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Lessons from Diabetes Boot Camp

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The name makes you think of raw recruits sweating it out on an Army base. “Diabetes Boot Camp” takes the same mental commitment but is a good bit simpler, kinder and easier than that.

The intensive 12-week professionally monitored program for people with hard-to-manage diabetes is also remarkably effective at helping people with type 2 diabetes bring their blood sugar under control, according to a new study.

Even better: Even if you’re not in a boot camp, you can reproduce its essential elements yourself with a little help from your health-care team. To find out more, we spoke with study leader Michelle Magee, MD, director of the MedStar Diabetes Institute and an associate professor of medicine at Georgetown University School of Medicine in Washington, DC. She didn’t invent the diabetes boot camp concept, but she is one of the first to study it.

WHEN DIABETES IS OUT OF CONTROL

If you have diabetes, your body responds quickly to what you eat, how active you are and the medications you take. But even if you are checking your finger-stick blood sugars, if you see your doctor only every few months to review your results, it’s hard to understand exactly how your daily actions can make a difference.

It is also complicated to live with diabetes if you haven’t learned enough to balance all of what you need to know about it. There’s a lot to learn about nutrition, not to mention exercise, psychology and medicine. You might have areas of ignorance holding you back.

No wonder millions of Americans have trouble controlling their diabetes. They show up on an urgent basis at their doctor’s office. They miss days of work. They get hospitalized or go the the emergency room with episodes of too high or too low blood sugar.

In search of a better way, five primary care practices in and around Washington, DC, enrolled 125 people with hard-to-control diabetes in boot camp. Everyone had had diabetes for at least a year, was taking glucose-lowering medication or insulin, and was asked to regularly monitor their blood sugar.

They all had A1c levels—a measure of average blood sugar over the past two or three months—above 9% and at least one other health concern, such as high blood pressure. (The average A1c level for these patients was even higher—11.4%.) A target A1c for someone with diabetes is usually around 7%, and people with an A1c of 9% or higher are considered to have uncontrolled diabetes.

The great thing is that those out-of-control numbers went down dramatically.

BOOT CAMP CURRICULUM

Here’s the program…

In the first week, each participant met twice with a certified diabetes educator (CDE)—a health-care professional who is specially trained to teach people how to manage diabetes. They took a survey to identify knowledge gaps about diabetes—and then were given video clips that addressed the specific diabetes-related information that they didn’t know. They were also surveyed on medication adherence and then given tailored support so that they could take their medications as prescribed. Both diet and medications—as well as exercise and other issues—were covered in the two sessions.

That’s it for the face-to-face interactions—just two visits. But each participant was also given a “cellular-enabled” blood glucose monitor. As soon as each patient completed a normal finger-stick blood glucose test, the results were displayed in real-time on a “dashboard” visible to their diabetes educator.

Next, participants graduated to “virtual visits,” with phone calls, e-mail or text messages instead of face-to-face meetings. Over the course of the next 12 weeks, most patients had eight to 10 interactions with their diabetes educator. “Educators were able to adjust their patients’ medications frequently via the virtual visits to help them get to their goal for blood glucose control and to continue to deliver critical ‘survival skills’ information about lifestyle management,” said Dr. Magee.

One of the main benefits was immediate feedback to tie actions taken by the patient to blood glucose results. Say a participant had a big dessert and did a finger-stick test, and the blood glucose dashboard showed a higher-than-desired reading. This would signal a teaching point—the diabetes educator who was monitoring that patient could call or text the patient right away. “Normally, patients wait months in between primary care visits, when their doctors discuss blood sugar levels,” says Dr. Magee. “But this almost-immediate response led to a lot of ‘eureka moments,’ when patients can markedly increase their understanding of how their lifestyle impacts their blood sugar.”

BIG BENEFITS

The results were astounding. Within three months, the average A1c levels declined from 11.4% to 8.3%. “Each 1% reduction in A1C is associated with a roughly 15% decline in risk for major cardiovascular events,” explains Dr. Magee. Within six months, when compared to prior use of health-care services by the same participants…

  • Urgent visits to primary care practices dropped by 92%.
  • Missed days of work or other activities declined by 77%.
  • Hospitalization declined by 66%.

The study is being prepared for publication, so its results are still preliminary—and we don’t yet know how well the participants will maintain their A1c levels after the intervention ended. But the results do show just how effective personalized education and counseling combined with timely medication management can be in helping people who are floundering on their own with this complex disease.

BRINGING IT ALL BACK HOME

While this boot camp program is being further developed, almost anyone with diabetes can incorporate its lessons and take steps to help improve their diabetes-care outcomes by working with their own doctor and a certified diabetes educator. Here’s how…

  • Ask your primary care doctor to refer you to a certified diabetes educator (CDE). Many large health-care systems and hospitals have them on staff, but you can also find a certified one online at the National Certification Board for Diabetes Education. Most insurance plans pay for this service with a referral from your doctor.
  • Once you meet with your diabetes educator, ask him/her if he can work with you if you use a glucose monitor that can relay data wirelessly so that you can look at your sugars together more often. These meters are relatively recent, but new ones are coming on the market now. This will allow you to work with your new “coach” more easily.
  • Your provider or educator may recommend that you also try a smartphone diabetes-coaching app program—these often-free programs provide nutrition info and help you track your carbs and blood sugar—to help you manage your diabetes. “There is emerging evidence that these apps can help with diabetes control, too, and some people do find them helpful,” says Dr. Douglas, “but an app is no substitute for working closely with your doctor and your CDE.
  • If you have worked with the CDE on your lifestyle management and your sugars still are not where they should be, you also need to work with your own doctor so that your diabetes medications can be adjusted to help get you to your targets for blood glucose control.
  • The more you know, the better you do may never be more true than it is for people with diabetes. Get educated.

Working with a diabetes educator isn’t new, of course—the profession has been around for decades. But here’s what’s changing—now that your blood sugar numbers can be transmitted immediately, you, your educator and your doctor can become a much more powerful team. This Diabetes Boot Camp has shown that just a few face-to-face meetings with a handful of “virtual visits” can get you on the right track and keep you on the right track—managing diabetes much better than you have ever been able to do.

To learn more, see Bottom Line’s article “Diabetes Coach to the Rescue!”…and our guide to nondrug approaches…and be sure to watch out for these five diabetes mistakes to avoid.

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Source: Michelle Magee, MD, endocrinologist, director, MedStar Diabetes Institute, associate professor of medicine, Georgetown University School of Medicine, both in Washington, DC. Her study, titled “Diabetes Boot Camp Reduces A1c and Health-Care Services Utilization,” was presented at the 2016 annual meeting of the American Diabetes Association in New Orleans. Date: August 9, 2016 Publication: Bottom Line Health
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