Monitoring in Diabetes Self-Management: Issues and Recommendations for Improvement

Abstract

The American Association of Diabetes Educators hosted a Monitoring Symposium during which 18 invited participants considered pre-set questions regarding how diabetes education can more effectively address barriers to monitoring for people with diabetes and related conditions. This report provides a summary of the moderated discussion and highlights the key points that apply to diabetes educators and other providers involved with diabetes care.

The participating thought leaders reviewed findings from published literature and participated in a moderated discussion with the aim of providing practical advice for health care practitioners regarding monitoring for people with diabetes so that the overall health of this population can be enhanced. The discussants also defined monitoring for diabetes as including that done by the clinician or laboratory, as well as self-monitoring. The discussion was distilled into key points that apply to diabetes educators and other providers involved with diabetes care. Participants developed specific recommendations for a self-monitoring behavior and monitoring framework.

People with diabetes benefit from instruction and guidance about self-monitoring and decision making that is based on monitored results and informed interactions with providers. Importantly, collaboration among the entire diabetes care community is needed to ensure that monitoring is performed and utilized to its fullest advantage. Going forward, it will be critical to mitigate barriers to diabetes self-management and training and to identify linkages and partnerships to address barriers to self-monitoring. (Population Health Management 2011;14:189–197)

Introduction

F or individuals with diabetes, active monitoring of various physiological and behavioral parameters is associated with better health outcomes. Self-monitoring of blood glucose is an integral element in diabetes self-management education and training (DSME/T).¹ Self-monitoring of weight, nutritional intake, and physical activity also play a key role in the prevention and control of diabetes.^2,3

In December 2009, The American Association of Diabetes Educators (AADE) hosted an invitational Monitoring Symposium in Chicago, Illinois, with follow-up iterative collaboration. Eighteen invited participants examined diabetes self-management, attributes of diabetes education, and barriers to monitoring among people with diabetes. The Symposium was designed to consider several predetermined questions exploring how health care providers and diabetes education services can more effectively address barriers to monitoring by people with diabetes and related conditions. Self-monitoring of blood glucose is an integral element in diabetes self-care and DSME/T.¹

The questions addressed by the Symposium participants can be summarized as:

What does the literature relating to self-management tell us regarding the benefits of self-monitoring and other types of monitoring for the person with diabetes?

Within the context of monitoring, what approaches can be adopted by health care teams to improve clinical and behavioral assessments and interventions so that the best treatment and behavior change plans can be designed for people living with diabetes?

Can best practices be identified for addressing barriers to monitoring in relation to diabetes and its comorbid conditions?

How can the diabetes educator enhance the provision of DSME/T with regard to monitoring behaviors for ongoing self-management support for people with diabetes and facilitate the integration of monitoring into the management decisions of the diabetes care team?

The participating thought leaders (Table 1), several of whom are authors of this article, distilled findings from published literature with the aim of providing practical advice for health care practitioners regarding monitoring for people with diabetes so that the overall health of this population can be enhanced. A member of the AADE Research Committee served as chair of the invitation-only Symposium and the event was facilitated by a professional moderator. This report provides a summary of the moderated discussion and highlights the key points that apply to health care providers involved with diabetes care. The Symposium began with a formal presentation of published literature on monitoring that focused on self-monitoring by persons with diabetes, including a systematic review for type 2 diabetes not using insulin.^1

–4,8,10 The presentation was followed by a discussion of empirical literature on all types of monitoring for people with diabetes, as well as associated current clinical care guidelines. Several of these materials had been provided to participants in advance of the Symposium.

Table 1.

Participants in the Symposium

Participant	No.
Physician	3
Registered dietitian	4
Registered nurse	2
Behaviorists/behavioral psychologists	3
Academic/researcher	9
Staff from a national association	3
Diabetes educator	6

Individuals may be counted more than once.

Ideally, monitoring requires the person with diabetes to track the results of self-care activities, such as healthy eating and being active, as well as risk-reducing services provided by professional health care providers, such as eye exams and urine ketone measurements. Monitoring also includes activities undertaken by health care providers and may include findings from clinical and laboratory data (Table 2). Lasting behavior change, however, can be a difficult process, and research shows that many persons with diabetes lack awareness and understanding of their clinical tests results, even in the context of having had a recent diabetes-related visit to their health care provider.⁴

Table 2.

Monitoring in Diabetes Management

Type of Monitoring	Self-Monitoring (eg, monitored by person with diabetes)	Professional Monitoring (eg, monitored by health care team)	Typically Tracked in DSME/T (by the diabetes educator)
Blood glucose	X	X	X
Blood pressure	X	X	X
Weight/BMI	X	X	X
Physical activity (eg, steps taken)	X		X
Nutrition intake	X		X
Feet inspection	X		X
Foot examination (clinical)		X
A1C		X	X
Urine albumin		X
Ketones		X
GFR		X
Cholesterol		X	X
Triglycerides		X	X
Dilated eye examination		X	X
Dental health		X	X
Fetal surveillance during pregnancy		X
Immunizations	X	X	X
Behavioral health (ie, screening for depression and anxiety, disordered eating behavior)		X	X
Assessment of coping and self-efficacy (eg, patient empowerment)	X		X
Medications (and their adjustment)	X	X	X

BMI, body mass index; DSME/T, diabetes self-management education and training; GFR, glomerular filtration rate.

What Does the Literature Relating to Self-Management Tell Us about Self-Monitoring and Other Types of Monitoring for the Person with Diabetes?

Diabetes is a chronic illness that requires self-management and continuous medical care to prevent, delay, or manage microvascular and macrovascular complications.^5,6 Early signs of diabetes complications (eg, retinopathy, nephropathy) can be identified by assessing markers and often can be treated or have their onset delayed.⁷ When tied to targeted behaviors, monitoring of numerous health parameters can help to minimize the progression and impact of diabetes complications.^8,9 Clinical practice guidelines include monitoring as a component of diabetes management.^3,10 While some assessments are performed only by health care professionals, others are accomplished by the person with diabetes through self-monitoring efforts.

Self-monitoring is a self-management behavior that has been integrated into the National Standards for Diabetes Self-Management Education and practice guidelines.^11
–13 When used optimally, self-monitoring is a strategy for both data collection and behavior change.^14
–16 In other words, the individual makes an observation, turns that observation into a measurement, ideally records the measurement, and utilizes those data to initiate actions.^17,18 Monitoring might apply to A1c, blood pressure, cholesterol and other lipids, weight, urine albumin, glomerular filtration rate (GFR), ocular health, as well as behaviors related to physical activity, nutrition, foot care, oral hygiene, and skin care.¹¹ Specific recommendations for monitoring related to reducing risk (eg, eye and foot exams) are also available.^3,10

The most researched monitoring activity in diabetes is self-monitoring of blood glucose (SMBG), a measurement that guides glycemic management strategies and has the potential to improve problem solving and decision making by people with diabetes and their health care providers.¹⁵ SMBG provides feedback on blood glucose levels, thereby allowing the person with diabetes to compare these levels to target blood glucose goals, make judgments about what actions are needed to reach goals (eg, eat a certain number of carbohydrates, add a bolus of insulin, engage in physical activity), and to engage in the necessary behaviors to achieve the desired goals.¹⁹ As such, SMBG can promote improved understanding of the impact of foods, physical activity, and medications on blood glucose concentrations as well as facilitate more timely adjustment of therapeutic regimens.¹²

SMBG in type 1 diabetes has been clearly defined with regard to indications and systematic use and was a core strategy in the Diabetes Control and Complications Trial, which demonstrated that improved glycemic control led to a reduction in the risk of microvascular complications.^3,10,20 SMBG is especially valuable during pregnancy for those with gestational diabetes who are taking insulin or those with preexisting type 1 diabetes. Intensive glycemic control has been demonstrated to significantly benefit maternal and neonatal outcomes for those with or at risk of diabetes. ^21

–24

SMBG in type 2 diabetes is encouraged, although several recent reviews have highlighted that research regarding its impact on outcomes remains mixed, particularly for individuals who are not treated with insulin.²⁵ A systematic review evaluated the impact of SMBG on A1c levels for people with type 2 diabetes and explored mediators and moderators within a self-regulation framework.¹ The findings from this review suggest that self-monitoring may lead to improvements in glucose control in non-insulin-treated type 2 diabetes. A study by Schwedes et al showed that meal-related blood glucose monitoring within a structured counseling program significantly improved glycemic control in the majority of non-insulin-using people with type 2 diabetes.²⁶

In 2007, Farmer et al published the results of a large randomized controlled trial in which people with diabetes received one of the following: no SMBG; SMBG with doctor interpretation/action; or SMBG skills training within a behavioral framework, and instruction in personal interpretation.²⁷ The study did not support SMBG as a way to improve glucose control for people with reasonably well-controlled non-insulin-treated type 2 diabetes (A1c above 6.2%, with a mean of 7.5%). This may be attributable to differences in the skills training provided in the study versus those taught during DSME/T that is provided in accordance with the Guidelines for the Practice of Diabetes Self-Management Education. In addition, subjects in the study were in relatively “good control” of their diabetes. Discussants noted that interventions conducted with people with diabetes who are in good glucose control may show marginal changes in outcomes but are unlikely to produce substantial clinical improvements.¹¹

Data regarding SMBG impact on morbidity and mortality in type 2 diabetes are also mixed.¹² Methodological issues, including statistical adjustment for potential confounding variables, have been discussed as a source of conflicting findings.²⁸ Other studies with more promising results continue to inform providers as to the role of SMBG.^29,30 Although the debate continues, in 2009, the International Diabetes Federation released guidelines supporting the use of SMBG by people with non-insulin-treated type 2 diabetes, stating that it is likely to be an effective self-management tool when results are reviewed and appropriately acted upon to actively modify behavior and/or adjust treatment.³¹ A1c levels, which reflect blood glucose control, are often a factor in payer/purchaser assessments of provider quality, which are often linked to pay for performance. Clinical considerations aside, the payer community may look to SMBG as a way to promote blood glucose control and A1c levels at 7 or lower.

Specific recommendations for monitoring related to reducing risk (eg, eye and foot exams) are also available and generally accepted by diabetes care teams.^3,11 Still, lasting behavior change can be a difficult process for most individuals, and many psychological and environmental barriers can interfere with efforts to succeed. Often, potential barriers can be identified on the basis of past failed attempts to change behavior. Attitudinal and behavior-specific barriers may become evident as difficulties arise in performing self-monitoring or in the context of disappointing results.³² For some individuals, this may be discouraging. This was observed in the Efficacy of Self-Monitoring of Blood Glucose in Patients with Newly Diagnosed Type 2 Diabetes study. Participants had not previously engaged in SMBG and were randomized to SMBG or no SMBG groups. At 12-month follow-up, no group differences in A1C levels were observed; however, the SMBG group had higher depressive symptomology scores.³³ Observations of disappointing results or barriers to self-care or SMBG may provide opportunities for timely intervention by diabetes care providers. Monitoring logs may provide insights into negative moods, social pressures, family problems, stress, and burnout associated with living with diabetes.³⁴

Depression is a common comorbidity of diabetes and has been linked to poorer self-care.³⁵ One popular option for depression screening consists of either using the full PHQ-9, which is a brief self-report measure that has been validated in medical populations, or asking the 2 questions from the PHQ-2 (a subset of the PHQ-9 questions).^36
–38 Anxiety also may be an issue for people coping with diabetes and assessment of anxiety symptoms may be useful; however, this has not been widely studied among people with diabetes.³⁹

A number of scales for assessing anxiety in people with diabetes and medical conditions are available.⁴⁰ Self-monitoring also has limitations, including the need for high levels of motivation and effort on the part of the individual; the potential for fabricating the results reported to health providers in response to social desirability; and the fact that during the act of monitoring, the observed behavior may objectively be different than at times when monitoring is not taking place.^41,42 An additional limitation of the use of SMBG in type 2 diabetes is the absence of clear evidence regarding optimal monitoring frequency and timing, highlighting the need for future studies.¹² In particular, clinical studies are needed to examine the optimal monitoring frequency as it relates not only to clinical outcomes but also patient satisfaction and quality of life. More research is also needed to elucidate the different aspects of education that influence SMBG—specific subgroups of individuals with type 2 diabetes who might be aided most or be at risk of harm related to monitoring.²⁵

Within the Context of Monitoring, What Approaches Can Be Adopted by Health Care Teams to Improve Clinical and Behavioral Assessments and Interventions so that the Best Treatment and Behavior Change Plans Can Be Designed for People Living with Diabetes?

The discussants noted that monitoring may encompass self-monitoring, assessments performed by health care professionals, and external (ie, laboratory) assessments. Health care providers typically rely on clinical data but may also use patient-collected data to identify and guide potential behavior modifications. By involving people with diabetes in discussions and problem-solving sessions using their monitored results, health care providers can educate them about the importance and relevance of those results.⁴³ For example, post-meal blood sugars can be used to determine if medication dosing at meals is on target and/or if meal intake is appropriate. People with diabetes may also learn to use pre- and post-activity blood sugar results to assess the effectiveness of lifestyle changes. Symposium discussion highlighted the importance of using SMBG and laboratory monitoring results as tools for feedback in making decisions regarding behaviors needed to achieve target goals. This has been echoed in the research literature, with calls for the training of individuals with diabetes and health care providers to optimally utilize monitoring as part of a feedback process rather than considering it an intervention in and of itself.^12,.25,44 Specific educational interventions aimed at utilizing SMBG readings as feedback for decision making have been successfully applied and resulted in positive outcomes across a variety of settings.^45,46 Utilization of monitoring as a feedback process in clinical trials examining the impact of SMBG has also been recommended.¹² Ultimately, people with diabetes who are adequately prepared before beginning self-monitoring may have better self-management and, in turn, better health outcomes.⁴⁷ Self-monitoring expectations should be individualized to suit the individual's ability and preparedness to self-monitor, the environment in which the individual's health care is delivered, access to required equipment or devices, and reimbursement issues.

Once persons with diabetes can react to changes in their health status, they can set appropriate goals. Goal setting includes planning target behaviors that are specific, meaningful to the individual, and simple to quantify through counting or other means of measurement.⁴⁸ Examples of target goals might include blood glucose levels, counting carbohydrates eaten per meal, daily calories consumed, and number of steps taken daily. Goal setting also includes having sufficient information (via monitoring strategies) to make changes in day-to-day management that result in quantifiable improvement in longer term outcomes such as weight maintenance or loss.

The underlying framework for this behavior includes interpreting and understanding information gleaned from self-monitoring and monitoring by health care professionals. Self-monitoring is only useful if the patient can share the monitoring results with the diabetes care team and use the information to make adjustments that improve diabetes self-management, and/or reduce the risk of complications. Accordingly, the Symposium participants identified specific elements of the self-monitoring framework. These recommendations, shown in Table 3, apply to the person with diabetes as well as health care professionals.

Table 3.

Recommendations for the Self-monitoring Behavior and Monitoring Framework

• The monitoring behavior should be predicated upon a basic framework that can be summarized as follows:

○ Framework: Recognizing the importance of either self-monitoring or participating in monitoring conducted by medical professionals;

○ Goals: Understanding the desired target or ranges for optimal self-management;

○ Interpretation: Interpreting the self-monitoring data and feedback, including patient education regarding the interpretation of the data;

○ Decision Making: Determining the options for responding to the self-monitoring information or readings, including patient education regarding the decision-making process;

○ Action: Taking appropriate actions to better manage diabetes and related conditions.

• Recording information/assessments should be done with a purpose in mind, whether to identify long-term trends for corrective action, take immediate corrective action, or provide motivation for goal attainment.

○ To record the measure, the individual should have a way to easily summarize goal attainment (eg, a well-designed, convenient diary).^25,47

○ Feedback to the person with diabetes regarding the efficacy of the monitoring method and usefulness of the information obtained is essential.

○ The summary of data and feedback should be cumulative and include a comparison to the goal.

○ People with diabetes and/or providers should be aware of action options when the goal is not met.

• Monitoring should be implemented as a team effort.

○ Collaborative goal setting should be used to identify individual, realistic goals.

○ Shared decision making between the person with diabetes and provider should link self-monitoring results to a clear set of instructions or actions.¹⁹

○ Follow-up should be performed by diabetes educators and/or other health care providers in order to review the individual's self-monitoring records.

○ The person with diabetes should work with a diabetes educator and an integrated diabetes care team to optimize the potential success for self-management of his/her condition.

• Diabetes self-management education and training should be an essential component of effective monitoring because people with diabetes are ultimately responsible for and in control of their own self-monitoring and self-management of the disease.

Can We Identity Best Practices to Address Barriers to Monitoring in Relation to Diabetes and its Comorbid Conditions?

Members of the diabetes care team can collaborate to overcome barriers to monitoring and self-care by encouraging realistic goals, facilitating problem solving, providing helpful feedback, and identifying useful resources.⁴⁹ Research studies have identified a number of specific perceptions and skills that serve as barriers to SMBG in people living with diabetes, including cost, perceived hassle, competing demands, believing that it is not helpful, not understanding what to do and when/how to do it, depression, and perceived intrusiveness and burden of testing.^50,51 Symposium participants noted that practitioners who engage in best practices are able to effectively adopt a patient-centered approach, identify barriers, and communicate the importance and advantages of self-monitoring. For both self-monitored and professionally-monitored parameters, when people with diabetes adequately understand the implications of the assessed measurement—for example, what their blood pressure reading means about their current health status—they can make appropriate choices that are conducive to better health. People with diabetes may significantly benefit from training with a diabetes educator or other health care provider regarding interpretation of clinical tests to maximize benefits and minimize risks. Such understanding and knowledge enables individuals to witness their behavior and reflect on the situational context, allows the capture of detail not possible through recall, and provides immediate feedback to facilitate timely problem solving and decision making.⁴⁷ New remote monitoring technology is available that can be used to augment self-monitoring and overall diabetes self-care.⁵² New patient-controlled devices, such as constant glucose monitors, provide refinement of measurement that can be used for refinement of treatment decisions.⁵³

Patient-centeredness and empowerment form a compelling paradigm in diabetes self-management that can help to facilitate monitoring.⁵⁴ Because of the central role played by the person with diabetes, self-monitoring reflects a paradigm shift in diabetes management from an acute care model to the chronic care model.^55,56 This model supports self-efficacy and patient empowerment, which can be integrated into care plans that involve behavior change and monitoring. Symposium discussants generally concurred that a patient-centered approach means that no matter who performs the monitoring activity, the locus of control ultimately lies with the person with diabetes rather than with the health care team. For example, to successfully perform SMBG with the goal of improving diabetes outcomes, the person with diabetes must be competent and confident in (1) operating a glucometer, and (2) interpreting the SMBG data to make behavior changes. People who engage in the self-care behavior known as problem solving benefit from coaching on how to interpret values and respond to them in appropriate ways through use of dietary and exercise-related information, and algorithms to respond to dysglycemic SMBG readings.^57,58

Patient education, skill attainment, and support are essential but not sufficient to ensure proper performance and maximize the value of self-monitoring. Psychosocial well-being also plays a role.^35,39,59 People with type 1 or 2 diabetes benefit from structured self-report or interview assessment of depression, anxiety, stress level, and disordered eating behaviors.³⁵ Specific considerations relating to these dimensions during pregnancy and in older adult populations are also warranted.^24,60

Barriers and challenges exist that can thwart the ability of the diabetes care team to support self-care by people with diabetes.⁶¹ Some of the discussants noted that the failure to address monitoring as a major tool of care may stem from limited patient-provider contact time available within the existing health care system. Time constraints also may restrict communication between diabetes educator and other health care providers. Once barriers are brought to light through assessments of physical health, medications, interpersonal relations, financial status, and emotional issues, areas for education and clinical intervention can be identified. As an example, some individuals with diabetes have limited access to care and supplies due to minimal or no health insurance coverage for monitoring and/or education costs. In such cases, the diabetes care team is encouraged to advocate for the person with diabetes and assist in formulating and implementing feasible solutions whenever possible. Often, such solutions may entail obtaining support from interdisciplinary colleagues such as psychologists or social workers. In addition, it is within the scope of practice of diabetes educators and other health care providers to help people with diabetes identify resources that can reduce barriers to effective diabetes care and self-management, including monitoring.⁶²

Discussants felt that limited access to health care providers and DSME/T are significant barriers to monitoring and diabetes self-management. As an example, despite the value of education in contributing to the health and well-being of persons with diabetes, fewer than half of people with diabetes receive such education even though the stated goal is considerably higher.^63,64 This is puzzling because diabetes education is cost-effective and participants report high levels of satisfaction with their education experience.^61,65,66 A multifaceted approach is needed to improve access to DSME/T, understanding of diabetes management and control, and successful acquisition of self-management skills. This can perhaps be achieved through increased referrals by physicians to DSME/T, increased follow-through by people with diabetes, and increased availability of educational tools in forms that appeal to patients and physicians. Improvements in insurance reimbursement for DSME/T can also help improve access.

How Can the Diabetes Educator Enhance the Provision of DSME/T with Regard to Monitoring Behaviors for Ongoing Self-Management Support for People with Diabetes and Facilitate the Integration of Monitoring into the Management Decisions of the Diabetes Care Team?

Diabetes educators are specially prepared health care professionals (eg, registered nurses, registered dietitians, registered pharmacists, mental health professionals) who are particularly suited to this clinical role because they are trained to (1) advise people with diabetes of the benefits of discussing their self-monitoring results with the health care team; (2) educate people with diabetes on the meaning of monitored results, explaining how to have meaningful conversations with other health care providers to improve outcomes; and (3) help people with diabetes frame questions concerning monitored parameters to encourage clinicians to provide meaningful feedback.⁶⁷ Diabetes educators and other members of the diabetes care team can prepare people with diabetes to self-monitor by providing information that helps them to understand the assessment and goals, perform the appropriate activities, and make effective self-management decisions. Diabetes educators provide DSME/T and thereby play a key role in assisting people with diabetes in identifying strategies for self-care. Some educators, however, do not routinely ask people with diabetes about their monitoring efforts or emphasize the purpose of monitoring, reflecting the need for improvement in this area.⁶⁸

The benefits of educating people about monitoring extend to clinical and quality improvements and reduced health care costs. By helping to clarify behavioral goals and identifying challenges and concerns of the person with diabetes, the diabetes care team—and diabetes educators in particular—can help people with diabetes optimize their self-management behaviors and appropriately evaluate progress toward meeting these goals. Duncan et al reported finding better HEDIS (Healthcare Effectiveness Data and Information Set) quality measures and lower expenditures for patients seen by providers who use diabetes education.⁶⁵ This finding may be a result of the ability of high-quality providers to help people with diabetes track and understand laboratory values and other clinical measures and to empower them to interact with their providers and use the information to make decisions regarding appropriate self-care behaviors.⁶⁹ Diabetes educators and other members of the diabetes care team also can guide caregivers to additional reliable sources of information such as credible Web-based resources.⁷⁰

Summary

Monitoring applies to self-observations and/or laboratory assessments relating to other diabetes risk factors and outcomes that could benefit from self-regulation (ie, serve as both a data collection tool and behavior change strategy). Monitoring is most effective when undertaken by both health care professionals and the individual with diabetes and/or the family or caregiver. Monitoring for diabetes prevention, control, and management involves a range of activities that address metabolic control and chronic complications related to diabetes; achievement of optimal health is predicated upon self-monitoring that includes measuring weight, blood pressure, blood glucose levels, and nutritional intake, and making daily foot inspections. Self-monitoring is an essential self-care behavior that provides a way to obtain information that can be integrated into other self-management behaviors such as medication taking, healthy eating, and being active.

Monitoring of physiological and behavioral parameters is integral to diabetes care and self-management, and it has been shown to provide specific clinical benefits. When effectively coupled with goals and targeted behaviors, self-monitoring plays a vital role in the overall management of diabetes. In this way, self-monitoring can help to improve quality of life, well-being, and impact other health conditions by providing accurate information and feedback to the diabetes care team, the person with diabetes, as well as the family and caregivers. Training and education in self-monitoring, which can be provided by diabetes educators, facilitates the patient-centered approach and should be included in all diabetes care management efforts.¹⁵

Conclusion

The purpose of monitoring is to (1) provide feedback to the individual and health care team, (2) inform them about current status, (3) compare current indices of health to targets/goals, (4) make decisions regarding next steps for care, and (5) take action in the form of behavior change or change in treatment regimen. Regarding overall health, monitoring includes assessments relating to A1C, blood glucose, blood pressure, weight, urine albumin, GFR, cholesterol and other lipids, ocular health, physical activity, nutrition, foot care, dental health, and skin. In addition, persons with diabetes should be assessed for depression, anxiety, stress level, disordered eating behaviors, self-efficacy, patient empowerment, and considerations related to pregnancy and older populations.

Successful and continued use of self-monitoring and resultant decision making is based on adequately delivered instruction and guidance for self-monitoring, review of monitored results, and informed interactions with providers. Importantly, collaboration among the entire diabetes education community is needed to ensure that monitoring is performed and utilized to its fullest advantage. Diabetes educators hold a unique place in the chain of communication between people with diabetes and providers and play a vital role in the care team. Going forward, it will be critical to mitigate barriers to DSME/T and identify linkages and partnerships to address barriers to self-monitoring.

Footnotes

Acknowledgment

We recognize the contributions of Annette Lindsey Martin, BA, Barbara Connell, CAE, CMP, and Audrey Porritt, BS to the development of this article.

Author Disclosure Statement

Drs. Stetson, Schlundt, Peyrot, Ciechanowski, Young-Hyman, McKoy, Dorsey, Fitzner, and Narva and Ms. Austin, Ms. Hall, Ms. Quintana, Ms, Urbanski, Ms. Homko, and Ms Sherr declared no conflicts of interest.

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