Healthcare leaders take strong role in diabetes healthcare

By DAVID REESE, Montana Health Journal

Miracles sometimes come in small packages.

That’s how it was for Elaine Ryan, when in 2007 she overheard a coworker talking about a weight-loss program in Missoula for people at risk for diabetes.
Ryan, 60, had lost her mother to chronic high blood pressure from being overweight, so she knew she had to do something about her weight, which at that time was 237 pounds.

Ryan was a textbook case for someone at risk for diabetes. She was overweight, her cholesterol was high, her blood sugar was high, and so was her blood pressure. She also had a family history of diabetes. So, two months after hearing about the program (her little miracle) Ryan got a doctor’s referral and entered the first class of the Diabetes Prevention Program at Community Medical Center in Missoula.
The program is designed to help people who have diabetes or are at risk for diabetes live healthier by reducing their weight, adding exercise and modifying their diets.
Since it was begun in that first class of February 2008, the program has helped over 450 people. “I just took to the program,” Ryan said. “To me, this was about opportunity. The 10 months I was in it, I just really took to it, like a duck to water. It expanded my horizons.”

Ryan is now a speaker at the Montana Cardiovascular Disease and Diabetes Prevention Program classes at Community Medical Center. “I’m a cheerleader,” she said.

Diabetes mellitus is a group of diseases characterized by high blood glucose levels that result from the body’s inability to produce or use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy for the body.
There are three types of diabetes.

Type 1 diabetes is usually diagnosed in children and young adults, and was previously known as juvenile diabetes. In Type 1 diabetes, the body does not produce insulin.
Type 2 diabetes is the most common form of diabetes. Type 2 diabetes is caused by genetics, being overweight, and not getting enough exercise. Over consumption of food and poor food choices, like sugary drinks, can also lead to Type 2 diabetes.
The third type of diabetes is gestational diabetes. During pregnancy – usually around the 24^th to the 28th week – many women develop gestational diabetes. Having gestational diabetes is also a risk factor for developing Type 2 diabetes later in life.
Type 2 diabetes can usually be prevented, managed and treated, and that’s why programs at diabetes education centers around Montana seek to reduce the increasing trends in diabetes diagnoses. The diabetes education programs are designed to educate people how to manage their diabetes and also to inform people who might be at risk for developing the disease.

The 10-month program at Community Medical Center in Missoula helps people develop an exercise regimen, offers classes on healthy eating, and helps people make lifestyle changes to reduce their chances of heart disease or diabetes. To enter the program participants must have a doctor’s referral, be overweight and have at least one other risk factor for diabetes or heart disease, such as high blood pressure, high cholesterol, a history of diabetes or gestational diabetes.

Most people in the program report an average weight loss of 15 pounds, plus improvements of blood pressure, cholesterol, and fasting blood glucose levels, according to Shirley Schneiter, program director at Community Medical Center
According to the Center for Disease Control, there are 25.8 million people in the United States with diabetes, affecting 8.3 percent of the U.S. population. Eleven percent of America’s population who are 20 years old and above — roughly 79 million people — have pre diabetes or are at risk but undiagnosed for the disease.

Montana is seeing an increase in diagnosis of Type 2 diabetes, which is caused, in part by being overweight. That’s why the focus of the wellness program at Community Medical Center — and others around Montana — is on diabetes prevention. The education effort is among 14 sites providing diabetes-education programs in Montana. The programs are funded by a grant from the Montana Department of Health and Human Services. Kalispell Regional Medical Center, St. Patrick Hospital in Missoula and Missoula City/County Health Department are some of the other institutions that offer diabetes-education programs.

Without those government grants, the diabetes prevention classes will likely cease to exist, Troupe said. “Diabetes centers are always on the chopping block,” she said. “They don’t make money at the front end, due to poor insurance. But diabetes education could help prevent a heart surgery, which would easily pay for two years of a certified diabetes educator’s salary in that one intervention.”
The increase in diabetes in Montana and across the nation is due in large part to high-fat diets, large portion sizes, low exercise, and fast foods, according to Schneiter. “All of these things contribute to being overweight,” she said.

Diabetes prevention is geared toward weight loss and increasing activity level. This decreases a body’s insulin resistance, so a body’s cells are more responsive to the insulin they are producing. This helps lower blood sugars, which reduces the risk of developing Type 2 diabetes. “Weight and exercise are the two things that people can do to reduce their risk,” she said.

DIABETES ADVOCATE

JENNIFER TROUPE is a tireless advocate for diabetes education and prevention. Troupe, a certified diabetes educator at Providence St. Patrick Hospital in Missoula, helped start the diabetes clinic in Kalispell, and has worked at the diabetes education center at St. Patrick in Missoula for 2 years.

Diabetes is not what kills people. It’s uncontrolled diabetes that causes problems and leads to dialysis, eye issues, neuropathy, amputations, wounds, emergency room visits and death. That’s why education, disease management and prevention are important, Troupe said.

Uncontrolled diabetes can lead to other serious health conditions, namely heart disease. People with uncontrolled diabetes have a three- to four-times higher risk for a stroke than the general population, according to Troupe.
Diabetes is the seventh-leading cause of death now, but Troupe said she sees that moving up to No. 1 in the near future unless Americans make efforts to control their weight.

“We have a big challenge coming up,” she said. The cost to the U.S. health care system is sizable. In 2007 $174 billion was spent in the United States on diabetes care, according to Troupe.

Caring for people with diabetes is one of the biggest cost centers of St. Patrick Hospital, Troupe said. A diabetic patient may need care in the cardiac surgery center, or need emergency care from uncontrolled diabetes.
Troupe is adamant about people with diabetes working with a knowledgeable diabetes educator — preferably a physician with experience in diabetes management and a Certified Diabetes Educator.

She says diabetes educators provide a crucial service to patients, as well as primary-care physicians who are overwhelmed with daily patient loads. Many primary-care doctors have less than 15 minutes to spend with a patient, and if someone has diabetes, 15 minutes is not enough time for a doctor to diagnose treatment, diet, medication or exercise regimens, she said.

“People with diabetes need to see a certified diabetes educator,” she said. “The impact we have can really change their lives. There are so many myths out there. We build lifelong relationships with clients, and help them manage their disease.”
Colleen Karper works at Kalispell Regional Medical Center to provide diabetes education. Because of the rural nature of northwest Montana, KRMC’s focus is on outreach to communities like Libby and Browning. Her goal as a former hemodialysis nurse is to keep people with diabetes healthy — and prevent those with pre-diabetes from ever getting the disease. “My goal is to keep someone off a dialysis machine,” Karper said. “I just have a passion for helping people prevent and manage diabetes.
“With education you can help people make changes in their lives and live a healthier lifestyle.”

Troupe wants to bridge the gap between physicians and certified diabetes educators, and develop teamwork with a person’s primary-care doctor.
“We are an extender of a physician practice with a person’s diabetes management, not a replacement,” Troupe said. “Our goal is to assist the physician in improving the diabetes care of their patient and help carry the load. Communication with physicians and a good relationships are keys to success.”
Another challenge to diabetes education is the lack of access to care in rural communities. People don’t want to leave their communities to get their care, and that’s especially difficult when diabetes is prevalent on Montana’s seven Indian reservations, Troupe said.

St. Patrick Hospital is focusing on outreach to small communities in Montana, such as Drummond, Superior and Florence. They also work in Polson, a part of the Salish-Kootenai Indian Reservation, where about 25 percent of the population has diabetes, Troupe said.

CHANGING DIABETES EDUCATION

THERE ALSO NEEDS to be a change in the way diabetes education is paid for by Medicare and insurance companies. Currently, Medicare pays for 10 hours the first year someone is diagnosed with diabetes for diabetes management and education with a certified diabetes educator. The counselor then gets paid for only three hours per year after that. Montana-based insurance companies are mandated to pay $250 per year for diabetes self-management education, which is “barely enough to pay for ongoing consultation work with a diabetes educator,” Troupe said.
Troupe has seen the inconsistencies in how diabetes is managed by health insurance companies. For instance, a private company won’t pay $60 for a client to visit her and get nutritional or dietary advice related to their diabetes; but the insurance companies will, on the other hand, pay $60,000 surgery for that same patient to have a gastric-bypass surgery, an extreme form of weight loss control. “This just doesn’t make sense,” Troupe said.
Accountable Care, an aspect of the Affordable Care Act, could impact the way diabetes education is paid for, since a health care system could get penalized for not managing their diabetes patients to national standards. This could lead to a person with diabetes being referred to a more effective provider or source, such as a certified diabetes counselor, Troupe said. Under Accountable Care, a physician will, however, make more money per client visit if a person with diabetes meets national standards, such as a Hemoglobin A1C level.
Getting tested for diabetes is hard enough for some people. And for those who find out they do have the disease, the results can be hard to live with. That’s why a certified diabetes educator is so important, Troupe said.
A diabetes counselor can help a person adapt to the life choices they must make when they find out they have the disease. “People go through a grieving process when they learn they have diabetes,” Troupe said. “Some accept it, some deny it. The deniers are the tough ones. You can’t push them too hard. If you’re taking insulin, it doesn’t mean you failed. And it’s not a death sentence.”
By the year 2050, she said, roughly 30 percent of Americans will have Type 2 diabetes. “Once you have Type 2, you have it and it doesn’t go away. It’s like being pregnant. Either you are or you aren’t,” she said.

Continually monitoring blood-sugar levels is important for people with diabetes, and simple tests can tell if a person has diabetes if they think they may be at risk. “Don’t put your head in the sand — find out what your number is,” Troupe said. Signs of diabetes are blurred vision, extreme thirst, infections that won’t heal such as a prolonged urinary tract infections, or numbness and tingling in feet.
Diabetes has other effects aside from the disease.

The stress of managing diabetes can also be difficult, and depression is often something that people with diabetes must cope with, Troupe said. A person’s insulin needs change over time, so there’s a constant adjustment in a person’s life. This is another reason why a certified diabetes educator is helpful, Troupe said.
Having diabetes in the teenage years can be difficult to manage, Troupe said, because of the independent nature of this age group.
Regardless of age, it’s important for people with diabetes to have partners or friends around them who are aware of their condition.

That’s why schools are making more of an effort to know the signs of people with diabetes. Currently only a nurse or parent can give an insulin injection to someone with diabetes, and there’s not always a school nurse around if someone is experiencing drastic fluctuations in blood sugar. Teachers need to be trained in how to help students with diabetes, Troupe said, and how to educate students about the risks of the disease.

One way schools can be proactive in diabetes management for students is to have a supply available of glucagon, a hormone that causes the liver to produce glucose and increase blood sugar. It’s often the first treatment that a paramedic — or a school nurse, for example — would administer to a person with diabetes suffering extremely low blood sugar. This simple, inexpensive treatment could save a child from an emergency-room visit, but not all schools choose to have glucogon available, Troupe said.
 


MONTANA IS CONTINUING to see an increase in the diagnosis of Type 2 diabetes, Schneiter, of Community Medical Center in Missoula, said.

“That’s really a national trend and we’re seeing it in Montana as well,” she said. “We see that percentage continue to climb, and that’s why part of our program now consists of an effort toward diabetes prevention.”

Schneiter said the programs around Montana are having a positive impact on detecting and treating diabetes. “For the amount of people we’ve worked with, it’s helping, considering that we’re doing this in 14 sites across the state,” she said.
“Montana is making a big effort to reduce the incidence of Type 2 diabetes in the state, through these programs.”

As Troupe and Schneiter can attest, diabetes is the biggest health issue facing America. “The increase in diagnoses of diabetes is result of more obesity and less activity,” Schneiter said.

Technology has improved delivery of treatment for all types of diabetes. That’s why it’s so important to attend a diabetes-education program, Schneiter said. “It’s a unique disease, in that people are really the self managers of their condition, along with guidance of medical providers,” she said. “People have to stay up on the education through their lives, because it’s a chronic condition that changes over time. What works today might not work two years from now. It’s something that requires continuous care. And as we learn more about the treatment of diabetes it’s helpful to continue with education to stay up with the newest technology and information.”
Continuous contact with a physician or certified diabetes educators is crucial for people with diabetes or those at risk for the disease. “That’s why it’s so important stay in close touch with their medical providers and test annually to make sure they are not experiencing symptoms of diabetes,” Schneiter said.
Even though there are 14 diabetes prevention centers and many more diabetes educators in Montana that are helping people manage diabetes, this help might not last forever if healthcare providers and insurance companies don’t find a way to cover the costs of providing services.

Schneiter said it’s crucial that the centers demonstrate their effectiveness so that insurance companies will be able to reimburse for those services in the future.
And the needs for diabetes education and prevention are not going to go away. In fact they’re only going to get worse. “I see it continuing to increase unless we make a serious effort at helping children maintain healthy lifestyles, and to help them learn to eat healthy and be active,” Schneiter said. “A lot of diseases are affected by our behavior. Diabetes is reflective of our lifestyle.” Reducing risk means changing diets that are high in fat and sugar, and increasing physical activity.

“If people realize how their risk for diabetes increases with poor diet, they’d make changes,” Schneiter said. “Education is a key piece for people to understand, but it’s up to the person.”
 

HOW ONE PERSON CHANGED THEIR LIFESTYLE

ELAINE RYAN was one of those people who knew she had to do something — about her weight and about her lifestyle.

At 237 pounds, Ryan said office desks and even toilet stalls seemed small to her. Then she began the journey to lose weight and make healthier lifestyle choices at Community Medical Center’s diabetes and heart health education program.

Through the program she began to take her weight loss seriously. She said she “really got into” the exercise part of the program, and was fastidious about what she ate. She writes in her food journal every day about what she eats, and how much, watching, in particular her fat consumption. “I’m not worried about carbs or protein,” she said.
Her exercise goal started out at a half hour a day, five days a week.

She met the goal of taking off seven percent of her body weight pretty easily, she said, but in order to keep off the weight, she went further, taking advantage of programs at Missoula Women's Club, walking miles on the treadmill.
She lost 90 pounds in a 16 months.

How did she get so big?

“I didn’t say no to anything,” she said. “I just kept buying bigger clothes. I let myself get into some really sloppy habits of poor diet and little exercise.”
Ryan has become an advocate of the importance of exercise, diet and, most importantly, the diabetes education centers.
She spoke at a state hearing for the Department of Health and Human Services, carrying several sacks of kitty litter.

Ryan said she told the hearing, “A year ago I had four of these in my body.”
Having the discipline and accountability of a diabetes education program or counselor helps people like Ryan make better, healthy choices about their lives. “I got the tools I needed,” Ryan said. “All my life I’ve heard the information. I knew that, but I didn’t really do it. Now it’s become a lifestyle.”

The change has helped her family also, because they now see what a healthy diet looks like.
“I read more food labels than I ever did, and when I go shopping I look in my shopping cart. It’s helped me to continue to make wise, healthier decisions about what I consume,” she said.

Working out at the gym is still a priority for her.
She has remained on blood-pressure medication on recommendation from her physician, but Ryan doesn’t have to take any cholesterol-reducing medications because she takes care of that herself. “My family twinkles at me,” she said. “They’re really excited about it.”

She took second place in a 5-kilometer race at her hometown in Minnesota. “Through all this I accidentally started running,” she said. A reflection on her accomplishment is when she goes clothes shopping and medium-sized clothes are too big.
Ryan, a self-described cheerleader for weight loss and diabetes prevention, says people at risk for diabetes should not wait to get help.

“Don’t come up with any excuses; put your foot out and take that first step,” Ryan said, “and don’t beat yourself up if you slip back. It’s never too early and it’s never too late.”

HOW DIABETES AFFECT AMERICANS

Diabetes affects 8.3 percent of the U.S. population For people ages 20 and over, 11 percent (25.8 million) have Type II diabetes and 7 million people are undiagnosed, 79 million American adults, 20 years or older, have pre-diabetes.

35 percent of U.S. adults 20 and over have pre-diabetes, including people age 65 and older Symptoms of diabetes might be frequent urination, vision changes, fatigue, or involuntary weight loss.

People with diabetes or at risk for diabetes should:
- monitor blood sugar daily
- get their blood pressure checked
- get feet exams
- get a hemoglobin A1C test, which gives patient an idea of what average blood glucose has been over past two to three months. That should be checked twice annually.
- get an annual microalbumineria test for kidney problems
- receive a dilated eye exam
- have cholesterol levels tested annually
- see their dental hygienist or dentist twice a year
 — Source: Centers for Disease Control
 On the Web: mtprevention.org 
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