CHAPTER
5

Finding Care and Support

In This Chapter

• Members of your diabetes care team
• What your diabetes care team can do for you
• Asking for help from family, friends, and co-workers

Once you’ve made up your mind to start managing your diabetes, you want to do it right and get the best possible results. Having medical care and personal support are wonderful ways to help you achieve your goals.

Because it can be confusing to figure out who does what in the medical field, this chapter reviews the roles of diabetes care team members, unravels how to identify knowledgeable experts, and discusses what type of help you can expect from the experts once you find them. We also talk about how people in your personal life can support your diabetes management, as well as what to do when you aren’t getting the proper support from others. With a winning support system lined up on your side, you will be well on your way to becoming a diabetes manager extraordinaire!

Creating a Diabetes Care Team

Because there are so many components to managing diabetes, sometimes it is difficult to remember them all, let alone excel at them. That is where your team comes in. There are various roles that each team member fills to support you in your efforts, whether it’s additional assistance with medical management, nutrition, diabetes self-care skills, behavior change, and more. The team will work with you to develop an individualized plan that is unique to you.

Leading the Team

Before we get into the different experts that make up your team, though, let’s start with the core of the team: you. As the person with diabetes, you are the leader—the captain of the team, the star of the show, the one in the driver’s seat. Unfortunately, you can’t give away the responsibility to manage your diabetes any more than you can give your diabetes away. However, you have the power to be the deciding factor on what’s best for you. After all, you are the expert on you; you’ll be the first to notice anything when it comes to your body. You decide what you’re able, willing, and choose to actually do. Deciding what you’ll eat, if you’ll take your medication and/or insulin as prescribed, and if you’re going to be physically active is also up to you. You have the responsibility of checking your blood glucose to see if it is all working or identifying where changes are needed. (Wow, that’s a lot; no wonder you need a team!)

As the captain, you are actively involved in daily decision making and changing and modifying your plan. While the team can’t be there with you the moment you are choosing whether or not you will eat a cookie or take the stairs instead of the elevator, with appropriate education from your team of experts, you can make informed decisions and have a better understanding of how your actions will affect your diabetes control.

DIABETES DECODED

You are your own best advocate when it comes to your medical care. To get the most out of your visit to your team of experts, write out your top two or three questions and bring them with you to the appointment. It’s best to focus on the ones that are most important to you; that way, you won’t forget to ask them and you’ll have time for the critical questions. If you go in with a laundry list of questions, it is difficult to stay on track and you might run out of time. When your provider asks you questions in return, be honest and do not hold back pertinent information. Not answering truthfully or only reporting the part you think the provider wants to hear only hurts you. The right medical decisions can’t be made if the information you share isn’t accurate.

Primary Care Provider

Generally, primary care providers are physicians with an internal medicine or family practice background. Mid-level medical providers, such as nurse practitioners and physician assistants who work in conjunction with physicians, are also increasingly becoming primary care providers. Your primary care provider generally oversees all of your medical care and makes referrals to other team members and specialists as needed.

If you’re currently looking for a provider who accepts your insurance, it is best to find one who sees a number of patients with diabetes and is comfortable with the medical management of diabetes. It is important that you feel you can talk with your provider about health concerns and that you can ask questions to clarify anything you don’t understand.

The following are some questions we suggest you ask your primary care provider or potential primary care provider about diabetes, as well as the answers you should be looking for:

• What percentage of the patients you see have diabetes? If the potential provider only sees a handful of patients with diabetes, it may be best to find someone with more experience in diabetes management.
• What tests do you order for your patients with diabetes? How often are they ordered? You can use the Diabetes Care Measures chart in Appendix C to see which tests are recommended by the ADA and how often they should be completed. If the potential provider states he uses the ADA standards, that means he follows ADA recommendations for appropriate medical tests.
• Do you work with other diabetes professionals here in your office? If not, do you refer to endocrinologists, diabetes educators, and dietitians? Look for a medical provider who refers to diabetes educators, registered dietitians, and endocrinologists when needed. It’s not necessary to have diabetes educators and registered dietitians on site in the same office, but that makes it convenient for you.
• What targets do you recommend for my diabetes management? Ask about what your blood glucose, blood pressure, and cholesterol targets should be and what references the potential provider uses to determine those targets. If the provider isn’t familiar with treatment targets, it’s best to talk with someone else.

By being on the same page with your primary care provider, you ensure the information the rest of your team will receive from your provider will be in line with what you want and need.

Endocrinologist

Not everyone with diabetes—in particular, people with well-controlled type 2 diabetes—sees an endocrinologist. However, if your diabetes is not as well-controlled as you’d like and the standard management isn’t working, it could be the time to request a referral to one. An endocrinologist is a doctor who specializes in diagnosis and treatment of conditions involving the endocrine system. Endocrinologists are board-certified internal medicine physicians who have met extra training and practice requirements in endocrinology and have passed a national standardized exam. Physicians who have accomplished this are board-certified in endocrinology, diabetes, and metabolism. While some endocrinologists specialize in diabetes, some choose to specialize in another specific area of the endocrine system (such as the reproductive system). In addition to treating diabetes, most endocrinologists treat conditions like hypothyroidism, Cushing’s syndrome, osteoporosis, and Addison’s disease.

DEFINITION

An endocrinologist is a physician who specializes in disorders of the endocrine system. Some endocrinologists are diabetes specialists. The endocrine system is a collection of glands that regulates metabolism, reproduction, growth, mood, sleep, and other body functions.

Endocrinologists who specialize in diabetes are familiar with the nuances of diabetes management and how to individualize treatment targets. They keep up to date on new diabetes treatment options and can work with you to develop more effective management strategies. Also, if you are dealing with diabetes complications, the additional training and experience of endocrinologists are helpful in giving you the information needed to make your decisions on the best course of action to improve your quality of life.

Diabetes Educator

Diabetes educators are health-care professionals specially trained to help people with diabetes learn self-care skills, achieve behavior change goals, and improve their health status. The majority of diabetes educators are registered nurses (RNs) and registered dietitians (RDs). However, diabetes educators may also be pharmacists, physical therapists, psychologists, podiatrists, and other qualified health-care professionals. Diabetes educators can be found in hospitals, physician offices, clinics, pharmacies, and community settings. Look for diabetes educators in recognized or accredited diabetes education programs.

You may have seen the CDE credential listed after a health-care professional’s name. The letters CDE stand for Certified Diabetes Educator; this is an additional certification that diabetes educators can obtain. To become a CDE, a diabetes educator has to hold an eligible professional designation, such as RN or RD, have 1,000 hours of experience providing diabetes self-management education, meet additional training requirements, and pass a national exam. If you see “CDE,” you can be confident that the health-care professional has knowledge and experience in working with people with diabetes.

A diabetes educator can help you learn how to do the following:

• Test your blood glucose and know what to do with the results
• Understand how your diabetes medications work
• Inject insulin
• Fit physical activity into your lifestyle
• Treat hypoglycemia
• Make healthier food choices

As you can see from this list, diabetes educators focus on helping you with real-life situations and the day-to-day aspects of diabetes care. This education is usually offered by them in classes or as individual sessions, with problem-solving skills and making healthier choices key areas discussed. Diabetes educators also coordinate your care with your provider so you benefit from a comprehensive diabetes management plan. Most insurance plans and Medicare cover diabetes education; you need a referral from your medical provider for diabetes self-management education to be covered by insurance.

DID YOU KNOW?

Diabetes educators and other health-care professionals can also be board-certified in advanced diabetes management (BC-ADM). To be eligible, health-care professionals must hold a Master’s degree or higher and be an RN, RD, pharmacist, physician assistant, or physician. Also required for this certification are a minimum of 500 advanced clinical practice hours face-to-face with diabetes patients and passing a national exam.

Registered Dietitian Nutritionist

The Academy of Nutrition and Dietetics states “all registered dietitians are nutritionists, but not all nutritionists are registered dietitians.” Therefore, the Academy recently approved an option for professionals who hold the RD credential to include the word nutritionist after registered dietitian, abbreviated as RDN. The rigorous requirements to become credentialed as an RDN are exactly the same as for the RD. RDs have a minimum of a Bachelor’s degree, have completed specific nutrition/dietetics coursework, have supervised dietetics practice experience, and have passed a national exam. When you see an RD, it is important to find one who is experienced in diabetes care.

Nutrition education is a component of a comprehensive diabetes self-management education program. While making healthier food choices and understanding how different foods affect your blood glucose are something that all diabetes educators can help you with, RDs are the only members of the team who can provide medical nutrition therapy or more in-depth nutrition counseling.

RDs can help you learn to do the following:

• Plan meals to meet your nutrition needs
• Decipher food labels and understand key ingredients
• “Lighten up” your favorite recipes
• Modify diabetes meal plans to meet additional nutrition needs
• Include foods you enjoy in your meal plan
• Balance food and activity with your medication

When is it especially beneficial for you to see an RD? If you have diabetes complications such as kidney disease, digestive problems, or heart disease, dietitians can address your more complex nutrition needs. And if you have other unique nutrition issues not specific to diabetes—such as food allergies or intolerance, sports competition training, or preparations for gastric bypass surgery—RDs can also help.

FOR YOUR SAFETY

In most areas of the United States, anyone can call themselves a nutritionist without actual qualifications. Use of RD and RDN is legally protected and can only be used by health-care professionals who meet the criteria to hold those credentials. Therefore, to assure you are getting sound nutrition advice from a qualified professional, look for the RD or RDN credential.

Other Team Members

Because diabetes can lead to other health complications, it helps to be proactive in all areas of your health. Having regular exams can help prevent problems or catch them in very early stages, when treatment is easier. Therefore, the following are some additional health-care professionals who don’t specialize in diabetes but can or should still be included on your diabetes care team.

Eye doctor: Because eye damage is much more treatable when discovered early, we recommend having an eye doctor (either an ophthalmologist or optometrist) on your team. Annual exams with your eye doctor can catch any changes in your sight and general eye health from year to year. Ask your eye doctor about experience with patients who have diabetes and understanding treatment options.

Dentist: When you have diabetes, you are more likely to get gum disease. This is especially true if your blood glucose has been elevated. Therefore, it’s important to let your dentist know you have diabetes and to visit the dentist’s office every six months to help decrease the risk of gum disease and tooth loss. Brushing your teeth twice a day and flossing daily can also go a long way to preventing tooth decay and gum disease.

Podiatrist: Nerve damage and circulation issues caused by diabetes can lead to problems with your feet. Numbness and decreased blood flow can increase the risk of sores and infection. Even something that looks like a simple callus might be hiding a bigger problem underneath. It is important for you to look at your own feet daily to check for any redness, swelling, cuts, blisters, or cracks in the skin of your feet that could be signs of larger issues. Contact your medical provider if you see anything suspicious. Your medical provider can determine the need for a referral to a podiatrist. Podiatrists have specialized training to treat these type of foot problems.

Pharmacist: Pharmacists are medication experts, making them helpful to talk to about any diabetes medications you’re taking. Some of the things a pharmacist can do for you are: identify potential drug interactions, counsel you on how medications work, recommend over-the-counter medications (taking into account your prescription medications and medical condition), and advise you about potential medication side effects. Pharmacists must be licensed in their state of employment. Credentials for pharmacists include RPh and PharmD.

Psychologist or counselor: Diabetes can contribute to so many different emotions, including anxiety and depression. Your feelings can also be all over the map when you’re making changes to your life to manage your diabetes. If you feel you need help dealing with your emotions, you can add a psychologist or counselor to your team. Counselors may be licensed clinical social workers or other qualified health-care professionals, while psychologists may hold a doctorate degree or a Master’s degree in psychology. To get in touch with one, your primary care provider will need to make a referral for you. Not all clinical psychologists or counselors accept insurance, so you will want to check on that before your first visit.

Physical therapist: If you’re having difficulty getting started with regular physical activity, your primary care provider can refer you to a physical therapist. Even if you’re dealing with limitations due to diabetes complications or other physical issues, exercise is beneficial for your overall health. A physical therapist can evaluate you and help you come up with an activity plan while improving your physical ability to exercise. Even if you’ve suffered from an injury or had surgery, a physical therapist can work with you to regain strength and improve your activity level. Exercise physiologists and physical therapists can coordinate with your primary care provider to put together the best care plan for you.

Gaining Support from Others

You have already learned how important medical support is for your diabetes management efforts; the next step is getting support from the people in your personal life. When you have diabetes, it is too difficult to go it alone performing your day-to-day activities. By enlisting support from your family, friends, and co-workers, you can get the help you need and reinforce the positive changes you are making.

However, it’s not as simple as them being there—it’s also about supporting you in the way you respond best. Apart from mind reading, they won’t know how to do so unless you tell them. So how can you make sure they “get it” and give you the help you need? Read on to learn how!

Family

Family members are the people who love you no matter what. This makes them great allies—and also the people who are the easiest on which to take out your anger, frustration, disappointment, or other negative behaviors. That’s why when family members offer support for your diabetes management in an unwanted way, it is easy to respond with strong emotions that wouldn’t be displayed to strangers.

DIABETES DECODED

Invite someone to officially be your “diabetes support person.” The role of a diabetes support person is to help you with your efforts to successfully manage your diabetes. You can certainly have more than one! They could be co-workers, friends, family members, or anyone you talk with on a regular basis.

For example, one of the ways family members can offer unwanted support is by telling or “reminding” you that you can’t eat something with comments like, “Are you supposed to be eating that cake? You’re not supposed to eat cake. You had better stop eating that.” It’s like having the food police living with you! In return, you might respond, “Quit telling me what I can’t eat,” followed by thoughts such as I’ll show her, I’m going to eat twice as much now. Hardly anyone’s natural reaction would be to be grateful for this reminder and say “Oh, thank you very much for the reminder. I wouldn’t have thought of that on my own.” (Well, maybe with a very sarcastic tone someone might.)

Luckily, there is a communication tool you can use that can be very helpful in situations where your family members aren’t providing the support you desire. You can break down your words as follows:

1. Describe: “When you ____________”
2. Explain: “I feel ____________”
3. Specify: “If you would do ____________ instead”
4. Consequence: “I will feel ____________”

Here’s how this would look using the cake example:

1. Describe: “When you tell me I can’t eat cake”
2. Explain: “It makes me feel like I want to eat more cake”
3. Specify: “If you would go for a walk with me instead”
4. Consequence: “I will feel that you are supporting me”

It is a good idea to practice this a few times before you try it out on someone else, so it feels more natural. You can then think of things your family members can do to support you. It’s important to be specific about what it is you want. If you stop at telling them what it is you don’t want them to do, they will flounder and probably do the same thing again. Once you let them know what specifically they can do, you will both benefit.

Another way your family can support you is by attending diabetes education classes with you. They can learn along with you that there are ways for you to have your cake and eat it, too!

Friends and Co-Workers

Friends and co-workers can provide a great opportunity for additional support for your diabetes management. Friends are a little more like family, so like family, it is a good idea to tell them specifically how they can support you. For instance, if you and your friends usually go out for pizza on Friday nights and you decide it’s too difficult not to overeat, let them know. You can even offer an alternative, like taking turns preparing healthy recipes or choosing a new restaurant that makes it easier for you to stay on track.

As for support from your co-workers, many larger companies offer worksite wellness programs, walking clubs, or weight management programs. By participating in these programs, you may find that a number of your co-workers have similar fitness and even diabetes goals. Even if these programs aren’t offered at your workplace, you can still invite co-workers to start walking with you at lunch time or make a pact with a co-worker to bring fruit and vegetables to replace the high-calorie snack options that take up residence in the break room.

The Least You Need to Know

• You need support to successfully manage your diabetes.
• With a diabetes care team, you can have health-care professionals experienced in diabetes care and management, as well as other areas of your health that can be affected by diabetes.
• Support from family and friends is important to stay on track. Improving communication and being specific with requests for help can minimize your frustration and maximize results.