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Objectives

OBJECTIVES
• What is Self Management Education
• The Concept: diabetes self-management education and support.
• Components of DSME/S
• When to provide and modify DSMES.
• Recommendations to implement DSMES.
2018 Diabetes Canada CPG – Chapter 7. Self-Management Education and Support

Self-Management Education (SME)

An intervention that involves

active patient participation
in self-monitoring and/or
decision-making with the application of
knowledge and skills.
DSMES is underutilized

1. Lin J, et al. Population Health Metrics, 2018 4. ADA. Standards of Medical Care, Diabetes Care, 2020
2. ADA. Diabetes Care, 2018 5. Strawbridge LM, et al. Health Educator, 2015
3. Kazemian P, et al. JAMA Internal Medicine, 2019 6. Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020
DSMES is underutilized

1. Li R, et al. Morbidity Mortality Weekly Report, 2014

2. Strawbridge LM, et al. Health Educator, 2015
 2018 Diabetes Canada CPG – Chapter 7. Self-Management Education and Support

Knowledge is Power
• Empowering patients through
self-management education
improves:
– A1C
– Quality of life
– Weight loss
– Cardiovascular fitness
ADCES. AADE7 Self-Care Behaviors, The Diabetes Educator, 2020
1. Healthy Eating
• What and how much you eat plays a huge role in the control of your blood sugars.  
• Proper timing, modest portions and well-balanced meals are the cornerstones of healthy
eating.  
• A well-balanced intake consists of lean proteins, lots of non-starchy vegetables, some
low-fat dairy, fruit, whole grains,  and a little heart-healthy fat.
• It’s also important to limit your intake of carbohydrate foods, which have the largest
effect on your blood sugars.  Carbohydrates include fruit & fruit juice, milk & yogurt,
grains, beans, and starchy vegetables.
• Reading food labels for total carbohydrate is one of the best ways to help you limit your
intake.  
• Most adults only need about 45-60 grams of carb at each meal.  
• A diabetes educator can help you put together a healthy meal plan
2. Being Active
• Moving your body every day is so important for our overall health and well-being.
 It helps to lower your blood sugars, it’s good for your heart, it can help maintain
strong bones, it can reduce stress, and it can help you control your weight.  
• You don’t need a fancy gym membership or exercise equipment to be active.  
• Walking is a fantastic, free and easily accessible form of physical activity for most
people with diabetes.   
• The goal is 10,000 steps a day, or 150 minutes of physical activity a week.
• Start off slow!  Even just 10 minutes a day is a great start.  
• Focusing on just “sitting less” can help to increase your physical activity level.  
• For those with physical limitations, talk with your doctor or diabetes educator for
alternative ways to move.  And always talk to your doctor before you begin any
exercise program
3. Monitoring
Know Targets
• SMBG
• HbA1c
• Blood Pressure
• Cholesterol
• Creatinine
• Foot Exam
• Eye Check up
• Dental Check up
• Doctor Visit
4. Taking Medication
• Know your Medicines
• We can classify diabetes treatment into five groups:
• Insulin provider: it includes insulin itself or medicine which increases insulin production overall.
(sulfonylurea and glinides)
• Incretin Enhancer: it includes medicines which help to increase Incretin hormone action. (DPP4 inhibitors
and GLP1 receptor agonists)
• Glucose excretor: they help to excrete out excess glucose into urine.
• Insulin sensitizers: they improves insulin action and reduces insulin demand in body.
• Glucose restrictors: it stops glucose absorption through intestine. It acts in gut.
• If your doctor has prescribed medication to help control your blood sugar, it’s important to take
it exactly as prescribed in order for it to do its job.  
• If you often miss or forget a dose, try placing your pills next to the coffee maker or on top of your
dinner plates.  
• Some people find it helpful to set reminders to go off on their phone.
5. Problem Solving
• There are certainly going to be times when your blood sugars go a lot higher
or lower than they should. (A low blood sugar is anything lower than 70).    
• You want to be able to help yourself figure out why that may have happened.
• Think about what may have been different from the usual.  
• If your blood sugar went up too high, did you eat too many carbs?  Eat too
large of portions? Forgot your meds?  
• How about if your blood sugar goes too low?  Did you go too long between
meals?  Or not eat enough carbohydrates?  Take too much insulin?
• If you can figure out what caused the problem, you can come up with
solutions for the next time and learn from that mistake.
6. Reducing Risks
• Having diabetes increases your risk of heart attack and stroke, as well as other
complications such as kidney disease, retinopathy of your eyes and nerve damage to
your legs and feet.  
• It’s important to visit your doctor on a regular basis, at least once a year.  If your
diabetes is out of control, you should visit more often.  
• It’s also highly recommended that you visit your dentist every six months and your eye
doctor once a year.  
• Smoking and diabetes are a bad, bad combination; so if you smoke, talk your doctor
about ways to help you quit.
• Finally, make sure to take good care of your feet.  
• Look for open sores everyday (use a mirror if you need to) and take your socks off at
your doctor’s visit and ask your doctor to exam your feet.
7. Healthy Coping
• We all know that life is filled with stress.  Dealing with diabetes can
often add to that stress.  Because stress can raise your blood sugars,
finding healthy ways to deal with that stress is an important part of
your diabetes self-management.
• There are a lot of ways to help you cope with stress.
• Some of the best stress relievers include daily physical activity,
meditation, or developing a hobby that can take your mind off daily
stress.
• It’s also important to seek the support of your friends and family or
even join a diabetes support group
Score 5 4
A1c At or below target
SBP
Normotensive
DBP
C No dyslipidemia
D Fully adherent
E Fully adherent
F Fully adherent
General health*** Obesity, respiratory disease’ OSA, mental stress/disease, liver dysfunction/NAFLD, bone/joint problems, thyroid disorder, anemia
G 0/8
H Never
3 2 1 0 Score
A. Average blood sugar - hba1c
0.1-0.5% more than
0.6-1% more than target 1.1-2.0 % more than target 2.1-4.0% off target >4.0% off target
target
A. Blood pressure (bp)
0-10 mmHg above target 11-20 mmHg above target
21-40 mmHg above target or >40 mmHg above target or
or or
At target with medicine
0-5 mmHg above target 6-10 mmHg above target 11-20 mmHg above target >20 mmHg above target
A. Cholesterol TG, LDL, non HDL
TG > 500 or
All 3 at target with
One of the 3 above target Two of the 3 above target All 3 above target LDL > 190 or
medicine
Non HDL > 220
A. 0Diet*
Mostly adherent Partially adherent Mostly non-adherent Totally non adherent Not willing
A. Exercise** ; aerobic/yoga- meditation /resistance
Mostly adherent Partially adherent Mostly non - adherent Totally non-adherent Not willing
A. Follow up***: clinical, lab, smbg
Mostly adherent Partially adherent Mostly non adherent Totally non adherent Not willing or not able
≥5/8 or ≥1 advanced disease*
1/8 2/8 3/8 4/8
condition
A. Habits****
Light smoker (<10) light Moderate smoker (10-20) Heavy (>20)
Ex smoker Not willing
tobacco (<5) Tobacco (5-10) Tobaco ( >10)
A. Infection*****

Fully vaccinated and Partial vaccinated Not vaccinated Vaccinated (fully/partial)

Recurrent
I taking all precautions Taking precautions No precautions Precautions ± Recurrent severe
Non-severe
No infections No infections No infections Occasional infections

A. Jeopardy of Diabetes Management*****

Probable ADR Probable ADR
No ADR Documented ADR Documented severe ADR ADR / Hypo that needs
J LEVEL 1 LEVEL 1
No hypo LEVEL 2 LEVEL 3 hoospitalisation
Asymptomatic Symptomatic
12/8/21 17
Maximum Score: 50
 2018 Diabetes Canada CPG – Chapter 7. Self-Management Education and Support

How should SME be delivered?

Interprofessional team Personal contact

and/or peer-education with health-care
workers

Combination of group Combination of

and individual sessions didactic and interactive
2018 Diabetes Canada CPG – Chapter 7. Self-Management Education and Support

Self-Management Support (SMS)

• Defined as strategies that augment an individual’s
ability to self-manage their diabetes.
• Such support may include frequent follow up by a
health-care provider, diabetes coaching, peer
support or community health workers, linkages with
community support groups or interest groups.
• To date, a growing body of research evidence
indicates that combining SME and SMS is most
advantageous for improving glycemic control, self-
efficacy and self-care behaviours, and reducing
diabetes distress and foot complications.
SME, self-management education; SMS, self-management support
2018 Diabetes Canada CPG – Chapter 7. Self-Management Education and Support

Steps to Success
Evaluate and
support long-term
self-management
Implement a realistic plan
for skills training
Collaborate on decisions and
goals for action
Make informed consideration of
self-care options
Assess & identify personal self-care
needs
Four critical times to provide and modify DSMES

1) At diagnosis.
2) Annually and/or when not meeting treatment targets.
3) When complicating factors develop.
4) When transitions in life and care occur.

Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020
ADCES. AADE7 Self-Care Behaviors, The Diabetes Educator, 2020
DSMES benefits

Summary of DSMES benefits to discuss with people with diabetes

• Provides critical education and support for • Promotes lifestyle behaviors including healthful meal
implementing treatment plans. planning and engagement in regular physical activity.
• Reduces emergency department visits, hospital • Addresses weight maintenance or loss.
admissions and hospital readmissions. • Enhances self-efficacy and empowerment.
• Reduces hypoglycemia.
• Increases healthy coping.
• Reduces all-cause mortality.
• Decreases diabetes-related distress.
• Lowers A1C.
• Improves quality of life.

No negative side effects | Medicare and most insurers cover the costs

Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020  
If DSMES were a pill, would you prescribe it?

Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020  
If DSMES were a pill, would you prescribe it?

Prescribe DSMES

DSMES requires a referral

Factors that indicate referral to DSMES services

At diagnosis
• All newly diagnosed.
• Ensure that both nutrition and emotional health are addressed or
make separate referrals.

Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020  
Factors that indicate referral to DSMES services

Annually and/or when not meeting treatment targets

• When knowledge and skills need to be assessed.
• Long-standing diabetes with limited prior education.
• Treatment ineffective.
• Change in medication, activity, or nutritional intake or preferences.
• Maintenance of positive clinical and quality of life outcomes.
• Unexplained or frequent hypo- or hyperglycemia.
• When psychosocial and behavioral support is needed.

Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020  
Factors that indicate referral to DSMES services

When complicating factors develop

Change in:
• Health conditions or health status requiring changes in nutrition,
physical activity, or medication.
• Physical limitations.
• Emotional well-being.
• Basic living needs.
• Planning pregnancy or pregnant.

Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020  
Factors that indicate referral to DSMES services

When transitions in life and care occur

• Change in living situation.
• Discharge from inpatient to outpatient.
• New clinical care team.
• Initiation or intensification of medication, devices or technology.
• Insurance coverage changes.
• Age-related changes.

Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020  
Evidence for greatest impact of DSMES

Engaging adults with type 2 diabetes in DSMES results in statistically significant and
clinically meaningful improvements in A1C. The greatest improvements are achieved
when DSMES:
o Involves both group and individual education.
o Is provided by a team vs a single individual.
o Participants attend more than 10 hours.
o Is tailored to the individual participant.
o Is focused on behaviors and engages the participant rather than didactic interventions.

Chrvala CA, et al. Patient Education and Counseling, 2016

DSMES consensus report recommendations

Recommendations for: health policy, payers, systems, providers, care teams

• Expand awareness, access, and utilization of innovative and non-

traditional DSMES services.
• Identify and address barriers influencing providers influencing
referrals to DSMES services.
• Facilitate reimbursement processes and other means of financial
support in consideration of cost savings related to the benefits of
DSMES services.

Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020  
DSMES consensus report recommendations

Recommendations: for providers

• Discuss with all persons with diabetes the benefits and value of initial
and ongoing DSMES.
• Initiate referral to and facilitate participation in DSMES at the 4 critical
times: (1) at diagnosis, (2) annually and/or when not meeting
treatment targets, (3) when complicating factors develop, and (4)
when transitions in life and care occur.
• Ensure coordination of the medical nutrition therapy plan with the
overall management strategy, including the DSMES plan, medications
and physical activity on an ongoing basis.
• Identify and address barriers affecting participation with DSMES
services following referral.

Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020  
Summary

• There are many evidence-based benefits of DSMES. Of note are the many psychosocial benefits and
behavioral improvements.
• DSMES is grossly underutilized.
• The DSMES consensus report:
o Describes the 4 critical times to provide and modify DSMES.
o Provides clear guidance as to when to refer to DSMES services.
o Includes a checklist for providers and diabetes care and education specialists providing and
modifying DSMES services.
• Health systems and providers should mobilize to ensure all people with type 2 diabetes have easy access
to DSMES, including nutrition, physical and emotional health support.
o Consider automatic referrals for DSMT and MNT; opt-out versus opt-in.

Powers MA, Bardsley JK, et al. DSMES Consensus Report, The Diabetes Educator, 2020