A leading diabetes educator discusses how the role of nutrition has evolved and how payers can do more to promote the role of education in helping patients improve their diets.
Melinda Maryniuk, MEd, RD, CDE, is the director of clinical education programs for Joslin Diabetes Center’s national and international care alliances. She has published dozens of papers on the nutritional management of type 2 diabetes, and she has spent more than 20 years advocating a greater role for dietitians in patient care. Her efforts have won her a Medallion Award, the Outstanding Diabetes Educator Award from the American Diabetes Association (ADA), and an Excellence in Clinical Practice Award 2004 from the American Dietetic Association. Maryniuk is also a co-author of the 2015 joint position statement on diabetes self-management education and support from the American Association of Diabetes Educators, the ADA, and the Academy of Nutrition and Dietetics.1 She spoke with Evidence-Based Diabetes Management for this special issue.
EBDM: How did you get involved with diabetes self-management education?
I studied to be a registered dietitian in college and then came to Boston to do both a dietetic internship and a grad school program in education. I discovered quickly that I was uncomfortable in the inpatient hospital setting, working with acutely ill patients. I also disliked the very short-term nature of my relationships with patients. I’d see people for 2 or 3 days after a heart attack sent them to the hospital. I tried to teach them as much as I could in that period about a heart-healthy diet, and then I’d never see them again.
Fortunately, my first job was at Joslin Diabetes Center, and I quickly realized that I wanted to focus on diabetes, not only because I liked developing relationships with people over time in the outpatient setting, but also because diet plays such a huge role in the quality of each patient’s life. Diet is integral to diabetes care. It was, until the advent of insulin, the only way to control diabetes, and it still plays a bigger role in the management of diabetes than any other major disease.
When did you become interested in developing education programs in addition to educating individual patients?
After several jobs where I worked one-on-one with patients, I had the opportunity to become the director of a Joslin affiliate in New Jersey. I never had an administrative role prior to that and, while I missed working with individual patients, I realized that I could help an even larger number of patients by training my team members to use the strategies I had developed for counseling and incorporating the best of the strategies they had developed into the program. A few years after that, I returned to Boston, and I’ve been with Joslin for 25 years. I help design educational programs for hospitals and physicians’ groups and employers and all sorts of other organizations all over the world.
How have dietary recommendations for patients with diabetes changed over the years?
The dietary recommendations that we give patients haven’t changed quite so much as you might infer from media coverage of dieting trends, but there have been some shifts in how different aspects of the diet are emphasized. After the discovery of insulin (in 1921), carbohydrate was gradually added back into the diet. By the late 70s, diabetes medications were good enough at controlling diabetes that patients were advised to eat what was then considered a standard healthy diet, with carbohydrates accounting for 40% to 45% of all calories and fat accounting for 30% or 40% of all calories. Then, on the basis of incomplete research on the effects of fat on heart disease, dietary recommendations shifted such that all people—and especially people with diabetes (who are at higher risk for heart disease)—were told to substitute carbohydrates for most of that fat. Some organizations were recommending carbohydrate constitute 50-60% of calories in order to have fat less than 30%. The idea was to reduce heart attacks, but it probably ended up increasing weight gain, insulin resistance, as well as diabetes. In recent years, the dietary recommendations for total consumption of fat, carbohydrate, and protein have become more balanced again. There’s also more emphasis on eating high-quality carbohydrates—whole grains, fruit, legumes, and dairy—rather than refined, processed sugars and carbohydrates that spike blood sugar. Our emphasis, now, is less on individual nutrients (carb, protein, and fat) and more on helping individuals choose a balanced diet of high-quality, unprocessed foods that are rich in fiber and minimal in added sugars and trans fats.
How have strategies for motivating patients to eat healthier changed over that same period of time?
I would say our teaching strategies have changed to be more patient centered. We used to tell people what to do. We came in with slides and turned the lights off and lectured people at length on the physiology of insulin and glucose and the mechanics of digestion. We gave them long handouts full of sample meals that they stuck to for a week and then abandoned. Now, we don’t subject patients to the sort of presentations that our professors gave us in college. We ask patients how they are eating and how they might like to improve, and we help them create their own plans for improvement. When you listen to patients, you learn that different people struggle with different things. No one solution will work for every patient, so you have to work with them to create customized action plans. Also, we typically try one small step at a time—the elimination of sugary beverages being the first step in a lot of cases. In another session, you might ask about snacks and hear that a typical snack for one patient might constitute 3 or 4 cookies. Rather than trying to order the patient to swap broccoli for cookies, you would then ask whether the patient had any concerns about that eating pattern, and most patients would say that they were concerned about the sugar and calories in all those cookies. You would then ask the patient to suggest a healthier alternative that might still fulfill the craving for something sweet and you would work with the patient to get to a compromise along the lines of having 1 cookie. It’s a huge shift from the days when I would give patients a lecture in “academic” nutrition and a handout with sample meal recipes. Now, the emphasis is on “real” nutrition and it’s more effective.
Are doctors putting more emphasis than they once did on diet—along with exercise and other lifestyle choices—in the management of diabetes?
The answer to that depends upon the timeframe. Before the advent of pharmaceutical insulin, a specialized diet was the only treatment for diabetes. Only the avoidance of almost all carbohydrates could prevent patients from dying relatively soon after they developed the condition. In an age that offers medical treatments for diabetes, diet will never be emphasized to the degree that it once was. We’re never going to have patients weighing food on scales again, which is a good thing. That said, if you look only at the past 20 years, the emphasis on diet has increased. Some places, notably Joslin, always emphasized diet, but many others believed that medication had become good enough that diet could largely be ignored. Nobody believes that now. Research has also made it very clear that patients who combine a healthy diet—along with exercise—and medical treatment have far better quality of life than those who rely on medical treatment alone. That’s not to say that most general practitioners offer extensive dietary counseling to patients with diabetes. They don’t. They have neither the time, nor the training necessary to do so effectively. But, most of them will at least tell patients about the importance of eating a healthy diet and direct them to a Registered Dietitian Nutritionist who will help them do so.
What steps would you like to see doctors take to improve the care they provide to patients with diabetes?
First of all, I would say to become aware of resources within their community that they can turn to for support. By that, I mean registered dietitians, diabetes educators, and quality education programs that are often part of community programs offered at a hospital. In addition, many other organizations are offering diabetes prevention programs based on the model of the highly successful national trial—the DPP or Diabetes Prevention Program. Secondly, they should be aware of an algorithm for diabetes self-management education recently jointly published by the ADA, AADE, and AND [Academy of Nutrition and Dietetics] that describes 4 critical times for referral to diabetes self-management education: at diagnosis, annually (if certain referral triggers indicate the need), when complications arise, and when transitions occur (such as after a hospital discharge or moving to a new care provider).1
I would also like to see continuing education programs put more emphasis on diabetes self-management education, effective patient communication, and behavior-change strategies. Endocrinologists are certainly expert in managing medications, and they keep current with changing standards of medical care, but there is clearly room for improvement among general practitioners who are the only physicians that most patients with diabetes ever see. There is also clearly room for improvements, among both types of physicians, in terms of their practical understanding of what it is like to live with diabetes. It is incredibly common for physicians who come to our education programs to tell us that they have never monitored their own blood glucose or experienced an injection with an insulin pen or syringe, read a food label to count carbohydrates, or done any of the other things that they ask their patients to do every day. Not only does this make it impossible for them to give practical advice to patients who are struggling with the mechanical difficulties of performing these tasks, it also makes it very hard for them to empathize with the patients they are trying to serve. When we conduct training programs, we have the physicians who come “live with the disease” for a few days. We make them check their blood sugar, inject themselves with saline solution, stick to a diet, and do everything else that they want their patients to do. We don’t have any research that proves any statistically significant benefit to patients, but when we do hear back from physicians who have gone through the program, they generally tell us that the exercise helped them understand the condition in a way that textbooks could not and helped them provide better care for their patients.
How about payers? Have they become more willing to pay for programs designed to improve patient diet and lifestyle?
Yes. We spent a lot of years arguing that educational programs would improve outcomes and save costs in the long run. Payers were naturally skeptical, though, so researchers at places like Joslin began to systematically test specific programs and demonstrate that certain programs can improve outcomes in a cost-effective manner. About 10 years ago, Medicare, and then private insurers, began to cover limited amounts of MNT, which stands for medical nutrition therapy, and DSMT, which stands for diabetes self-management training.
How effective are these programs?
Both types of programs are very effective. A systematic review conducted by the American Association of Diabetes Educators and published in 20162 looked at 118 unique diabetes self-management interventions for adults and found that a combination of group and individual education resulted in the largest decrease in [glycated hemoglobin, A1C]—nearly 1 percentage point. Similar evidence showing the effectiveness of MNT in lowering A1C has also been published and also reported in the Evidence Analysis Library of Academy of Nutrition and Dietetics. In other words, the evidence is that DSMES and MNT is as good—and in some cases better—than the best individual medications in controlling A1C levels. Many interventions were also associated with significant reductions in weight, blood pressure, and cholesterol. All of the diabetes self-management programs that insurers cover must be recognized or accredited by either the ADA or the AADE, and the certifying process is pretty rigorous.
< What might payers do to better support patients with diabetes?
I would love to see them give patients significantly more time in education programs. Payers currently cover only 3 or 4 hours a year of medical nutrition therapy. As for DSME, Medicare currently covers an initial 10-hour program and then 2 hours a year after that (Editor’s Note: The Medicare program is called diabetes self-management training, or DSMT). Also, we would love to see them expand access to the programs. People with prediabetes are currently ineligible, even though there is significant evidence the programs designed to spur healthy eating and exercise can either prevent the onset of diabetes, or at least delay it for many years, in a large percentage of people.* Also, both MNT and DSMT are only covered if patients have a referral from a doctor. That may be a significant barrier to usage. Certainly there are barriers out there because only 5% of Medicare patients and 7% of privately insured patients take advantage of such educational programs. I would love to see payers take some steps to increase the utilization rate, perhaps by encouraging healthcare providers who rarely refer patients with diabetes or perhaps by offering incentives directly to patients. It is tricky, though, because both physicians and patients tend to resent it when payers seem to insert themselves into medical care. Done right, however, it could be a help. Simply notifying patients that the benefit exists and suggesting that they ask their physicians about it would be a big help because many patients are probably unaware that type of help is covered.
How has the Internet affected what the person with diabetes knows about nutrition and how they eat?
While I don’t know of any studies that have answered this question, the Internet certainly makes it easier for patients to find dietary recommendations from scientific organizations that reflect the most current research results. It also makes it easier for them to find incredibly bad dietary recommendations that reflect no research whatsoever. Often these 2 types of information sit right next to one another on the same message board. My feeling is that the positives outweigh the negatives. Most patients realize that advice from the ADA should carry more weight than the advice of random individuals. There are an increasing number of apps and resources designed to help individuals support healthy behavior changes, such as meal planning and activity trackers, and these can be great. Also, patients seem to benefit significantly from being able to reach out through the Internet and find support with people who are in the exact same position in striving for the exact same goals. People who are trying to change their habits and benefit from this kind of support.
* Please see the cover story on Medicare’s proposal to reimburse the Diabetes Prevention Program beginning January 1, 2018. References
1. Powers MA, Bardsley J, Cypress M, et al. Diabetes Self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educ. 2015;41(4):417-430. doi: 10.1177/0145721715588904.
2. DiBenedetto JC, Blum NM, O’Brian CA, Kolb LE, Lipman RD. Achievement of weight loss and other requirements of the Diabetes Prevention and Recognition Program: a National Diabetes Prevention Program network based on nationally certified diabetes self-management education programs [published online September 12, 2016]. Diabetes Educ. 2016;42(6):678-685.