Linda S Gottfredson, PhD
School of Education
University of Delaware
Kathy Stroh, MS, RD, CDE
Diabetes Prevention and Control Program
Delaware Division of Public Health
CEHD Colloquium, University of Delaware, February 28, 2013
1

Juvenile Diabetes
Insulin dependent
Diabetes (IDD)
Type I Diabetes
Maturity-onset Diabetes
Non-insulin dependent
Diabetes (NIDD)
Type II Diabetes
Type 1 Diabetes Type 2 Diabetes
2

Type 1
Type 2
Gestational

-cell destruction; autoimmune disease ; complete lack of insulin
5-10% of total patients

-cell dysfunction and insulin resistance

-cell dysfunction and insulin resistance during pregnancy
3

There is no such thing as Borderline Diabetes or a “Touch of Diabetes.”
4

Pre-diabetes
There is no such thing as
Borderline Diabetes or a “Touch of Diabetes.”
5

DM defects
6

Diabetes is a cardiovascular disease.
People with diabetes are twice as likely to suffer a heart attack or stroke compared to people without diabetes.
The Burden of Diabetes in Delaware, 2009. Diabetes Prevention and Control Program
7

Family
Insulin Resistance
History
Obesity
350
300 Prediabetes
250
200
150
100
50
Diabetes
Post-meal Glucose
Uncontrolled
Hyperglycemia
Fasting Glucose
250
200
150
100
50
-10

-cell Failure
-5 0 diagnosis
5
Insulin Resistance
Insulin Level
10 15 20
Years of Diabetes
25 30
Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.

• Patients must control their blood glucose (BG) levels to avoid complications
• Controlling BG is a complex, 24/7, life-long task
– Rx’s change, increase; may not insure optimal BG control
– Changes in dietary intake & physical activity necessary
– And more…
• So much to learn and do (or stop doing)
9

* “Diabetic” is not a noun
10

11

12

13

14

$673 billion
Regulations
Private schools
0.4 mil teachers
5.4 mil pupils
Diabetes education??
3 million
50 million
15

$673 billion
Regulations
Instruction
Learning tasks
Private schools
0.4 mil teachers
5.4 mil pupils
Diabetes education??
3 million
50 million
16

Number needing instruction
Public schools Diabetes cases
Millions enrolled 1
Fall of
Total
Elementary ( preK -8)
HS (9-12)
1970
45.5
32.5
13.0
1990
41.2
29.9
11.3
2010
49.5
34.6
14.9
2020
52.7
37.3
15.4
Millions diagnosed with diabetes Type 1 or 2
(non-institutionalized civilians)
All ages
Adults (18+)
Older (65+)
1970 2
3.6
1990 3
6.6
6.6
2.8
2010 3
20.9
20.7
7.8
2020 4
33.5
2004 % diagnosed adults > 20 years 5 2009
Just 5 years!
4
1 2012 Condition of Education, Table A-3-1. http://nces.ed.gov/pubs2012/2012045_5.pdf
2 For 1970, All Ages is interpolated from 1968 and 1973. http://www.cdc.gov/diabetes/statistics/diabetes_slides.htm
.
3 For 1990 and 2010, All ages and 65+ derived from http://www.cdc.gov/diabetes/statistics/prev/national/tnumage.htm
, and 18+ from http://www.cdc.gov/diabetes/statistics/prev/national/figadults.htm
Type 2 alone: Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990.
5 CDC’s Diabetes Data & Trends. http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx
,

Students in public schools , K-12 Diabetes cases, diagnosed and undiagnosed
Total expenditures
(2010 dollars)
Medical costs only
(2010 dollars)
1970
Total $ (billions) 1 270
Average $/person 2 4,310
1990 2010
415 673
7,925 10,694
(2008)
Type 1
11
Type 2
111
11,093 6,745
2007 3
Undiag
12
1,834
Pre-diab
27
466
Total
160
2020 4
Type 2
237
Costs as % of GDP 1,5
15,0
10,0
5,0
0,0
Diabetes
Schools
1970 1980 1990 2000 2010 2020 2030
1 2011 Digest of Education Statistics, Table 28, http://nces.ed.gov/programs/digest/d11/tables/dt11_028.asp
. Table reports costs in current dollars, so inflation calculator used to bring up to 2010 values.
2 2011 Digest of Education Statistics, Table 194, http://nces.ed.gov/programs/digest/d11/tables/dt11_194.asp
3 Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. Used inflation calculator to translate dollars from 2007 to 2010. http://www.usinflationcalculator.com
4 Huang et al. (2009) Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990. Includes Type 2 only. Type 1 would be <5% of cases but higher per capita cost. Inflation calculator used to change costs from 2007 to 2010 dollars. 18
5 No 2020-2030 projections available for school expenditures, so just repeated % GDP from the prior 2 decades. Used Huang et al.’s total diabetes medical costs for 2007, together with 2007 GDP, to calculate costs as % GDP in that year (1.1%). Then used their Exhibit 3 (projected real growth as multiple of GDP) to estimate % GDP in 2010, 2020, and 2030. No data prior to 2007, so just took line toward asymtope .

$ (billions)
25.3
%
(prevalence)
105.7
11.0
10.5
19
Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars.

14 000
11 722
12 000
35,365
Average cost ($)
10 000
9 061
8 198
8 000
6 387
6 000 5 425
4 775
4 561
5 077
5 359
4 763
3 714
4 000
2 327
2 063
2 000 1 374
210 305 391 488 537
0
Ages: 18–34 35–44 45–54 55–59 60–64 65+
Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars.
Type 1
Type 2
Undiagnosed
Pre-diabetes
Average
20

Dedicated space
Guaranteed funding
Mandatory attendance
Teaching force:
Public schools
Permanent buildings
100% tax-supported 1
(local, state, federal)
10-14 years
Trained in content area
Certified to teach
All (N=3.1 million) 1
99% 1
Curriculum content
&
Teacher lesson plans
Classroom teachers
State national standards (CCSS 2 )
Always. Vary by teacher common planning
More variable for DSME
Diabetes self-management education
Varies; hospitals, medical offices, community sites
Varies by health plan; free community classes provided by
DPH/DPCP.
None, all voluntary.
~ 24% of Medicare patients attended DSMT class.
Many staff do DSME: medical (e.g., MD, RN, RD, NP, PA, RPh); non-medical (e.g., CHW, CHES, peer educators).
DSMP classes given by lay trainers.
Trained in disease management: MD, RN, RPh, RD, NP, CDE.
Trained to educate: Only CDEs (N=8710), national credential; possible state licensure too.
Curriculum content: ADA and AADE certify Recognized
Programs. DSMP has evidence-based curriculum.
Lesson plans: vary with ADA & AADE programs. Fidelity agreement for DSMP.
= trend towards
21
1 2012 Condition of Education, Tables A-19-1 (2008-2009), A-17-1 & A-17-2 (2007-2008)
2 http://www.corestandards.org/

o Level 1, non-healthcare professional, o Level 2, healthcare professional non-diabetes educator, o Level 3, non-credentialed diabetes educator,
 Level 4, credentialed diabetes educator, and
 Level 5, advanced level diabetes educator/clinical manager.
*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and
Standards of Professional Performance for Diabetes Educators, p. 4.

op0 Public schools Diabetes self-management education
Hours of instruction in content area
(average per year)
Instructional strategies
State/district-mandated minimum hours: 1
G1-4: 418 read/write
194 math
292 science
Systematic use of pedagogical principles
Varies greatly by health plan & site
- Classes: 10-15 hrs
Limited time
Special needs students
Established protocols?
Yes, legal obligation (IDEA)
Age- and ability-differentiated instruction & materials
Age grouping, preK-12
Elem: reading/math groups within or between classrooms, all with different lessons
HS: Tracks
For individual patients: CDE’s assessment of patient’s needs.
For groups: scripts for some non-medical educators (e.g., DSMP)
Pace, sequencing, Bloom level not always considered.
Materials too complex
Currently, no DSME materials or curricula specifically for elderly or persons with disabilities.
None.
Growing concern over low “health literacy” & age-related cognitive decline with PWDs, but complexity, matched to PWD’s learning needs.
- PWDs are given pre-determined meters and supplies, regardless of their abilities.
1 Data for 2003-2004. Source: “Changes in Instructional Hours in Four Subjects by Public School Teachers of Grades 1 Through 4,“ May 2007, NCES report 2007-305 http://www.eric.ed.gov/PDFS/ED497041.pdf/
2 http://www.cdc.gov/diabetes/statistics/preventive/tNewDEduAgeTot.htmwww.eric.ed.gov/PDFS/ED497041.pdf
23

24

1.
Describe job of self-care from patient’s perspective.
– Collaboration with CDS: AUCD Conference
– AADE Conference: “Cognitive Demands of DSME”
– NACDD Teleconference: “Cognitive Demands of DSME”
– AADE Conference 2013: “Psychometrics of DSME in the Elderly”
2.
Identify the job’s most critical tasks
3.
Trace (and limit) cognitive complexity of learning tasks
4.
Differentiate instruction by ability (“literacy”) level
5.
Provide scripts for providers that minimize complexity
6.
Provide patient handout that reinforces learning
25

Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that:
• Requires making and acting on choices, on a regular and recurring basis, that affect one’s health
• Includes
 learning the body of knowledge relevant to the disease state,
 defining personal goals, weighing the benefits and risks of various treatment options,
 making informed choices about treatment,
 developing skills (both physical and behavioral) to support those choices,
 evaluating the efficacy of the plan toward reaching self-defined goals.
*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards
of Professional Performance for Diabetes Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf
26

Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that:
• Requires making and acting on choices, on a regular and recurring basis, that affect one’s health
• Includes
 learning the body of knowledge relevant to the disease state,

AADE7 TM
 making informed choices about treatment, curriculum content
 developing skills (both physical and behavioral) to support those choices,
 evaluating the efficacy of the plan toward reaching self-defined goals. 1. Healthy eating
2. Being active
What Bloom level would you assign to each?
3. Monitoring
•
•
Remember
Understand
• Apply
• Analyze
•
• Evaluate
Create
4. Taking medication
5. Problem solving
6. Reducing risks
7. Healthy coping
27

Our more patient-centered job description
Objective: Maintain blood glucose within healthy limits to avoid complications
• Learn about diabetes in general (At “entry’)
– Physiological process
– Interdependence of diet, exercise, meds
– Symptoms & corrective action
– Consequences of poor control
• Apply knowledge to own case (Daily, Hourly)
– Implement appropriate regimen
– Continuously monitor physical signs
– Diagnose problems in timely manner
– Adjust food, exercise, meds in timely and appropriate manner
• Coordinate with relevant parties (Frequently)
– Negotiate changes in activities with family, friends, job
– Enlist/capitalize on social support
– Communicate status and needs to practitioners
• Update knowledge & adjust regimen (Occasionally)
– When other chronic conditions or disabilities develop
– When new treatments are ordered
– When life circumstances change
• Conditions of work— 24/7, no days off, no retirement
Training
Selfmanagement
28

Objective: Maintain blood glucose within healthy limits to avoid complications
• Learn about diabetes in general (At “entry’)
– Physiological process
– Interdependence of diet, exercise, meds
– Symptoms & corrective action
– Consequences of poor control
• Apply knowledge to own case (Daily, Hourly)
– Implement appropriate regimen
Training
– Continuously monitor physical signs
– Diagnose problems in timely manner
– Adjust food, exercise, meds in timely and appropriate manner
• Coordinate with relevant parties (Frequently)
– Negotiate changes in activities with family, friends, job
– Enlist/capitalize on social support
Selfmanagement
– Communicate status and needs to practitioners
• Update knowledge & adjust regimen (Occasionally)
– When other chronic conditions or disabilities develop
– When new treatments are ordered
– When life circumstances change
• Conditions of work— 24/7, no days off, no retirement
29

1. Describe job of self-care from patients’ perspective
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
30

UD survey:
Criticality rankings
31

1. Describe job of self-care from patients’ perspective
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
32

Latest (2001) revision
Not just readability!!
Bloom levels = continuum of cognitive complexity
33

“To be or not to be”
To be or not to be, that is the question.
To be or not to be, that is the question.
To be or not to be, that is the question.
To be or not to be, that is the question.
Bloom’s taxonomy of educational objectives
(cognitive domain)*
Simplest tasks
1. Remember recognize, recall,
Identify, retrieve
2. Understand paraphrase, summarize, compare, predict, infer
3. Apply execute familiar task,, apply procedure to unfamiliar task
4. Analyze distinguish, focus, select, integrate, coordinate
To be or not to be, that is the question.
To be or not to be, that is the question.
5. Evaluate check, monitor, detect inconsistencies, judge effectiveness
*
Revised 2001: Anderson, L. W., & Krathwohl,
D. R. (2001). A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational
objectives. NY: Addison Wesley Longman.
6. Create hypothesize, plan, invent, devise, design

Remember to measure foods, drinks & read labels.
Remember to take
BGs & Rx.
Recall effects of exercise on glucose.
Bloom’s taxonomy of educational objectives
(cognitive domain)*
Simplest tasks
1. Remember recognize, recall,
Identify, retrieve
Anticipate effect of exercise & foods on blood glucose.
2. Understand paraphrase, summarize, compare, predict, infer
Coordinate meds, diet, and exercise.
Manage sick days.
3. Apply execute familiar task,, apply procedure to unfamiliar task
Determine when & why blood glucose is out of control
4. Analyze distinguish, focus, select, integrate, coordinate
Monitor symptoms; assess whether action needed; evaluate effectiveness of actions
Create daily and contingency plans that control blood glucose
5. Evaluate check, monitor, detect inconsistencies, judge effectiveness
*
Revised 2001: Anderson, L. W., & Krathwohl,
D. R. (2001). A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational
objectives. NY: Addison Wesley Longman.
6. Create hypothesize, plan, invent, devise, design

36

37

Information is better because it’s in chart form
But, it contains a confusing technical symbol .
Can you spot it?
“Amount/serving”
Amount per serving
38

39

40

Pros:
• Fewer items
• Single vertical list
• Major headings stand out
Cons:
• Lots of irrelevant info
• Seemingly inconsistent info
41

42

Bloom’s taxonomy of educational objectives
(cognitive domain)
Simplest tasks
1. Remember recognize, recall,
Identify, retrieve
2.
Understand paraphrase, summarize, compare, predict, infer,
3. Apply execute familiar task,, apply procedure to unfamiliar task
4. Analyze distinguish, focus, select, integrate, coordinate
Location of relevant
CHO (carb) gms
Carb vs non-carb ??
Sequence of label
Total CHOs important,
“Sugars” not
Grams as volume vs wt
How many CHO gms in 1 serving?
Subtract fiber gms from CHO gms
Distractors:
CHOs vs Fiber vs Fat
5. Evaluate check, monitor, detect inconsistencies, judge effectiveness
6. Create hypothesize, plan, invent, devise, design
Most complex tasks
Part of meal vs snack OK?
CHOs in intended serving?
CHOs vs Fat/Chol vs Na
Plan a meal or snack
43

1. Describe job of self-care from patients’ perspective
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
How different in ability can adults be?
44

National Adult Literacy Survey (NALS), 1993
NALS difficulty level (& scores)
5
(375-500)
4
(325-375)
3
(275-325)
2
(225-275)
1
(0-225)
% US adults
(age 65+) peaking at this level
3%
~
0%
15%
4%
Simulated everyday tasks
Daily self-maintenance in modern literate societies
 Use calculator to determine cost of carpet for a room
 Use table of information to compare 2 credit cards
 Use eligibility pamphlet to calculate SSI benefits
 Explain difference between 2 types of employee benefits
31%
16%
28%
33%
23%
47%
 Calculate miles per gallon from mileage record chart
 Write brief letter explaining error on credit card bill
 Determine difference in price between 2 show tickets
 Locate intersection on street map
 Total bank deposit entry
 Locate expiration date on driver’s license
45

National Adult Literacy Survey (NALS), 1993
NALS difficulty level (& scores)
5
(375-500)
4
(325-375)
3
(275-325)
2
(225-275)
1
(0-225)
% US adults
(age 65+) peaking at this level
3%
~
0%
15%
4%
31%
16%
28%
33%

Simulated everyday tasks
Not reading per se, but
“problem solving”
Use calculator to determine cost of carpet for a room





Use table of information to compare 2 credit cards
 number of features to match
Use eligibility pamphlet to calculate SSI benefits
 level of inference
(“connecting the dots”)
Calculate miles per gallon from mileage record chart
 abstractness of info


Determine difference in price between 2 show tickets
 distracting information
23%
47%
 Total bank deposit entry
 Locate expiration date on driver’s license
46

47

Age
8
Learning & reasoning ability
Basic cultural
Knowledge
(G
C
)
Age
80
g - Basic information processing
(G
F
)
48

1. Describe job of self-care from patients’ perspective
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
49

“Rx for Physical Activity” for a Rural Community Health Center
Linda S. Gottfredson, PhD
School of Education
University of Delaware
Kathy Stroh, MS, RD, CDE
Diabetes Prevention & Control Program
Delaware Division of Public Health
Presented at the 2009 Diabetes Translation Conference of the Centers for Disease Control & Prevention (CDC).
Long Beach, CA, April 24, 2009
50

51

52

53

speed
increases
http://www.udel.edu/educ/gottfredson/Rx
54

55

Teaching the teacher: Script for CDE when prescribing “Rx for Walking”
Provides the CDE with:
Educationally sound teaching strategy
• Key ideas
• Content, sequence, and pace of instruction, etc.
Implicit training
• Be concrete, personalize, use meaningful metaphors, etc.
56

57

58

59

Lesson plan: Don’t assume they know what’s obvious to you
Can’t assume:
That patient will know:
• What a pedometer is
• How to wear it
• The exact regimen of the Rx
• i.e., extra steps
That the educator will know specific learning steps for:
• Aim of script (e.g., extra steps)
• How to adjust regimen
60

1. Describe job of self-care from patients’ perspective
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
61

62

63

64

o Level 1, non-healthcare professional, o Level 2, healthcare professional non-diabetes educator, o Level 3, non-credentialed diabetes educator,
 Level 4, credentialed diabetes educator, and
 Level 5, advanced level diabetes educator/clinical manager.
*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and
Standards of Professional Performance for Diabetes Educators, p. 4.