one of his patients, Leon, about challenges with diabetes self-management education and how his patient Leon has thrived with his guidance.  Gene is here today to tell us more about these programs.  Gene serves as a quality coordinator for the Johns Hopkins Diabetes Center Diabetes Self-Management Training Program.  Gene is a registered dietitian and nutritionist and certified diabetes educator.  His interest in nutrition began as a student athlete at Trinity College, where he’s earned his undergraduate degree in psychology.  He completed his master’s at Montclair State University and nutrition education with a minor in food science and his dietetic internship at the University of Oklahoma Health Science Center.  He then joined the in-patient nutrition team at Johns Hopkins Hospital later that year and serves in our Outpatient Diabetes Center.  Welcome, Gene.

Gene Arnold:   Rita, thank you for having me.

RK:                  We’re so glad to have you back again this time to really zero in on diabetes self-management trainings.  I wonder, Gene, if you could start off by telling us what is DSMT?

GA:                  DSMT is only one of the acronyms.  We have DSMT/ DSMES.  One stands for diabetes self-management training, the other stands for diabetes, self-management education and support.  Mouthful.  They mean the same thing, they’re interchangeable.  The DSMT is more of a Medicare definition, and I believe ACDES is going with the DSMES… because it kind of outlines more as to what all the service can entail.  Diabetes education, diabetes self-management training… there’s a lot of ways you can phrase this.  I think it is important to think about the way that we label this because there’s a lot of inferences that can be taken.  Hoping that we can get more into the details that in the podcast, you know about the way you explain it, and then what the patient thinks, etc. or what the participant thinks.

RK:                  Yeah, that’s really helpful.  For our listeners, this might not be something that they’ve heard of before.  Is this the same as diabetes education or diabetes education classes?  Or is this something different?

GA:                  The phrase ‘diabetes education’… I don’t feel that strongly about it.  For this reason, it implies that the person attending is possibly not educated or not educated enough, right?  Or needs to go to a class.  So DSMT/DSMES… What actually is it?  The best way that I can describe it.. it’s a one-on-one visit, initially, with a Certified Diabetes Care and Education Specialist.  That person could have a variety of professional licenses; that person could be a nurse, it could be a dietitian, could even be a social worker.  If they’re certified, that means that this person has been trained to be an expert in the variety of content areas related to diabetes self-management.  That could be glucose monitoring, that could be medication management, that could be nutrition, right?  It could be healthy coping, there’s a lot of different content areas that can be included with DSMT/DSMES.  It’s not a class.  When somebody goes to visit like this, the initial visit is a one-on-one visit with a certified individual. Our program is set up in such a way where we want the patient to be able to choose how they receive care. If you want to come back and participate in a group discussion you’re welcome to do that. If you don’t, then our goal is to have you not do that. There are some insurance nuances, right? Some people are covered for different types of care depending on the insurance somebody has. It is really individualized in the sense that somebody’s benefit may dictate what they can receive. One important thing to know about DSMT/DSMES is it’s a benefit that renews annually. Maybe you did it a long time ago, and it wasn’t that great or you didn’t have a good experience because you moved or something. You can you have two years every year as long as you have diabetes. It’s never a bad time to try again. There’s pluses and minuses to the benefit.

RK:                  Well, that’s really great to hear that everyone should have the opportunity to have at least two visits a year.  So if it didn’t work the first time they can they can try again. Can you tell us a little bit more about what exactly is included? If a patient comes and meets with you, what kind of topics do you cover? Or is it individualized to the patient?

GA:                  There’s no way for me to tell a patient beforehand how our conversation will go.  They have an in-depth assessment with a Certified Diabetes Educator.  Our job really is to help really dissect what’s going on with a patient, help them understand, ‘okay, what are your goals?’  ‘What are you trying to achieve?’  Let’s say somebody’s goal is to lower their A1C, which is a common goal.  The job of the Certified Diabetes Care and Education Specialist is to really help the patient participant understand, ‘hey, these are the big things that you can do that are actually going to help.  Because there’s a lot of things that somebody could work on, on a day-to-day, minute-to-minute basis, that would be healthier.  But this is not always obvious and it’s not always clear.  The Certified Diabetes Educator, the way that I describe it is, they try to teach patients to use what they have, to the best of their ability.  That’s the essence of it.  So there’s no way to predict you know how it will go.  Somebody’s thinking about coming and decided not come or not do it.  You don’t know what you miss.  It’s a great service.  And people that do participate, they find it very helpful, and the retention rate is very high.  Folks want to come back.  If somebody doesn’t need to come back and they’re doing awesome, then we’ll see you when we see you.  There’s no obligation. It’s just supposed to be another resource in between visits with your NP or primary care doctor, endocrinologist.  It’s a lot of models that we have, and a lot of cadences of follow-up.  But generally speaking, the Diabetes Care and Education Specialist would see a patient in between their visits with the physician or advanced practice providers who’s managing their diabetes.

RK:                  I imagine that you probably do a lot of troubleshooting in terms of things that are working and not working.  You mentioned strategies to achieve glycemic goals for instance, as a topic that’s covered.  Could you share some other topics that you’ve commonly seen in patients that you’ve treated?

GA:                  It’s not super common, but folks who are new who are maybe thinking about an insulin pump can come in for that sort of evaluation discussion, you know, on which pump would be maybe best for that person and understanding how the pumps work, how to be successful on a pump.  Same conversations happen with glucose monitors, different diabetes technologies.  People come in asking about these things for training on these devices.  The visits can go in that sort of direction.  I think it’s important to distinguish the difference between a DSMT visit, right?  Which is really an assessment, holistic view of how our diabetes is being self-managed, compared to a medical nutrition therapy visit, which is a visit specifically about eating and how that may relate to different chronic conditions or even acute conditions.  For diabetes self-management training, we do cover eating strategies for folks with diabetes.  However, it’s a little bit more abstract and less directive, less prescriptive than a medical nutrition therapy visit.  So the services are complementary, but they’re similar.  And depending on where you receive care, they might offer one and not the other, which can be confusing.  ‘What is that?’  And ‘what is nutrition?’  ‘What is diabetes self-management training?’  The things overlap.  That’s kind of… there’s a lot of things that can be talked about.

RK:                  That’s a really helpful distinction to make because I imagine that some listeners might be asking, “Well, I see a dietitian to really talk about nutrition goals and what I’m eating. Why do I have to have another appointment to see someone for DSMT?” How would you respond to that?

GA:                  Yeah. Well, if you’re wondering that, you might be right, you might not.  But if somebody has well-controlled diabetes.  They’re doing a great job with their self-management, and they’re working on their nutrition for any reason, whether it’s weight loss, right, whether it’s another condition, right, maybe they have a heart condition they’re working on nutrition for that.  Maybe [they] wouldn’t benefit much from seeing somebody for DSMT.  Totally possible.  When somebody has uncontrolled diabetes, when they’re working really hard on their nutrition, right?  I actually see this kind of often, and their diabetes is still uncontrolled, that means there’s some missing link somewhere somebody is not identifying.  And that’s really where diabetes self-management training can come in clutch.  Because you’re gonna get that in-depth assessment.  Their job is to find out what could not be right about your regimen or what’s going on with you that is preventing you from reaching your goals despite your efforts.  One important thing to consider is if a patient or participant is being asked to put in effort and they don’t see a benefit, that’s a tough sell.  It’s gonna be hard to get that patient to continue to work towards goals, if they’re trying and it’s not working.  I think if you’re if a patient or somebody listening to this is wondering, ‘Hey, I already see a dietitian, do I need this?’  If your diabetes is not under control yet, then you should definitely think about it.

RK:                  And it’s so true, isn’t it, that the majority of diabetes care really relies on self-management of the patient at home.  And when we talk about self-management, it’s not just nutritional modifications, but it’s really changes in behavior to daily routines, to getting used to the frequent glucose sticks, or taking your insulin as prescribed, or if you have technology, changing the sensors as you need to.  Do you find that you focus a lot on behavioral change strategies or what are your conversations like when you talk with patients?

GA:                  Sure.  So here’s a very common one.  I will have folks who feel maybe a little confused about what foods to eat for their diabetes.  So they will ask their provider, “hey, I don’t know what to eat,” and then, you know, I will get a referral because I happen to be a dietitian.  I also provide diabetes self-management training.  And what I find very frequently, this happens a couple times a week, that individual, maybe it’s not monitoring their glucose.  You know, they’re eating different things that they think might help but they have nothing to check against.  That’s a great example of where that missing link.  There’s a missing piece there that we don’t know where we are, it’s hard to really get first of all return on our investment, right?  If you’re making changes that are not easy, you want to see some kind of benefit soon, right?  You don’t want to wait three months to get your A1C. It’s too long.   That’s an example of a way a conversation goes pretty frequently.  Then we’re talking about glucose targets; you know, ‘how do we know if our numbers are good?’  ‘At what point is it too high?’  You know, then the conversation can shift into complications.  If it gets to this level, ‘okay, what is that doing to my body?’  ‘If it gets low, what to do?’  You know, if somebody has hypoglycemia, maybe they never had hypoglycemia because their glucose has been very high.  We’re getting it under control and now they’re dealing with a new potential issue.  The conversation can go tons of ways, but those are just a couple.

RK:                  That’s really interesting. You know that feedback that you can get from the use of either older or newer technologies, it doesn’t really matter which one but just having that feedback is so important to be able to get insight into what you do and how it impacts your blood sugar numbers. That’s so interesting. So how would someone find out if they’re interested in the service of DSMT? How would they find out if their center offers this?

GA:                  For a while, services have only been offered out of Outpatient Center on Caroline Street so, downtown.  We realized this is like not necessarily the easiest access for folks.  An immediate benefit with the pandemic was the telemedicine became wildly popular with this.  A lot of folks recognize that it helps, you know, the fact that they can do it virtually and not have to be in traffic and all that.  Very high uptake via telemedicine.  Most folks love it.  I would say about 50% of my patients see me via video.  There are tons of folks who I’ve actually never met in person, and I feel like I know them.  For folks who don’t want to do telemedicine, we are expanding quite a bit.

RK:                  Do you know what it’s like in other parts of the country or the world in terms of availability of DSMT?

GA:                  The DSMT benefits, in terms of you know like insurance is recognizing this and covering it, but it’s not new.  I’d be fairly surprised anybody living in an urban or suburban area if there was no access to this.  You’re wondering how to find out, you go to the American Diabetes Association websites. They offer, like, you can start put your zip code, and they will show you all their recognized (AKA) accredited programs in your area.  I believe ACDES does the same thing.  They’re another accrediting body who they have the same feature, I’m pretty sure, where you can search your zip code and you can find out where you can go.

RK:                  For diabetes self-management education and support (DSMES), is that really only for people who are newly diagnosed with the disease?  Or can those who’ve had diabetes for a while also benefit?  At what point in the disease course do you recommend it?

GA:                  There are four critical times recommended by ADCES, one of them being at diagnosis.  So anybody who’s newly diagnosed with any type of diabetes, I highly recommend that you do this because a lot of the questions that you didn’t get to ask to your primary care physician, all in all likelihood, you’re gonna have an hour with this person, this educator.  And you’re gonna be able to ask all the questions that you have.  So I highly recommend if you’re newly diagnosed that you consider this.  Even if you know people with diabetes, you have to remember that everybody’s diabetes is different.  If you’re hearing things from people, you know, that might not kind of line up with what you feel might be right for you, this is definitely what you should do.  Try to find a program and go.  And other times you could do this.  If somebody’s diabetes is uncontrolled, the definition can vary but what I would recommend if A1C is over 8, I would definitely think about it.  Just because your A1C 7.9 doesn’t mean you can’t come.  But over 8, I would definitely consider it.  If you’re new to a health system where you’ve recently moved, it’s always prudent to establish care, but not a bad idea to meet your diabetes educator.  That’s probably one of the less urgent ways that somebody would establish care, but it happens.  And then the other time is if any of any complications arise.  You know, this is something that is an unfortunate nature of diabetes.  I get this fairly frequently.  If somebody finds out their kidney function as even decline just a tiny bit.  Our urgency is high, you know.  We’re highly engaged.  We want to make changes.  That’s a great time to meet with somebody who can help you develop a plan to prevent any further progression of complications.

RK:                  Well, Gene, this has been so helpful to really understand better what is DSMT and DSMES.  Is there anything else that you’d like to share with our listeners?

GA:                  I think just like you mentioned, Dr. Kalyani, DSMES [and] DSMT are the same.  So wherever you go, you’re gonna hear different things.  They are the same.  Like I said before, it’s not a class so it can be delivered in many different ways.  If you’re a patient or participant considering this, definitely advocate.  Ask for what you want.  There are likely ways to be seen individually if you ask.  We’re very aware of that when our program and some of the programs that have been around longer, they have a very long-standing class model.  You can get it in a group, but it doesn’t have to be a group and it’s not a class because we want to respect all the knowledge that our people have.  There’s a lot of pre-existing knowledge out there.  And lastly, if you’re thinking about doing it, you should do it.  Because if you put off diabetes, with any kind of chronic condition, if you put it off, you’re paying interest on that.  If you’re thinking about it, I would definitely go ahead and do it.

RK:                  Well, Gene, thanks so much for being here today and for sharing your expert input and really enlightening us on the need for patients really at all stages or their disease to consider whether it’s DSMES or DSMT.  I really appreciate the conversation today so thank you.

GA:                  Thank you for having me.

RK:                  I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed.  We developed this podcast as a companion to our Patient Guide to Diabetes website.  Our vision is to provide a trusted and reliable resource, based on the latest evidence, that people affected by diabetes can use to live healthier lives.  For more information, visit Hopkins diabetes info dot org.

That’s all one word.

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