The Bottom Line:
Research suggests that the first step toward achieving common ground can be both easy and effective. Begin each visit with a very open question designed to elicit the patient's story and agenda instead of assuming that what we see in the biomedical realm is the whole story or all that matters. Examples include questions like: "What brought you in today?" "What's going on with your diabetes, Joe?" and "What's on your mind today and how can I help?" This results in your having a more complete picture of what's going on. In addition, when patients feel listened to, they are more likely to listen in return.

The Bigger Picture:
Since nearly all diabetes treatment is performed by the patient, you are absolutely right that it's critical for all concerned be on the same page. Patients' engagement in self-care requires clear, personally-felt goals and the skills to achieve them. These are not things that can be successfully determined, dictated or conferred by someone else but must be developed internally by the patient in a collaborative process with their healthcare provider. But questions like yours are very common because collaboration is a skill that's just not routinely taught to health professionals. And it doesn't spontaneously arise through experience either. The process requires inquiring about the patient's perceptions, experience and agenda for the current visit or condition and listening to their answers. Research suggests that the first step can be both easy and effective. Begin each visit with a very open question designed to elicit the patient's story and agenda instead of assuming that what we see in the biomedical realm is the whole story or all that matters. Examples include questions like: "What brought you in today?" "What's going on with your diabetes, Joe?" and "What's on your mind today and how can I help?" This results in your having a more complete picture of what's going on. In addition, when patients feel listened to, they are more likely to listen in return.

It's also helpful to make sure your patients have adequate, up-to-date information about their diabetes in order to partner effectively with you in their own care. Referring them to a diabetes education program is one way to accomplish this. Another is to provide or recommend good reading material. Make sure it is accurate and easy to read. Our patient book, Diabetes Myths, Misconceptions and Big Fat Lies! is a good example.

The Bottom Line:
People want to feel well and that's generally what keeps them coming back, even when things are not improving. A thorough discussion of what patients want to achieve, what they are doing and what's happening as a result may help you find common ground in which a new plan can be negotiated – one that is both acceptable to the patient and capable of addressing their specific clinical needs and circumstances.

The Bigger Picture:
People want to feel well and that's generally what keeps them coming back, even when things are not improving. We ask you to consider that not making changes is not necessarily the same thing as not being "willing to make changes." Most people are willing to change when the change results in something they want and value. But few people are willing to "be changed" by someone else – even a well-meaning health care professional – especially when actions don't seem to produce a meaningful benefit. A thorough discussion of what patients want to achieve, what they are doing and what's happening as a result may help you find common ground in which a new plan can be negotiated – one that is both acceptable to the patient and capable of addressing their specific clinical needs and circumstances. If you can recognize a struggling patient's return to care as an indication of his or her desire to be well, it creates an opportunity to look for a way to help them achieve that goal. Consider further development of your consultation skill set with academic or continuing education courses on topics such as Motivational Interviewing and Medical Communication or through courses such as DMTC's Diabetes Manager University which present the delivery of diabetes clinical care in the context of patient-centered methods.

The Bottom Line:
Here are three very common possibilities:

• They didn't clearly understand what was expected. Research shows us that patients only understand what their doctor said and wanted about 50% of the time. Ask people what they heard before sending them out the door.
• They are afraid of making you angry by being honest. Health care professionals – especially doctors – are very important and powerful figures to people living with a serious condition like diabetes. It's scary to think that someone with a good deal of power of your life and health might get mad.
• Life got in the way. In spite of people's best intentions, sometimes other parts of their life intervene. That's why talking to patients about factors outside the biomedical sphere is critical.

The Bigger Picture:
The problem may be occurring after they leave your office, as you think, or it may actually start while they're still there. Here are three very common possibilities:

• They didn't clearly understand what was expected. Research shows us that patients only have a clear and accurate idea of what their doctor said and wanted about 50% of the time. That's no better than flipping a coin. Improve the odds that your patient will actually leave the office with the information you intended by asking him or her tell you in their own words what you've said. "I want to make sure I've done a good job of explaining, Joe. Could you tell me in your own words what I've asked you to do? (or what I just explained?)" And then, of course, correct any misunderstanding.
• They are afraid of making you angry by being honest. Health care professionals – especially doctors – are very important and powerful figures to people living with a serious condition like diabetes. It's scary to think that someone with a good deal of power of your life and health might get mad. So even when a patient may disagree with your plan or see it as unrealistic, they may be afraid to say so. To reduce this problem, work on your listening skills and use them to elicit the patient's view of their disease and your plans to treat it. "I told you what I think might be the best way to proceed but I'm sure you've also given this a lot of thought. Could you tell me what you've been thinking? Does what I've suggested sound doable?"
• The last common reason for incomplete action is simply life getting in the way. Even if the intention to act was there in the office, the patient may have encountered barriers to following through out in the real world. You can reduce the possibility by keeping agreed upon behavior change goals small and focused, and by asking specifically what the patient plans to do, and what they think might get in the way. Having talked about potential problems can help people adjust and keep trying when they encounter barriers.

The Bottom Line: No. Providing appropriate treatment, geared to the patient's presenting problems and duration of disease increases the likelihood of clinical improvement, regardless of their own actions. By offering every patient the most effective therapeutic options available for their situation – just as we would for a cancer patient – we act as more helpful collaborators with our patients in the care of their disease – giving them the best chance at both metabolic control and a feeling of personal efficacy around their disease.

The Bigger Picture: No. Providing appropriate treatment, geared to the patient's presenting problems and duration of disease increases the likelihood that they will see clinical improvement, regardless of their own actions. Seeing improvement builds confidence. In fact, even patients who are actively engaged in diabetes self-care – watching what they eat, checking BG, keeping records, being active, and so on – yet seeing no improvement because they are on inadequate or inappropriate pharmaceutical treatment are quite likely to become "burned out" and abandon self-care as ineffectual. By offering every patient the most effective therapeutic options available for their situation – just as we would for a cancer patient – we act as more helpful colloborators with our patients in the care of their disease – giving them the best chance at both metabolic control and a feeling of personal efficacy around their disease. Feeling effective and seeing measurable results promotes patient motivation and self-care efforts.

DMTC's Diabetes Manager University course presents a thorough update on the use of today's wider array of clinical tools.

The Bottom Line: Chances are very high that you can't. We know that the patient had probably lost about 80% of beta cell mass and 50% of insulin secretory capacity by the time of diagnosis and will most likely require insulin to reach glucose goals at some point. But it is possible to slow the loss of the remaining insulin production capacity. This is done by pursuing excellent blood glucose control from the time of diagnosis to slow beta cell destruction. There is also some very compelling evidence that exenatide (Byetta) improves beta cell function (and perhaps increases beta cell mass) over time. So consider adding this agent, preferably early in the course of disease.

The Bigger Picture: Since progressive loss of insulin secretory capacity is part of the natural history of type 2 diabetes, we cannot ethically promise that any set of patient behaviors or plan of medical treatment will protect them from requiring insulin therapy at some point. And the horse is actually well out of the barn on this problem by the time most health care providers arrive on the scene. We know that the patient had probably lost about 80% of beta cell mass and 50% of insulin secretory capacity by the time of diagnosis. But it is possible to slow the loss of the remaining insulin production capacity. This is done by pursuing excellent blood glucose control from the time of diagnosis. The body's glutoxic response to chronically elevated blood sugars speeds the loss of insulin secretory capacity. So "Treat to Target" from the beginning to protect endogenous insulin production as long as possible. There is also some very compelling evidence that exenatide (Byetta) improves beta cell function (and perhaps increases beta cell mass) over time. So the inclusion of this agent in treatment as early as possible is another potential tool for delaying a patient's progression to insulin as long as possible.

The Bottom Line. Type 2 diabetes involves a number of distinct pathophysiologic features. Different classes of agents address distinct problems. Their effect is complementary, not duplicative. Addressing one feature – such as insulin resistance – early in disease may be sufficient to normalize BG. But as the disease progresses and insulin secretion falls, it becomes necessary to address multiple defects, each with its own appropriate agent.

The Bigger Picture. The answer lies in the pathophysiology of Type 2 diabetes. It is a complex condition that includes several distinct abnormalities. As medicines geared to the treatment of each of these distinct defects have become available, the standard of care has evolved to include their routine use. Consequently, as you have observed, it is now common for a patient with long-standing type 2 diabetes to be taking a TZD to address insulin resistance, metformin and/or exenatide to address excess hepatic glucose production and insulin or a secretagogoue to address relative insulin resistance. In addition, the newer peptide therapies such as exenatide, DPP-IV inhibitors and other agents in development are expanding our arsenal in ways that target several defects at once, making them very logical agents to include as well, ideally from early in the course of disease.

For a simple means of explaining the rather complicated pathophysiology of Type 2 diabetes in patient-friendly terms, review the sections on Pills and Insulin in DMTC's patient book, Diabetes Myths, Misconceptions and Big Fat Lies!

The Bottom Line: Risk for hypoglycemia occurs when there is too much insulin in the bloodstream for the current need. This most often happens between meals and overnight and sometimes for the elderly patients you're asking about, virtually any time because they are not eating. So what's the answer? For frail, elderly patients with type 2 diabetes, our first choice would be agents that don't raise insulin levels: exenatide, metformin, and TZDs, for example. Avoid the highest risk therapies: sulfonyureas and pre-mixed insulins. They raise insulin levels for most of the day and provide no way to fine tune available insulin to the patient's blood sugars, food intake, or changes in activity.

The Bigger Picture: As you obviously realize, low blood sugar presents serious risks for frail, elderly patients and should be avoided. And, as you suggest, the choice of agent can make a big difference to the degree of risk, but the dividing line is not necessarily between tablets and insulin. Risk for hypoglycemia occurs when there is too much insulin in the bloodstream for the current need. This most often happens between meals and overnight and sometimes for the elderly patients you're asking about, virtually any time because they are not eating. So what's the answer? For frail, elderly patients with type 2 diabetes, our first choice would be agents that don't raise insulin levels: exenatide, metformin, and TZDs, for example. If insulin is needed to achieve glucose control, start with a long-acting back ground insulin such as insulin glargine (Lantus), checking overnight blood sugars to rule out nocturnal hypoglycemia and titrate accordingly. If meal insulin is required, as it will be for anyone with type 1 diabetes and many patients with long-standing type 2, favor rapid-acting insulin carefully matched to food intake (if the patient skips a meal they don't take it). And finally, avoid the highest risk therapies: sulfonyureas and pre-mixed insulins. They raise insulin levels for most of the day and provide no way to fine tune available insulin to the patient's blood sugars, food choices, or changes in activity.

The Bottom Line: There are two main reasons why we do not use prescribed diets. First and foremost, structured meal plans are not associated with a high rate of success. The second reason we avoid prescribed diets is that they violate our patient-centered philosophy of care. They rely on patient "obedience" rather than informed choices.

The Bigger Picture: There are two main reasons why we do not use prescribed diets. First and foremost, in most settings and patient populations, structured meal plans have not been associated with a high rate of success. We know from research that the "diet" is overwhelmingly identified by patients as the most "difficult" or "hated" aspect of diabetes management. Further, our clinical experience suggests that very few people actually use the structured diets they are given, at least not for very long. A tool that is almost universally hated and seldom used is unlikely to be a powerful self-management tool and we wanted something better. The second reason we avoid prescribed diets is that they violate our patient-centered philosophy of care. Diets are developed and prescribed by professionals and patients are expected to follow them. They are not skill-based, flexible nor reflective of normal human eating, i.e., exhibiting differences in appetite and intake from day to day. Rather, they rely on patient "obedience" for their effectiveness. We chose instead to focus on a patient-directed experience of discovering exactly how their preferred foods affect diabetes control. Coupled with the skills of carbohydrate management, this process takes blind obedience out of the picture and allows patients to develop a personally relevant and acceptable – as well as effective – eating plan.

The Long and the Short of It: We recommend Carbohydrate Management because it has a proven track record (e.g., in the DCCT), works with any pharmaceutical treatment (i.e., not just in patients using multiple component insulin regimens), is easy to teach, learn and use, and because it focuses patient effort where it has the most direct impact on blood sugar management. Importantly, it works equally well with all ethnic and regional cuisines, and can be used when eating out.

The Bottom Line: Most type 2 patients rely on body insulin to cover meals, especially early in the disease. For these patients, a ceiling amount of carbohydrate (their "budget") for each meal is determined by reviewing food and blood glucose records together. Type 2 patients who use rapid-acting insulin with meals count carbohydrates like those with type 1, adjusting the dose to match the amount eaten.

The Bigger Picture: The best approach to carbohydrate management for a given patient depends on their pharmaceutical treatment, not their diagnosis. Patients with type 2 diabetes who use and adjust rapid-acting insulin at meals should learn to "count carbs" the same way patients with type 1 diabetes on this type of regimen would. They count the number of grams or servings of carbohydrate they will be eating and use that value to set their mealtime insulin dose. But most patients with type 2 rely on body insulin to cover meals. Since they have a limited capacity to produce insulin, they use an approach we call "carbohydrate budget" in which they choose up to a certain amount of carbohydrate food to match but not exceed their body's ability to make insulin. What that level is can be best worked out by using pre- and post-meal blood testing and looking at the results relative to the actual amount of carbohydrate eaten.

DMTC's Diabetes Manager University course explains the use of carb management in Type 2 diabetes in depth and includes practice with its key methods.

The Long and the Short of It: The right carbohydrate "Budget" for a meal has been found when the blood sugar rise from pre-meal to the 2-hour post meal test is about 2-3 mmol (or 40-60 mg/dl). If the patient has a greater rise than this when eating small amount of carbohydrate (e.g., less than about 60 grams per meal), a medication adjustment is called for. They are no longer making enough meal-related insulin to handle a nutritionally adequate diet.

The Long and the Short of It: That's correct. And that is why information about healthy eating is also part of every DMTC diabetes program. Folks with diabetes need to know about variety, moderation, heart-healthy fats, the power of fruits and vegetables, the need for vitamin D, calcium and the rest of it… just like everyone else. They are guided to compare their intake to current guidelines. Strategies for improving the nutritional content of daily food choices are freely offered and discussed. But in our program, good nutrition is "uncoupled" from the skill of managing carbohydrates, giving people a powerful tool to achieve target blood sugars, even on the occasions when their food choices are not all that nutritious.

The Long and the Short of It: Yes, very well. Through the discovery process they can see exactly how to choose and portion whatever foods are available to them to best effect. If all that's left in the house until the next payday is bread and peanut butter, a patient managing carbohydrates can still keep their food and insulin in balance. And that's equally true whether the insulin is coming from a pen, a syringe, or the patient's own pancreas.

The Long and the Short of It: Probably not. Or at least not once the novelty has worn off! On the contrary, most people, when treated like adults, act like adults. The world is full of people who don't have diabetes and could theoretically be eating sweets with every meal – or even instead of every meal! But they don't. People want to feel and be well and so, without prodding from anyone, exercise some degree of adult judgment in choosing what they eat. When professionals adopt a more accepting and less judgmental approach to folks with diabetes, sweets are no longer "forbidden fruit." In our experience, most people with diabetes actually eat these foods less often or in lesser amounts when they learn how to include without harming diabetes control. Perhaps, no more "forbidden fruit" means less restriction to push back against.

The Bottom Line: First and foremost, because weight management is the weakest tool in the clinical arsenal. Research shows clearly that the vast majority of weight that folks lose is regained in no more than two years. We view weight loss as a strategy for helping achieve overall metabolic control, not as a separate goal. We emphasize the healthy behaviors that impact overall health, diabetes control, and well-being – being more active and making more thoughtful food choices. If they lead to modest weight loss, that's a plus.

The Bigger Picture: First and foremost, because weight management is the weakest tool in the clinical arsenal. Research shows clearly that the vast majority of weight that folks lose by most means (aside from Rou-en Y duodenal bypass surgery and that associated with exenatide use) is regained in no more than two years. And we also know that weight cycling – losing and regaining significant amounts of weight periodically – is associated with a significant increase in morbidity. Perhaps worse, these repeated "failures" are hurtful and emotionally damaging to those living with the problem of obesity. Their shame and defeat often keep them out of care as they try to avoid the guilt they feel and the judgment they experience. We view weight loss as a strategy for helping achieve overall metabolic control, not as a separate goal. And when we talk about weight in the program, we share newer understanding of the biological basis of obesity with participants, especially among those with "survivor" genetics. More activity (actually a LOT more activity) and healthier food choices are valuable strategies for overall health – and may also result in the modest level of sustainable weight loss known to improve insulin resistance, diabetes control and high blood pressure. But the absence of weight loss is not seen as a patient failure and we don't ever make it a barrier to offering other tools that might prove helpful in achieving clinical goals.

The Long and the Short of It: That all depends on what you mean by "trying." If it means stressing weight loss as a primary goal of treatment and withholding appropriate pharmaceutical management because patients "might not need it if they would just lose weight," the answer is no. If it means collaborating with patients in increasing activity, improving overall nutrition, staying abreast of evolving therapies that may prove helpful and generally beating the drum for healthier lifestyle choices, the answer is a resounding "Yes."

As patients choose to manage food choices and portions to improve blood sugars and become more active, many of them experience some weight loss. For most it is a modest weight reduction. For some, however, the amount of weight lost is quite significant. This is most often seen in patients who increase physical activity pretty dramatically – for example, patients that work up from walking to running or hiking and make this higher level of activity a feature of their lifestyle going forward. Another group that often experiences more significant weight loss are people changed to therapies that reduce high levels of insulin between meals, such as switiching from pre-mixed to basal-bolus insulin or from sulfonylureas to metformin or, especially, exenatide.

The Bottom Line: Most patients gather numbers and bring them back to their health professionals periodically. This is what you've noticed changes nothing. Research (Blonde L, Karter AJ, Am J Med 2005; 118: 20S-26S,) shows that when patients and providers learn how to use BG results to modify care (either self-care choices or medication doses), control improves. With some new skills for both you and your patients, you can make monitoring effective.

The Bigger Picture: Jack the Ripper had a scalpel but he didn't use it like a surgeon. Likewise, it's not BG monitoring per se that is at fault when outcomes don't improve with its use, but rather the WAY it is used. The truth is that monitoring changes absolutely nothing unless either the health care provider or the patient takes action on what's discovered. Research (Blonde L, Karter AJ, Am J Med 2005; 118: 20S-26S,) shows that when patients and providers learn how to use BG results to modify care (either self-care choices or medication doses), control improves. This is one of the main rationales behind DMTC's "Discovering Diabetes" process. People learn to use BG results to understand their diabetes, and to guide and evaluate their self-care choices. Our experience indicates that BG monitoring used in this way BY THE PATIENT does indeed result in improved control. The process becomes even more powerful when the patient's provider is engaged and discusses what the patient is doing in a knowledgeable and supportive way.

The Long and the Short of It: Most people will resist frequent testing when they do not experience an improvement in either their glucose results or quality of life from the tests they perform. Refer to DMTC's "Discover Your Diabetes" patient brochure for ideas on how patients can enjoy the benefits of testing. When they do, our experience is that they will then continue to use this vital tool. Our experience is that patients who get a benefit from testing, do much more of it. (*You can request a review copy by e-mail at info@diabetstraining.com.)

The Long and the Short of It: That depends on what they want and need to do with the number. Before meal checks reveal the action of background insulin. When pre-meal values are paired with post-meal values, the BG change between them is a good measure of the match between what was eaten and the insulin available to cover it. The morning fasting value reflects the action of overnight insulin. In general, more checking is needed to achieve control than to maintain it. So to begin, a person may benefit from a period of checking before and after meals, at bedtime and even occasional middle-of-the-night values. So 6-8 checks a day. Many people with type 1 diabetes need to maintain that level of checking chronically to stay in control because of the greater inherent variability of their blood sugar. Most people with type 2 can drop back to a much less intense schedule of routine checking and still remain in control. If the patient is USING the number, it should be done. If it's not being used, either by you or, preferably, the patient, save the strip!

The Long and the Short of It: We believe the most important difference is the Discovery Learning process itself. Through it, participants learn specific details of how their own diabetes and its treatment are working. They then use that information to guide and evaluate self-care decisions. Using other information learned through the DD classes and book, they can then fashion a personally relevant and acceptable way to manage their diabetes. By relying on this process of self-discovery and informed decision-making, we facilitate the development of self-management skills. In other words, people don't just learn about diabetes, they learn to actually manage their own diabetes in their real life. Discovering Diabetes is also fairly distinctive in its patient-centered approach to pharmaceutical treatment and its non-diet approach to food management.

You can request a sample packet that more completely describes the Discovering Diabetes Program" by e-mailing us at info@diabetestraining.com.

The Long and the Short of It: That depends entirely on how many patients you expect to serve. The Discovering Diabetes materials and the approach used to implement them can be used by a single educator; even on a part-time basis, if that's all that's needed to serve a small population. We have found that one educator with a part-time support person can serve about 250-350 new patients per year. We recommend two educators and 1 full-time support person for an expected patient load of 400-500 new patients yearly, and 4 educators with 2 full time support persons for a new patient load of 800-1200 patients per year.

The Long and the Short of It: Yes. The patient book (Diabetes Myths, Misconceptions and Big Fat Lies!), the audiovisual teaching materials, and all of the patient point of care forms have been translated into Spanish. It is one of three versions of the Discovering Diabetes Program. We also offer the original English version and a version designed for Native American and Aboriginal people. The same Program Manual (in English) is used with all three modules. Purchasers of the Curriculum receive one module of their choice as part of their curriculum package. If you serve a diverse population, you can add one or both additional modules to meet the specific needs of segments of your patient population.

The Spanish version of the Diabetes Myth book is Mitos Sobre la diabetes, Ideas falsas y Grandes Mentiras. All versions of the Myth Book are available through this web site.

The Long and the Short of It: Absolutely. We strongly recommend that every team implementing the Discovering Diabetes Curriculum at least attend the Diabetes Manager University as a group. This serves both a training and a team-building purpose. For larger programs, the course can be brought to your location in preparation for implementation of the Discovering Diabetes Program. And depending on the amount and type of experience of your staff members, we can also provide supportive consultation to plan the specifics of your program offerings, facility layout, business plan and so on.

The Long and the Short of It: Yes. The curriculum includes all the tools and processes you will need to perform and/or document in order to qualify for recognition by either organization.

The Long and the Short of It: Yes. DMTC can deliver The Diabetes Manager University course in any setting where a sufficient number of professionals wish to take the course. The course is three days in length and requires two faculty members for its presentation. Send an e-mail to info@diabetestraining.com to learn exactly how.

The Long and the Short of It: No. While many CDEs (Certified Diabetes Educators) attend the DMU and the Art of Diabetes Education courses, they are appropriate for just about anyone with a professional interest in diabetes. Physicians, nurses, dietitians, and pharmacists are frequently joined by program administrators, insurance company staff, and pharmaceutical and medical device industry employees. All of these diverse types of attendees rate the course highly.

The Long and the Short of It: No course qualifies individuals to sit for the CDE exam. Applicants must be health care professionals with significant experience in direct patient education and be currently working in the field. For complete details of sitting for the CDE exam visit www.ncbde.org. People who meet the qualifications must develop their own plan for making sure their level of knowledge in each of the areas tested (these areas are also listed on the web site shown above)is adequate. This is typically done by some combination of experience, continuing education courses and independent reading and study. DMTC's courses can certainly be a helpful part of the process.

The Long and the Short of It: Much like the Discovering Diabetes Patient Program, DMTC's professional courses seek to create an interactive learning environment. The small class size supports that learning model and increases each participant's ability to experience learning activities well-matched to their learning goals.