During a two-hour virtual presentation at this year’s Scientific Sessions, four diabetes care and education specialists discussed innovative programs and research designed to address care gaps in diabetes management.
The presentation, Addressing Care Gaps—New Frontiers for Diabetes Nutrition Providers and Services, can be viewed by registered meeting attendees at ADA2020.org through September 10, 2020. If you haven’t registered for the Virtual 80th Scientific Sessions, register today to access all of the valuable meeting content.
While lifestyle interventions have proven effective in the controlled setting of a research study, their effectiveness in routine care has been less clear. Linda Delahanty, MS, RDN, began the session with a review of a translational research effort to study lifestyle interventions in usual care at community health centers.
Delahanty, Director of Nutrition and Behavioral Research at Massachusetts General Hospital Diabetes Center and Associate Professor of Medicine at Harvard Medical School, presented results from the first year of REAL HEALTH-Diabetes, a National Institutes of Health-funded project to translate the lifestyle intervention from the Action for Health in Diabetes (Look AHEAD) trial.
Look AHEAD is a randomized trial comparing the effects of an intensive lifestyle intervention focused on weight loss achieved through healthy eating and increased physical activity versus diabetes support and education in overweight and obese individuals with type 2 diabetes. REAL HEALTH-Diabetes researchers adapted the lifestyle intervention and demonstrated successful implementation in usual care settings, she said.
“One-year weight loss outcomes in type 2 diabetes were comparable to those achieved in clinical trials, and we saw equivalent outcomes for the in-person and telephone conference call arms, which suggests protentional for scalability,” Delahanty said.
Jodi Krall, PhD, who conducts translational research at the University of Pittsburgh Diabetes Institute, discussed the use of technology, particularly telemedicine, to expand access to nutrition and diabetes education.
“Telemedicine has taken off since we first proposed this session,” Dr. Krall said. “In my own health system, the number of patient visits conducted through our patient portal jumped from an average of 20 to 30 visits a day to 4,000 to 5,000 a day.”
While many hospitals and practices are now using telemedicine to protect patients and staff and reduce the spread of COVID-19, Dr. Krall said virtual visits were an effective way to provide care and keep people connected even before the pandemic. Her team developed a program called TREAT—Telemedicine for Reach, Education, and Treatment—seven years ago. It uses a team-based approach that includes the primary care provider, the diabetes care and education specialist, the endocrinologist, and the patient.
“We’ve seen an almost 2 percentage point reduction in A1C for the telemedicine group, which was significantly more than the reduction seen in the usual care group,” Dr. Krall said. “We also saw significant improvement in psychosocial and behavioral outcomes, including decreased distress, increased empowerment, and better self-care behavior.”
Gretchen Benson, RDN, LDN, CDCES, Program Director of Women’s & Cardiovascular Health Science Centers at the Minneapolis Heart Institute Foundation, presented data that support an expanded role for dietitians in multidisciplinary diabetes interventions. Dietitians can help reduce therapeutic inertia, she said.
“Recent data from JAMA Internal Medicine showed that despite advances in diabetes treatment and evidence-based clinical practice guidelines, fewer than one in four individuals with diagnosed diabetes were achieving the composite goal for A1C, blood pressure, cholesterol, and nonsmoking,” she said. “We have an opportunity to enhance primary care with prevention practice and a collaborative team-based approach.”
Benson shared results from a variety of studies that demonstrated the effectiveness of dietitians with prescribing rights, including data from ENHANCED (DiEtitiaNs Helping PAtieNts CarE For Diabetes). The study, which enrolled 108 participants, included an average of 10 telemedicine sessions during the course of a year. The optimal care goals were A1C, blood pressure, and tobacco use.
“Our intervention group showed significant improvement from baseline,” Benson said. “We saw a mean of meeting 3.1 goals at baseline compared to 3.7 at the end for our intervention group. The control group had smaller improvement, with a mean of 2.9 goals met at baseline and 3.2 at the end.”
Medication adherence improved in the intervention group, while secondary outcomes such as daily fruit and whole grain intake also increased for the intervention group, but not for the control group, she said.
Michelle Passaretti, MSN, BSN, RN, CCM, Senior Director of Innovations at Geisinger’s Steele Institute of Health, discussed how a “food is medicine” approach is used to address food insecurity among diabetes patients in the Geisinger network.
“We learned that our patients, like everyone’s patients, are making tough choices that affect their health outcomes,” Passaretti said. “When we look at diabetes and how that might relate to food insecurity, we know that among individuals with A1C between 6.5 and 9, one in five are food insecure. For individuals with an A1C above 9, one in four are food insecure. We also know that as food insecurity worsens, so does a person’s illness, particularly type 2 diabetes.”
Three communities were identified in the Geisinger network area at risk for food insecurity and diabetes. The health system partnered with a local food bank to create the Fresh Food Farmacy to give at-risk patients access to healthy food options, including fruits and vegetables, lean meats, and whole grains. Participants receive enough food to create two healthy meals a day, five days a week, for the entire household. Program participants also receive in-person or telephone support from the diabetes care team. The care team screens for complications and provides assistance with meal planning and recipes.
“With the ‘food as medicine’ concept, we have been able to decrease patients’ A1C by an average of about 2 points,” Passaretti said. “We’ve also seen improved glucose measures and improved cholesterol.”
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