A multidisciplinary credential in advanced diabetes management has been developed by the American Association of Diabetes Educators (AADE) in collaboration with the American Dietetic Association, the American Diabetes Association and the American Pharmacists Association. Board certification in advanced diabetes management (BC-ADM) is available to registered dietitians, registered nurses, nurse practitioners, registered pharmacists, physicians and physician assistants who hold advanced degrees.1 Candidates for certification must meet practicum experience requirements of 500 hours and pass a national examination.1
This new level of diabetes management comes at an opportune time. Diabetes now affects 25.8 million people in the United States (18.8 million diagnosed and 7 million undiagnosed). By 2034, the number of diabetes cases is predicted to be 44.1 million.2
The prevalence of diabetes is exceptionally high in a region known as the diabetes belt.3 It is comprised of 644 counties located in Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia and West Virginia. Nationwide, the crude incidence of diagnosed diabetes increased 133% between 1980 and 2011.4
Advanced diabetes management (ADM) is vital due to escalating diabetes incidence and the predicted shortage of primary care physicians and endocrinologists.5,6 Nurse practitioners can fill this void in diabetes management in medically underserved areas and health provider shortage areas.7
The University of Alabama at Birmingham (UAB) School of Nursing recently developed ADM courses for nurse practitioners. The UAB ADM courses are funded by a grant from the Health Resources and Services Administration (HRSA). Through collaborative approaches, the UAB ADM grant's mission is to increase the number of nurse practitioners with ADM skills in medically underserved areas. The overarching goal of the grant is to meet legislative purposes of the Public Health Services Act and to support Healthy People 2020 priorities.8,9
Title VIII of the Public Health Service Act was enacted in 1944 to promote, protect and advance the nation's physical and mental health.8 In 1964, Title VIII was amended in response to a shortage of healthcare providers, especially within medically underserved areas. Title VIII programs focus on training nurses in advanced practice roles, increasing the enrollment of minority and disadvantaged nursing students, and ensuring nurse retention through career development for overall improved patient care outcomes.
An example of one such program supported by Title VIII (Section 811) is the Advanced Nursing Education Grant, which provides advanced nursing education and practice for master's and doctorate programs. In fiscal year 2008, the advanced nursing education grant supported the education of 8,820 advanced practice nursing students.10 The UAB ADM courses are funded through the HRSA Advanced Education Nursing Grant.
Three ADM courses are offered by the UAB School of Nursing. They are distance accessible, meaning that the content is provided nationally via an online format. Two didactic courses and one practicum course provide ADM students with a multidisciplinary educational framework to identify patients at risk for diabetes and to provide healthcare to patients with identified metabolic syndrome, prediabetes, type 1 or 2 diabetes and/or associated complications.
ADM coursework can be completed in two or three semesters. The courses are Advanced Management of Diabetes I, Advanced Management of Diabetes II and the Advanced Management of Diabetes Practicum. The required hours for the practicum course are completed at an approved clinic within the student's chosen geographical area.
The didactic courses encompass knowledge in ADM utilizing increased complexity of decision making, research, publications, mentoring and leadership/professional development. In the Advanced Management of Diabetes I course, a variety of management strategies are presented from multiple healthcare disciplines. The perspectives of the multidisciplinary team in assisting patients to achieve self-care goals is an important theme, as are current controversies, issues and research findings underlying approaches to treatment and patient/family education. Topics presented are based on the curriculum blueprint of the American Diabetes Educators Program recommendations for the American Nurses Credentialing Center (ANCC)/AADE Advanced Diabetes Management certification examination for NPs. Advanced Management of Diabetes II focuses on advanced diabetes management across the lifesup.
The Advanced Management of Diabetes Practicum course allows students to begin developing their ADM role by providing healthcare services to patients in a variety of settings. Students apply knowledge and current research findings to the management of actual and potential health problems including common diseases and human responses to disease. It is anticipated that students will be increasingly independent and skilled as each clinical experience progresses. This allows them to become proficient in diabetes management and contribute to the management of more complex health problems. The advanced practice role emphasis in this course begins the trajectory of the NP's experience from novice to beginning expert, and it includes role components such as interdisciplinary collaborator, coach, teacher, manager, researcher and consultant.
Upon successful completion of the three ADM courses (135 hours practicum), students receive a certificate of completion from UAB. Certification candidates must perform a total of 500 diabetes practicum hours to meet eligibility requirements for the AADE ADM examination.1 Additional information about the examination requirements is available at http://www.diabeteseducator.org/ProfessionalResources/Certification/BC-ADM/index.html.
The ADM curriculum plan was developed through the utilization of diabetes and cultural expert consultants, an advisory board of diabetes experts and as a formative and summative evaluation process. ADM curriculum evaluations focus on three components: project process evaluation to address whether methods and activities were accomplished within the stated timelines; project outcome indicators to evaluate whether outcome objectives were accomplished; and project quality indicators to examine faculty, student and external constituencies' perceptions of curricular performance.
The ADM curriculum is evaluated by advisory board members and expert consultants through biannual meetings; course and faculty evaluations from students; and student outcome measures utilizing course grades and completion of the national board certification for ADM offered by the AADE. Periodic evaluations are essential for the continuing success of the ADM courses.
Implications for Diabetes Educators
As the incidence of diabetes continues to escalate and management strategies evolve, continuing education for health professionals is imperative. Education has been identified as an access point for changing a person's knowledge about diabetes.11,12 As the largest group of healthcare professionals, nurses play an important role in conquering the diabetes pandemic using health promotion strategies. As technologic advances increase, so does the complexity of the medical regimen. Therefore, the management of patient care requires an even higher level of knowledge.
Many certified diabetes educators (CDEs) provide diabetes management and patient education today. After the Diabetes Control and Complications Trial (DCCT) in the 1980s and early 1990s, the advanced role of CDEs was defined and the value of the multidisciplinary team for intensive diabetes management was established.13,14
In collaboration with physicians, nurses, dietitians and pharmacists, advanced practice health professionals have filled an important need for diabetes management expertise. The evolution of advanced diabetes management intensified the need for a new certification to formally recognize advanced preparation and clinical experience. The scope of advanced clinical practice by NPs encompasses multiple complex diabetes medical management regimens. Advanced clinical practice consists of extensive knowledge and competence, critical thinking, complex decision making, evidenced-based practice and research, publications, mentoring activities and continuing professional development.
An Evolution of Experts
Diabetes is a chronic disease that requires continuous innovation and change in medical management. Nurse practitioners are critical in facilitating change and innovation toward the promotion and provision of quality improvements in diabetes management. Nursing education and support is an essential function of the ADM role.15 As the prevalence of diabetes increases, so does the need for diabetes education and management that will lead to optimal diabetes patient outcomes.
The ADM curriculum at UAB is a collaborative approach aimed at increasing the number of ADM providers in medically underserved areas in the diabetes belt as well as nationally through distance accessible platforms. In an era of rising demand for ADM services, the curriculum enables healthcare professionals to expand their diabetes expertise.
1. American Association of Diabetes Educators. Board certified-advanced diabetes management certification. http://www.diabeteseducator.org/ProfessionalResources/Certification/BC-ADM/index.html
2. Centers for Disease Control and Prevention. 2011 National diabetes fact sheet. http://www.cdc.gov/diabetes/pubs/estimates11.htm#4
3. Barker LE, et al. Geographic distribution of diagnosed diabetes in the U.S.: a diabetes belt. Am J Prev Med. 2011;40(4):434-439.
4. Centers for Disease Control and Prevention. Crude and age-adjusted incidence of diagnosed diabetes per 1,000 population aged 18-79 years, United States, 1980-2011. http://www.cdc.gov/diabetes/statistics/incidence/fig2.htm
5. Stewart AF. The United States endocrinology workforce: a supply-demand mismatch. J Clin Endocrinol Metab. 2008;93(4):1164-1166.
6. Sataline S, Wang S. Medical schools can't keep up. The Wall Street Journal. http://online.wsj.com/article/SB10001424052702304506904575180331528424238.html
7. Email correspondence received from Leslie Kolb, director of accreditation and quality initiatives at the American Association of Diabetes Educators, June 2012.
8. American Public Health Association. Public health service act title VII and title VIII: why are these programs so important? http://www.apha.org/NR/rdonlyres/13E647B5-E51B-4A47-91A8-652EE973A2DB/0/TitleVIIandTitleVIII.pdf
9. U.S. Department of Health and Human Resources. Healthy People 2020: 2020 objectives and topics: diabetes. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=8
10. Begeny S, et al. Testimony of the tri-council for nursing: regarding FY 2011 appropriations for nursing workforce development programs. American Association of Colleges of Nursing. http://www.aacn.nche.edu/government-affairs/resources/Tri-Council2011HouseLHHSAppropTest.pdf
11. Berlin N, et al. National standards for diabetes patient education programs: pilot study results and implementation plan. Diabetes Educ. 1986;12(3):292-296.
12. Mensing C, et al. National standards for diabetes self-management education. Diabetes Care. 2002;25(Suppl 1):S140-S147.
13. Ahern JA, et al. The Diabetes Control and Complications Trial (DCCT): the trial coordinator perspective: Report by the DCCT research group. Diabetes Educ. 1989;15(3):236-241.
14. Delahant L, et al. Expanded role of the dietitian in the Diabetes Control and Complications Trial: Implications for clinical practice. J Am Diet Assoc. 1993;93(7):758-767.
15. Stellefson M, et al. The chronic care model and diabetes management in US primary care settings: a systematic review. Prev Chronic Dis. 2013;10:120-180.
Annette Hess is a nurse practitioner and clinical nurse specialist who is an assistant professor at UAB. Michele Talley is a nurse practitioner who is an instructor at UAB. Renee Saul is a nurse practitioner who is an instructor at UAB. Mompoint-Williams is a nurse practitioner who is an assistant professor at UAB. Peggy R. McKie is a program manager at UAB.
New Research on Nocturnal Hypoglycemia Dangers
Evidence about the dangers of nocturnal hypoglycemia in diabetes continues to mount. In a study published in May, researchers linked hypoglycemic episodes to a higher risk of arrhythmia in patients with type 2 diabetes who were at risk for cardiovascular disease (Chow E, et al. Risk of cardiac arrhythmias during hypoglycemia in patients with type 2 diabetes and cardiovascular risk. Diabetes. 2014;63:1738-1747). Earlier research about nocturnal hypoglycemia studied patients with type 1 diabetes.
"Hypoglycemia at night is underrecognized in type 2 diabetes, and while we don't want to overly alarm people, this is something that should be recognized," said Simon R. Heller, a professor of clinical diabetes at the University of Sheffield in the United Kingdom and a member of the research team. Heller told Medpage Today that based on the study findings, it may be prudent to recommend nighttime glucose monitoring for at-risk patients and consider switching these patients from human insulin to modern insulins, which are more expensive but are associated with a lower risk for hypoglycemia.
Hypoglycemia has been linked to cardiac arrhythmias in patients with type 1 diabetes who died unexpectedly in their sleep. This is what led Heller et al to suspect that unrecognized nighttime hypoglycemia may increase cardiovascular disease mortality risk among vulnerable patients with type 2 diabetes.
Several nocturnal alarms are available to assist patients in recognizing hypoglycemia episodes that occur during sleep. Some alarms are connected to a patient's insulin pump and measure glucose levels directly, while others, such as Diabetes Sentry, detect physical signs of hypoglycemia, such as perspiration and reductions in body temperature.
Brain Atrophy Linked to Diabetes Duration & Severity
Type 2 diabetes may have an association with brain degeneration, and patients with a long duration of the disease may experience more brain atrophy. The findings were published online in advance of publication in the journal Radiology (Bryan R, et al. Effect of diabetes on brain structure: The action to control cardiovascular risk in diabetes MR imaging baseline data. Radiology. 2014; http://dx.doi.org/10.1148/radiol.14131494).
"We found that patients having more severe diabetes had less brain tissue, suggesting brain atrophy," R. Nick Bryan, MD, PhD, told Science Daily. Bryan was the lead researcher and is a professor of radiology at the Perleman School of Medicine at the University of Pennsylvania in Philadelphia. "They did not seem to have more vascular disease due to the direct effect of diabetes."
For the study, Bryan and colleagues used magnetic resonance imaging to investigate the association between severity and duration of type 2 diabetes and brain structure in 614 patients (mean age 62) at four medical centers. The mean duration of disease in the study group was 9.9 years. The researchers specifically tested whether more severe diabetes was inversely correlated with brain volumes and positively correlated with ischemic lesion volumes. The results showed that longer duration of diabetes was associated with brain volume loss, particularly in the gray matter. However, the researchers found no association of diabetes characteristics with small vessel ischemic disease in the brain.
"Our results suggested that for every 10 years of diabetes duration, the brain of a patient with diabetes looks approximately 2 years older than that of a nondiabetic person, in terms of gray matter volume," Bryan said.