continuing education

Opportunities in Diabetes
Education for Pharmacists
By David Pope, PharmD, CDE; and Cara Jones

U pon completion of this activity, the

pharmacist should be able to:
1. D
 escribe the different types of
diabetes education in the indepen-
dent pharmacy setting.
2. Explain the advantages of attracting a diabetes
patient to an independent pharmacy.
3. List the ancillary services pharmacists can
provide to diabetes patients in addition to
diabetes education to both newly diagnosed patients
and patients with a history of the disease that are not well
controlled. As a result of their lack of knowledge about their
condition, patients are often embarrassed and frightened
about their future with diabetes. After being diagnosed with
diabetes, many patients experience denial about the sever-
ity of their condition or feel helpless in managing it on their
own. With the myriad of questions presented by patients,
pharmacists can play a very important role in their diabetes
education. education. Not only can pharmacists offer valuable servic-
4. Discuss the different parts of the health care es to assist patients in self-managing diabetes, but these
team and their role in the treatment of the services can also help to grow a pharmacy’s business and
diabetes patient. reputation within the community.
5. Describe motivational interviewing and its role
in diabetes education. Two Different Models of Diabetes
6. Explain the empowerment model and its ad- Education
vantages in communicating with the diabetes Diabetes education can be divided into two basic types:
patient. group and individualized. While both of these types of edu-
7. Describe the use of conversation maps and cation are beneficial to patients, they may differ depending
other techniques designed to enhance com- on the style the moderator is seeking to create. When trying
munication with the patient. to decide what type of education experience to offer, it is
important to consider the individual patient’s wants and
Introduction needs as well as insurance authorization. In addition, phar-
One of the most important factors in diabetes macists should consider their current patient population
management is patient education. When pa- and discover the best method to fit their specific needs.
tients are first diagnosed with either type 1 or There are many advantages to the individualized
type 2 diabetes, they often know very little about patient education approach. In this traditional one-on-one
their condition. In fact, most diabetes patients style, the pharmacist educates the patient over several
have questions about controlling their condition. visits or in longer sessions and is able to develop a trust-
From healthy eating to exercise and medica- based relationship with the patient. The pharmacist meets
tions, persons living with diabetes are desperate with the patient individually or in small groups and reviews
for someone to explain the mystery of diabetes the patient’s lab values, identifies specific barriers to
management. learning, and creates an action plan toward improving the
Clinicians have also openly expressed a de- patient’s condition. When meeting for education in small
sire to further educate patients living with diabe- groups, the education method remains individualized. Also,
tes about their health. Many physicians prescribe using this method, the pharmacist is able to tailor each

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session to be specific to the patient’s needs, education above-average growth due to attracting new
level, disease state, and medications. This intensive and diabetes customers to the pharmacy.
individualized method is the preferred route of diabetes
education whenever feasible. However, this type of educa- Costs
tion is not always possible due to several reasons, includ- The costs associated with diabetes are stagger-
ing: insurance coverage, availability of a quality diabetes ing. According to the National Center for Disease
education program, and willingness of the patient to enroll Prevention and Health Promotion’s Diabetes at a
in an intensive program. Glance 2010:
From the standpoint of the pharmacy, several pos- • Total costs (direct and indirect) of diabetes are
sible barriers may present themselves when attempting $174 billion.
to create an individualized program. First, pharmacists • Direct medical costs equal $116 billion.
must be willing to have a semi-private area located inside • Indirect costs (related to disability, work loss,
the pharmacy (unless the pharmacist is able to meet with premature death) are $58 billion.
patients at another location). Second, pharmacists must
be able to charge for a private consultation to cover the People with diagnosed diabetes also have
costs associated with offering the individualized service. medical expenditures that are about 2.3 times
Finally, pharmacists must be able to effectively integrate higher than medical expenditures for people
a diabetes self-management education program in the without diabetes. By attracting a patient living
usual workflow of the pharmacy. Each of these barriers, with diabetes through innovative educational
however, can be overcome with a proper game plan, programs, the pharmacist is able increase foot
which will be explained in greater detail later in this article. traffic into the store. As a secondary windfall
Many pharmacies have successfully created diabetes benefit to attracting new patients into the phar-
niches through this powerful and effective method of macy, the pharmacy also typically increases
empowering persons living with diabetes. their prescription volume as well as OTC and
In contrast to the individualized technique is educa- other ancillary supplies.
tion offered in a group setting. While the individualized It is easy to see that there are advantages
setting may also be in small groups, group education is and disadvantages to each educational setting.
designed to educate a large number of patients. However, Many pharmacies choose to use both of these
the pharmacist may choose not to create an individualized methods in conjunction to find the perfect bal-
plan, nor will they identify barriers to learning or areas of ance for their patients.
improvement. Using this more open, less invasive style When creating an individualized diabetes
of education, a pharmacist is able to educate a large self-management program, special attention
number of patients in a classroom-like setting. Patients should be paid toward utilizing communication
often feel more comfortable and are encouraged to invite methods designed to maximize patient encoun-
family and friends to the classes, which allows for an area ters. There are many different education and
of growth within the pharmacy. When a patient is able to counseling styles to take into consideration.
invite someone to join them in a diabetes education class, These styles include motivational interviewing,
the pharmacy is able to stir up interest and potentially the empowerment model, and the use of con-
bring in future patients. This approach is less likely to build versation maps.
a strong pharmacist-patient relationship, but allows for a
greater amount of peer-support among the patients in the Motivational Interviewing
class. One of the disadvantages of this style of education The concept of motivational interviewing was
is that many patients may feel the inability to discuss their first introduced in the 1990s and is defined as
personal condition in detail within the classroom approach. “a directive, client-centered counseling style
This style of education is typically not reimbursable by for eliciting behavior change by helping clients
most major insurances. However, pharmacies may realize explore and resolve ambivalence.” This style

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of patient counseling is goal-directed, allowing tient is sharing, the pharmacist is able to pinpoint sources
patients to educate the pharmacist about their of discouragement and encourage patients to expand upon
goals while allowing the pharmacist to give what has not worked for them in the past. It is vital to show
advice. Motivational interviewing is centered patients that you are listening to their feelings and concerns.
around the acronym FRAMES, which stands By using sentences such as, “What I hear is that you have
for Feedback, Responsibility for change lying failed in managing your diabetes in the past and are weary
with the individual, Advice-giving, providing a to try again,” you are able to share the patient’s emotions
Menu of change options, an Empathic counsel- and ensure that they are being understood.
ing style, and enhancement of Self-efficacy. It is The last tool in the motivational interviewing toolbox
clear to see that using this approach allows the is the use of summaries. Counseling and education can
patient to be in control of the pace and direction be overwhelming to a patient, and using a summary to
of their education. There are a few counseling wrap-up the conversation allows the patient to leave with
tools that are essential to have when using the a few main points to focus on until the next meeting. Upon
motivational interviewing technique including completion of the conversation, the pharmacist should de-
open ended questions, affirmations, reflective cide on three to five of the most important points covered
listening, and the use of summaries. during the meeting and sum them up with the patient. This
Open-ended questions are designed to summary can be presented verbally, but it may be more
encourage patients to educate the pharmacist beneficial for patients to have their goals in written form.
of their knowledge about their disease state and This will give the patient a visual list of a few important
medications. The goal is to ask questions that things to use as goals until the next meeting. By focusing in
will persuade the patient to answer with state- on just a few goals, the patient will not leave overwhelmed
ments beyond “yes” and “no.” Examples in- and has a better chance of returning to the next meeting
clude, “What brings you here today?” and “What successful and able to tackle new challenges.
have your doctors told you about your condi- The goal of motivational interviewing is patient-guided
tion?” This type of conversation encourages the forward movement in understanding their condition and
patient to be the speaker and the pharmacist to beginning to manage it on their own. By using the few tools
be the listener. These questions allow patients to mentioned, pharmacists will create a relationship of trust
reveal their goals to the pharmacist when they with their patient, which will lead to open and goal-oriented
are comfortable and lead their own education. counseling and education. This method of education is
The forward movement is guided by the patient most beneficial in one-on-one, individual sessions that can
and allows the pharmacist to see what is most be led by one patient.
important from the patient’s perspective.
Affirmations are statements that confirm a The Empowerment Model
patient’s strengths. These affirmations are impor- Another effective method of patient education is the
tant because patients are often embarrassed by empowerment model. The idea behind this style of patient
their condition and believe that they are not able interaction is that “the individual is not blamed for his or
to change on their own. By using statements of her problems but is responsible for generating a solution.”
affirmation the pharmacist builds patients up on The empowerment model is very useful in the health care
their own strengths. This allows the patient and setting because patients are not to be blamed for their
the pharmacist to develop a plan that uses the condition or disease. This method allows a single patient
patient’s personal strengths as a focus, which or group of patients to be empowered to make their own
leads to more patient-driven success. choices. Much like motivational interviewing, patients are in
Reflective listening is the cornerstone of the control of the goals of their disease management and are
motivational interviewing method. The most im- responsible for applying these goals in their everyday life.
portant aspect of any conversation is active listen- The empowerment model is ideal for use in a self-manage-
ing. By repeating and reflecting upon what the pa- ment program such as diabetes education. It is centered

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on patient involvement, and encourages patients to ask tional Center for Disease Prevention and Health
questions to further empower them to manage their own Promotion revealed that 23.6 million people liv-
condition. Similar to motivational interviewing, the empow- ing in the United States have diabetes. Pharma-
erment model is based in active decision making by the cists are playing a key role in assisting patients
patient. This method of patient education could be applied living with diabetes by offering the following:
effectively in either an individual or group setting. • Medications
• Disease/medication education
Conversation Maps • Durable medical equipment
Lastly, a pharmacist can use the aid of conversation maps • Over the counter (OTC) supplies
to educate their patients with diabetes about their condition. • Insulin pump training and supplies
Conversation maps are supplied in a variety of shapes and • Medication therapy management (MTM)
sizes and cover many different topics related to health condi- • Weight management
tions, specifically diabetes. These colorful, interactive maps • Cholesterol management
are used to introduce facts and tips relevant to the patient’s • Immunizations
disease state that inspire conversation. Conversation maps
actively engage small groups of patients in conversations, As the health care system continues to evolve,
with the goal of creating strategies for disease management. the role of the pharmacist is evolving as well.
As the group of patients begin the conversation, the map Pharmacists are acting as health coaches and
encourages discussion among them centered on a specific partnering with their patients to improve their
topic, such as education about the disease state, signs and health in each of the above-listed roles.
symptoms, and medications. As the group journeys along
the conversation map, they encounter some discussions that Medications
are led by question and answer cards, which are usually pro- The traditional backbone of pharmacy practice,
vided. The tabletop display promotes peer support within the dispensing medications, remains the primary
group, which is a key difference between conversation maps role of the pharmacist. Care should be taken,
and motivational interviewing or the empowerment model. however, in this arena to ensure that pharmacists
The conversation map supports a discussion between pa- are maximizing their influence and knowledge
tients, guided by the occasional aid of a pharmacist, whereas with the patient. For example, pharmacists
motivational interviewing and the empowerment model use should monitor their patients’ adherence, offering
the pharmacist in a more verbal role. For this reason, the encouragement, a healthy accountability, and
conversation map is best used in a small-group setting. If a consider reporting their findings to the physician.
larger patient population is being approached, dividing the Pharmacists should also take an active role in
larger group into small groups, each having different conver- counseling their patients on their medications,
sation maps, is an effective way to utilize this useful tool. especially at the time of first fill. One tool to be
There are a variety of different environments for patient considered is a Medication Reconciliation Form,
education and many theories that can be employed to help which is a written document describing each
a pharmacist counsel his or her patients. The most impor- medication a patient takes. This form is typi-
tant thing to take into consideration when beginning to plan cally designed to be used at physician visits and
for a diabetes education program is the patient population. should be utilized when ordering refills.
Population size, disease severity, patient personalities,
and desired growth in the pharmacy are all factors to be Disease/Medication Education
thought out when designing a program. Pharmacists are highly trained and excel in
disease management. From one-on-one consul-
The Business of Attracting tations to large group presentations, pharmacists
a Diabetes Patient across the country are developing diabetes edu-
In the latest edition of Diabetes at a Glance 2010, the Na- cation programs designed to empower persons

42 america’s Pharmacist | February 2011 www.americaspharmacist.net

 Table 1. Pharmacies may receive recognition third parties. Offering an intensive program without charg-
of their diabetes self-management educational
ing for the services is typically cost prohibitive, due to the
programs from one of the following sources:
time the pharmacist must spend away from the usual du-
■w
 ww.diabetes.org ties of filling prescriptions. However, once the pharmacy
American Diabetes Association (ADA) is able to bill insurances (or is able to charge the patient
■ www.diabeteseducator.org directly for educational services), the pharmacy should
American Association of Diabetes Educators (AADE) see a positive cash flow quickly due to direct reimburse-
■ www.ihs.gov ment of the service. Alternatively, pharmacies that offer
Indian Health Service (IHS) once-monthly classes in the large group setting are also
maximizing their time by attracting a larger gathering at
living with diabetes with the proper knowledge one time. Classes should last approximately one hour,
needed for adequate control. Many pharma- which maximizes both the pharmacist’s and the patients’
cists have also decided to take the next step in time. These classes may be offered at no charge be-
disease education and are able to bill third party cause new patients will be attracted to the class and may
insurances including Medicare, for their efforts. decide to begin using the pharmacy for their health care
In order to bill for the educational services, most needs. With the time commitment for each pharmacist
insurances require recognition for their diabetes being approximately one hour per month, the pharmacist
self-management education program through is able to offer an innovative program that sets him or her
one of three governing bodies (see Table 1). apart from the competition without adding staff or other
To be recognized by one of the above significant costs.
sources for diabetes self-management educa-
tion, pharmacists must prepare for an application Durable Medical Equipment
process that demonstrates their program meets Pharmacists can provide durable medical equipment
the required standards, such as proper docu- (DME) services to diabetes patients to improve mobility
mentation and positive outcomes, just to name and activities of daily living (ADL), just to name a few. DME
a few. Pharmacists desiring more information services may include, but are not limited to, the following:
about attaining recognition from one of the above
sources should visit their respective websites or Table 2
contact the organization directly. Diabetes footwear (therapeutic shoes)
Pharmacists may also decide to utilize their Walkers/wheelchairs/mobility products
knowledge of diabetes to attract new diabetes Diabetes testing supplies
patients to their store. For example, many have
created large group monthly diabetes education Diabetes Footwear (Therapeutic Shoes)
classes, often offered at no charge, in order to The addition of diabetes footwear to the pharmacy offer-
set themselves apart from their competition. By ing is extremely beneficial both to the patient as well as
offering classes, the pharmacist is able to share to the pharmacy’s bottom line. Diabetes footwear can
key insights into living with diabetes to an audi- reduce the amount of foot-related wounds due to poor
ence that may not currently use their particular fitting shoes, as well as improve foot support. With proper
pharmacy. In return, the pharmacist also attracts training, therapeutic shoe fittings are a service that phar-
a diabetes patient that has an above average macists can use to attract a greater number of diabetes
pharmacy spend each year. patients as well. The advantages of offering a therapeutic
The cost of creating in-store or nearby dia- shoe niche include:
betes educational classes is typically minimal. • Above-average direct revenue generation (for sales of
Pharmacies that offer one-on-one and small therapeutic shoes and supportive inserts)
group classes should aim to attain recognition • Increased number of patients living with diabetes visiting
for diabetes self-management in order to bill the pharmacy

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• Increase in transferred prescriptions of diabetes patients • Sinus relief medications that do not raise blood
to the pharmacy (due to attracting new diabetes patients pressure/blood sugar
to the pharmacy) • Creams and lotions designed for the diabetes
• Increased ancillary sales (due to increased traffic inside patient
the pharmacy • Heart-healthy OTC products, such as aspirin
and fish oil
Pharmacists have the opportunity to quickly grow their • Diabetes meters and supplies
base of diabetes patients by adding this valuable service.
The pharmacist should also be eager to an-
Walkers/Wheelchairs, other DME Products swer questions from customers browsing in the
By attracting diabetes patients to the pharmacy, pharma- diabetes OTC section of the store. In doing so,
cists can also expect to see an increase in their DME sales. the pharmacist will solidify his place in the com-
From walkers and other mobility products to bathroom munity as a resource for diabetes knowledge,
safety products, pharmacists should offer DME services education, and supplies.
whenever possible.
Insulin Pump Training and Supplies
Diabetes Testing Supplies Pharmacists with extensive diabetes expertise
One of the keys to controlling diabetes is through test- may also consider offering insulin pump train-
ing blood sugar. In doing so, the patient is able to identify ing, support, and supplies. This service, which
hyper- and hypoglycemic events, determine which foods af- has recently emerged as a growing niche mar-
fect their blood sugar, and allow the patient to make adjust- ket for pharmacists in the community setting,
ments to their lifestyle with an informed decision. Diabetes offers a myriad of benefits for both the patient
testing supplies should be offered in any pharmacy when- and the pharmacy.
ever feasible. Pharmacists, in particular, should assume According to the American Diabetes Asso-
the responsibility of counseling their patients on the proper ciation, the benefits of insulin pumps include:
use of testing supplies and assist them, when necessary, in • Fewer daily injections
choosing the best meter for their lifestyle. Pharmacists who • Allows patients to adjust their insulin therapy to
do not offer diabetes testing supplies risk losing their pa- fit more closely with their personal lifestyle
tients to other pharmacies that offer such services. Commu- • Delivers insulin more accurately than injections
nity pharmacies should also take an active role in ensuring • May improve A1C
that patients receive their supplies from their local pharmacy • Usually results in fewer large swings in blood
and refrain from using mail order pharmacies. glucose levels
• Allows patients to be flexible about when and
OTC Supplies what they eat
Diabetes-related OTC sales were projected to reach $3.4 • May improve the patient’s quality of life
billion in 2010. This need represents an incredible oppor- • Usually improves large swings in blood sugar
tunity for pharmacists to provide a valuable service that levels
benefits both the pharmacist and the patient. Pharmacies • Eliminates unpredictable effects of intermedi-
should consider creative ways to demystify diabetes-related ate- or long-acting insulin
products and assist patients in choosing OTC items that are • Usually simplifies diabetes management
the most beneficial to persons living with diabetes. One cre-
ative idea many pharmacies utilize, for example, is to create There are several ways independent pharmacists
a diabetes-specific section in the store. Located within the can assist patients with insulin pumps.
diabetes section are OTC items specific to diabetes care
and are beneficial to healthy living. Such items may include: Pharmacists can initiate pump therapy
• Sugar-free cough preparations Before pharmacists initiate pump therapy with a

44 america’s Pharmacist | February 2011 www.americaspharmacist.net

patient, they should attain the proper credentials Medication Therapy Management
and be educated on intensive diabetes manage- One of the greatest advances in pharmacy practice over
ment using insulin pump systems. While insulin the past decade has been medication therapy man-
pump therapy can improve control of diabetes, agement (MTM). Through intensive reviews of patient
there is also a risk of harming a patient if the records, pharmacists are able to improve outcomes,
patient uses the pump incorrectly. reduce poor outcomes associated with medication-
Once a pharmacist attains the proper educa- related issues (such as drug interactions), and maximize
tion for initiating insulin pump therapy, he will communication between all health care providers through
also need to be certified by each manufacturer of feedback mechanisms. Diabetes patients, in particular,
insulin pump devices he wishes to use. This cer- should be offered MTM services whenever possible.
tification will allow them to initiate pump therapy This is not only due to the increased number of prescrip-
with that particular insulin pump device. tions seen with a diabetes patient (a diabetes patient fills
Overall, initiating pump therapy can also be a approximately 44 prescriptions per year on average),
great alternative revenue stream for the pharma- but also because of the depth of education needed for
cy. Pharmacists who offer this service are usually adequate control.
paid for pre-pump training (such as carbohydrate During an MTM session with a diabetes patient, phar-
counting classes) along with time spent educat- macists should use their clinical skills and knowledge to
ing the patient on the use of the pump. improve patient care and efficient medication delivery.

Pharmacists can offer post-pump training classes Weight Management

Patients who begin using an insulin pump device Pharmacists have also begun partnering with their cus-
usually benefit from additional training after they tomers, including type 2 diabetes patients, to lose weight.
have had the opportunity to use the device for a Diabetes patients who lose weight realize several benefits,
specified amount of time. Pharmacists can pro- including:
vide small group post-pump training classes as • Improved insulin resistance
well to assist these patients. The manufacturers • Lower insulin need
of insulin pump devices may also cover the cost • Improved blood pressure (if elevated)
of these classes. • Improved blood glucose levels

Pharmacists can offer supplies Pharmacists choosing to offer weight loss programs will
to insulin pump patients undoubtedly attract diabetes patients to their pharmacy
For pharmacists who do not wish to offer inten- practice. Such programs may include diet and exercise
sive training on insulin pump devices (and for plans, and should also include an accountability por-
pharmacists who wish to offer both training and tion to ensure success in meeting self-defined health
supplies), supplies such as infusion set tubing goals. There are several plans that pharmacists may
can provide a niche market to the pharmacy, adopt as a weight loss program. However, careful atten-
thus preventing the patient from using a large tion should be given to any weight loss plan to ensure
mail order company for services. Patients healthy weight reduction. Also, many plans educate their
looking for insulin pump supplies may drive patients to minimize carbohydrate intake, which may
long distances due to the fact that few phar- alter insulin or other medications needed for diabetes
macies and DME companies offer the needed management.
supplies. Once again, however, pharmacies Pharmacists who enter into a weight reduction niche
that offer insulin pump supplies also have an market should also consider using other health care disci-
opportunity to gain the customer pharmacy plines, such as registered dieticians, as resources and in
patient as well. design of the program. In doing so, patients will realize the
benefits of each discipline.

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Cholesterol and Hypertension Management cators (AADE) poorly controlled diabetes is the
Diabetes carries a number of co-morbidities along with it. leading cause of adult blindness, end-stage renal
In fact, approximately two out of three adults living with dia- disease, and non-traumatic lower-limb amputa-
betes also have hypertension. As a result, many pharma- tions in the United States. It also doubles the risk
cies are addressing this need by offering cholesterol and of stroke and heart disease. Taking these facts
hypertension education and management. into consideration, it is important that care of the
diabetes patient involves an entire health care
Screening team to assist in prevention and treatment. The
One of the greatest ways to offer cholesterol and hyper- diabetes health care team may include, but is not
tension management is to educate patients by using their limited to:
own personal cholesterol and blood pressure values. Many • Primary care physician
pharmacies offer cholesterol screenings inside the store, • Pharmacist
either by performing the test themselves (after obtain- • Diabetes educator
ing a CLIA waiver) or by contracting with another entity to • Endocrinologist
perform the screening. Once the results are known, the • Nephrologist
pharmacist can then educate the patient on lifestyle modifi- • Podiatrist
cations as well as proper medication adherence to encour- • Psychologist
age patients to reach their physician-driven health goals. • Dietician
Barriers to cholesterol screenings typically involve cost. • Ophthalmologist
Each pharmacy should also check its state regulations to • Dentist
ensure they have proper clearance to perform the service.
Blood pressure screenings are typically easier to per- Many diabetes patients suffer from co-morbid
form and are usually minimal in overall cost. Consider using conditions, including nephropathy, neuropathy,
a pharmacy student, nurse, or other health care provider heart disease, eye complications, complica-
to offer the service and maximize your time. Pharmacists tions with the skin or other infections, oral health
should refer patients to their doctor if a high reading occurs. problems, and even mental health imbalances.
In many situations, pharmacists are the most ac-
Patient Education cessible members of a patient’s health care team.
Pharmacists should also consider offering large group edu- This creates a setting that allows a pharmacist
cational programs based on cardiovascular risk reduction, to see a clear picture of the different health care
which also serves to aid the patient in learning key insights providers a patient may be visiting and ensure
into lifestyle modification. Again, pharmacists who perform that each patient with diabetes is being seen by a
a large group educational program will maximize their time collaborative group of health care practitioners to
while offering education beyond simple flyers or booklets. manage each of the possible complications seen
in most patients with diabetes.
Immunizations
Diabetes patients are also in need of vaccinations and are Primary Care Physician
considered by the CDC as high risk. Pharmacists have In addition to the patient themselves, the pri-
played a key role in immunizing the general population, mary care physician, who is most commonly in
including diabetes patients, with influenza, pneumococcal, a family practice or an internal medicine physi-
and other immunizations. Pharmacists should offer immuni- cian, is the head of the health care team. The
zations at their locations if feasible. primary care physician directs each of the other
members of the team and ensures the diabe-
An Interdisciplinary Health Care tes patient has the proper support for optimum
Approach to Diabetes Management care. Special care is always taken to also ensure
According to the American Association of Diabetes Edu- that the patient’s other co-morbid conditions are

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treated appropriately. One of the most common pertension. The ADA and National Institutes of Health (NIH)
co-morbid conditions treated in the diabetes recommend a blood pressure of less than 130/80 mmHg
patient is heart disease. for all patients with diabetes.
C — C stands for cholesterol. A complete lipid panel
Pharmacist or profile run by the patient’s primary care physician will in-
The role of the pharmacist in the diabetes health clude low-density lipoprotein (LDL), high-density lipoprotein
care team has grown quickly over the past (HDL) cholesterol, total cholesterol, and triglycerides. All
decade. In addition to the usual dispensing of four of these values are important for a patient with diabe-
medications, community pharmacists now offer tes to understand and follow.
diabetes self-management education programs.
From intensive educational programs to in-depth Not only can a pharmacist educate a patient about the
drug utilization reviews (DURs), pharmacists play medications used to control the ABCs of heart disease,
a key role in the diabetes health care team. but the pharmacist can also play a vital role in conjunction
One of the greatest interventions pharma- with the patient’s primary care physician to encourage diet,
cists can make for the diabetes patient is in the exercise, and lifestyle changes to better control blood glu-
area of heart disease. The Centers for Disease cose, blood pressure and cholesterol. A pharmacist should
Control and Prevention (CDC) reported in 2004 encourage patients to communicate with their primary care
that heart disease was noted on 68 percent of physician to know their numbers and better manage their
diabetes-related death certificates among pa- risk for heart disease and stroke.
tients age 65 and older. Stroke was noted on 16
percent of diabetes-related death certificates in Diabetes Educator
the same year. With such high numbers, it is easy The diabetes educator role may vary depending on the set-
to see how important heart health is for a patient ting and available health care staff. This critical piece of the
with diabetes. Not only can pharmacists play a health care team, which is typically a nurse, nurse practitio-
vital role in heart healthy education, but it is also ner, pharmacist, or dietician, explains the process of living
very important to ensure that every diabetes pa- with diabetes. The diabetes educator may also utilize other
tient is being seen regularly by their primary care members of the team to explain different portions of the
physician to screen for signs of heart disease. curriculum. For example, the diabetes educator may ask
Many diabetes educators teach their pa- the pharmacist to educate patients on medications while
tients to know the ABCs of heart disease, which the dietician teaches the basics of carbohydrate counting.
can help them remember three important num-
bers to keep track of when visiting their primary Endocrinologist
care provider. By keeping the ABCs controlled, Endocrinologists are also a key part of the diabetes health
patients can help to lower their risk of heart care team. From implementing intensive insulin therapy to
disease and stroke. improving glycemic control, endocrinologists provide criti-
A — The A in ABCs of heart disease stands cal insights and direction for the diabetes patient.
for A1C. A patient’s A1C reflects their aver-
age blood glucose reading over the past three Nephrologist
months. According to the American Diabetes As- Hyperglycemia and hypertension can lead to kidney dam-
sociation (ADA), a reading lower than 7 percent age. Many of the symptoms of renal failure are not specific
should be the goal for all diabetes patients. An and hard to diagnose. For this reason, it is important to
A1C can be checked by a pharmacist, but should support a patient’s health care provider in regularly testing
also be checked at least twice a year by the for microalbuminuria, hypertension, and hyperglycemia.
primary care physician. Along with medications such as ACE inhibitors, which have
B — B is for blood pressure. An estimated been shown to protect the kidneys, regular testing for signs
two out of three adults with diabetes also has hy- of nephropathy can aid in prevention.

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 Despite efforts of prevention, many diabetes patients causes 12,000 to 24,000 new cases of blindness
will progress to worsening kidney disease. In 2005, dia- each year. However, an ophthalmologist can treat
betes was the leading cause of kidney failure, accounting all three of the aforementioned complications and
for 44 percent of newly diagnosed cases. When diabetes prevent blindness. All diabetes patients should
nephropathy is diagnosed, it is important to add a nephrol- schedule a dilated eye exam with an ophthalmol-
ogist to a patient’s health care team. ogist at least once a year to check for any signs
of retinopathy.
Podiatrist
Hyperglycemia can cause blood vessel injury and eventu- Dentist
ally lead to nerve damage. About 60 percent to 70 percent Emerging research suggests that diabetes and
of people with diabetes have some form of nervous sys- periodontitis, a gum disease, go hand-in-hand.
tem damage, with the majority reporting impaired sensa- Diabetes can put patients at risk for having
tion of the feet. Decreased sensation in the feet can lead periodontitis, and at the same time, poor oral
to unrecognized injuries, which can progress into infection hygiene can lead to poor blood glucose control.
and possibly the need for amputation. In fact, according to In a recent CDC report, it was found that patients
the CDC, more than 60 percent of non-traumatic lower- with an A1C greater than 9 percent were nearly
limb amputations occur in patients with diabetes. This three times more likely to have severe periodon-
can be prevented. Pharmacists can promote good foot titis than those without diabetes. For this reason,
care and assist patients in purchasing specialty diabetes it is imperative to recommend that all patients
shoes, but it is also very important to encourage an annual with diabetes schedule a check-up with a dentist
visit to the podiatrist to perform a monofilament foot exam. every six months.

Psychologist Conclusions
Persons with diabetes are also at a higher risk of develop- Pharmacists play a key role in improving patient
ing symptoms of depression. Psychologists assist in this outcomes in the diabetes patient. Through diabe-
condition by working through barriers, preconceived no- tes education, pharmacists empower the pa-
tions, and fears. Psychologists on the diabetes health care tient to utilize lifestyle modifications, medication
team should be familiar with the usual needs of the diabe- management, and other techniques to improve
tes patient to properly relate to the patient. diabetes control. Pharmacists should ensure
maximum learning during appointments by using
Dietician communication techniques such as motivational
One of the primary ways to attain proper glycemic control is interviewing. Pharmacists also play a key role in
to eat properly and learn which foods affect blood sugar val- the diabetes health care team. With the patient at
ues. Dieticians should be involved in every diabetes health the helm, each member of the team is vital to im-
care team and should also be strongly considered when proving glycemic control as well as outcomes. By
developing a diabetes self-management education program. offering different forms of diabetes education as
Dieticians also develop individualized meal plans based on well as ancillary products needed by persons liv-
total caloric need, co-morbid conditions (such as kidney ing with diabetes, pharmacists can also improve
failure), and the need for weight loss, just to name a few. the bottom line of their pharmacy.

Ophthalmologist
Diabetes can cause many different complications of the eye David Pope, PharmD, CDE, is director of the Diabetes and
including glaucoma, cataracts, and retinopathy, which can Wellness Center for Barney’s Pharmacy in Augusta, Ga.,
all lead to a degree of blindness. Many patients with diabe- and editor-in-chief of CreativePharmacist.com. Cara Jones
tes are justly concerned about the risk of blindness associ- is a 2011 PharmD candidate at the South Carolina College
ated with their disease seeing as diabetic retinopathy alone of Pharmacy, Medical University of South Carolina.

48 america’s Pharmacist | February 2011 www.americaspharmacist.net

Continuing Education Quiz 5. In the latest edition of Diabetes at a Glance 2010, the
Select the correct answer. National Center for Disease Prevention and Health Promo-
tion revealed that ____________ people living in the United
1. You are finishing a diabetes education ses- States have diabetes.
sion with a newly diagnosed patient. What would a. 10 million
be the most effective method to summarize the b. 15.5 million
session? c. 23.6 million
a. End the discussion with one very important d. 50 million
take-home point or goal.
b. Pre-print a list of 10 goals that every patient with 6. People with diagnosed diabetes also have medical ex-
diabetes should be focusing on all the time. penditures that are about ___________higher than medical
c. Re-emphasize three to five important points expenditures for people without diabetes.
covered during the session for the patient(s) to a. 2 times
use as goals until the next meeting. Encourage b. 2.3 times
them to write them down. c. 4.5 times
d. Do not summarize the session with your d. 5.1 times
patients. This will only make them feel over-
whelmed. 7. The benefits of holding an educational class on a regular
basis include:
2. An example of a beneficial open-ended ques- a. Increasing the number of new patients filling prescrip-
tion is: tions at the pharmacy
a. “Do you understand what diabetes is?” b. Setting the pharmacy apart from the competition by of-
b. “What do you do when you feel that your blood fering programs for persons living with diabetes
sugar is low?” c. Increasing OTC sales through increased foot traffic
c. “Have you felt any signs or symptoms of hypo- inside the store
glycemia this week?” d. All of the above
d. “Has anyone in your family ever been diag-
nosed with diabetes?” 8. According to the American Association of Diabetes
Educators (AADE), poorly controlled diabetes is the leading
3. Pharmacists and other health entities may cause of:
receive recognition for diabetes self-management a. Adult blindness
education through: b. End-stage renal disease
a. American Diabetes Association c. Non-traumatic lower-limb amputations
b. American Association of Diabetes Educators d. All of the above
(AADE)
c. Indian Health Service (IHS) 9. In a recent CDC report, it was found that patients with an
d. All of the above A1C greater than 9 percent were nearly _________more like-
ly to have severe periodontitis than those without diabetes.
4 The benefits of insulin pump therapy include: a. Two times
a. Increased A1C values b. Three times
b. Increased weight loss c. Four times
c. Fewer daily injections d. Five times
d. Fewer blood sugar checks per day

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10. Pharmacists should help promote good foot care in c. The use of summaries at the end of the inter-
diabetes patients by: view process with at least 10 to 15 main points
a. Offering to cut toenails used for a closing and the use of non-reflective
b. O
 ffering foot spas to patients while waiting for listening.
prescriptions d. The use of reflective listening during the
c. O
 ffering diabetic footwear interview process and the use of summaries
d. None of the above with five main points at the end of the interview
process.
11. What is the goal of motivational interviewing in diabetes
education? 14.Choose the best example of the empower-
a. F
 or pharmacists to use motivational interviewing in their ment model?
diabetes educational programs to teach their patients a. This style of patient interaction is that “the
how they can set goals for themselves and help them individual is given a guideline of goals and
meet their self-defined goals the pharmacist uses daily calls or e-mails to
b. F
 or pharmacists to plan out their own goals for each of empower the patient and keep them on track
their patients and have them follow the goals they have with their goals.
set for them to achieve. b. This style of patient interaction is that “the
c. F
 or pharmacists to use motivational interviewing as a individual is placed in a group of diabetics with
patient-guided forward movement in understanding their similar health problems and through group
condition and beginning to manage it on their own. encouragement the patient is empowered to
d. T
 o cheer patients on to better health by giving them take on their own health goals.”
a written teaching plan of preset goals for the patient c. This style of patient interaction is that “the indi-
to meet. vidual is given some motivational empowering
books to read about how to take back their
12. What might be one downfall of individual patient educa- health outcomes by using friends and family to
tion? help them meet their goals.”
a. T
 he store would attract new customers by offering this d. This style of patient interaction is that “the
individual teaching service. individual is not blamed for his or her problems
b. T
 he pharmacist is away from the prescription counter but is responsible for generating a solution.”
and will need another pharmacist to cover prescription-
filling duties. 15. What is the key difference between conversa-
c. T
 he likelihood exists that the store would increase the tion maps and the use of motivational interview-
number of prescriptions after offering individual teaching ing or the empowerment model?
services. a. Conversation maps are best used one on one
d. T
 he store would scare off new patients by offering an where as the motivational interviewing is best
individual teaching service. used in a group setting.
b. The conversation map supports a discussion
13. Which is NOT an example of motivational interviewing? between patients, guided by the occasional
a. Using the acronym “FRAMES” which stands for Feed- aid of a pharmacist and mainly the use of peer
back, Responsibility for change lying with the individual, support for affirmation and guidance.
Advice-giving, providing a Menu of change options, an c. The empowerment model is different mainly
Empathic counseling style, and enhancement of Self- because the group comes up with a solution
efficacy. for every diabetes patient attending the class,
b. T
 he use of open-ended questions during the interviewing and the conversation map is used best just
process and the use of affirmations during your conver- between the pharmacist and the patient.
sation with the patient and the interview process. d. The motivational interviewing process involves

50 america’s Pharmacist | February 2011 www.americaspharmacist.net

 Opportunities in Diabetes
all diabetes patients in a class to affirm each Education for Pharmacists
other for support and guidance whereas the Feb. 1, 2011 (expires Feb. 1, 2014) • Activity Type: Knowledge-based
conversation map is used as a tool for the indi-
FREE ONLINE C.E. Pharmacists now have online access to NCPA’s
vidual diabetes patient to review on their own. C.E. programs through Powered by CECity. By taking this test online—
go to the Continuing Education section of the NCPA Web site (www.
ncpanet.org) by clicking on “Professional Development” under the
16. Which is not an advantage of attracting a Education heading you will receive immediate online test results and
diabetes patient to an independent pharmacy certificates of completion at no charge.
through innovative educational teaching?
To earn continuing education credit: ACPE Program 207-000-11-002-H04-P
a. The pharmacist is more likely to increase foot
A score of 70 percent is required to successfully complete the C.E. quiz.
traffic into the store. If a passing score is not achieved, one free reexamination is permitted.
b. The pharmacy typically increases its prescrip- Statements of credit for mail-in exams will be available online for you
tion volume to print out approximately three weeks after the date of the program
(transcript Web site: www.cecerts.ORG). If you do not have access to a
c. The pharmacy typically increases its OTC
computer, check this box and we will make other arrangements to send
product sales and other ancillary supplies. you a statement of credit: q
d. The pharmacy decreases its prescription volume
Record your quiz answers and the following information on this form.
q NCPA Member License

17. Advantages of having a pharmacist on the NCPA Member No. ____________________ State __________ No. _____________________
q Nonmember State __________ No. _____________________
diabetes health care team include:
All fields below are required. Mail this form and $7 for manual processing to:
a. Having a medication expert available for con- NCPA C.E. Processing Ctr.; 405 Glenn Drive, Suite 4; Sterling, VA. 20164
sultation for prescribers _____________________________________________________________________________________
Last 4 digits of SSN MM-DD of birth
b. Having a very accessible member of the health _____________________________________________________________________________________
care team available for the diabetes patient Name
_____________________________________________________________________________________
c. Having a member of the health care team Pharmacy name
_____________________________________________________________________________________
available for educational consultations Address
_____________________________________________________________________________________
d. All of the above City State ZIP
_____________________________________________________________________________________
Phone number (store or home)
18. Diabetes can cause many different complica- _____________________________________________________________________________________
Store e-mail (if avail.) Date quiz taken
tions of the eye including:
Quiz: Shade in your choice
a. Glaucoma a b c d e a b c d e
b. Keratopathy 1. q q q q q 11. q q q q q
c. Episcleritis 2. q q q q q 12. q q q q q
3. q q q q q 13. q q q q q
d. All of the above
4. q q q q q 14. q q q q q
5. q q q q q 15. q q q q q
19. Members of the diabetes health care team 6. q q q q q 16. q q q q q
may include, but are not limited to: 7. q q q q q 17. q q q q q
8. q q q q q 18. q q q q q
a. Dietician 9. q q q q q 19. q q q q q
b. Pharmacist 10. q q q q q 20. q q q q q
c. Family practice physician
d. All of the above Quiz: Circle your choice
21. Is this program used to meet your mandatory C.E. requirements?
a. yes b. no
20. An estimated _________________ adults 22. Type of pharmacist: a. owner b. manager c. employee
living with diabetes have hypertension.  ge group: a. 21–30 b. 31–40 c. 41–50 d. 51–60 e. Over 60
23. A
a. One out of five  id this article achieve its stated objectives? a. yes b. no
24. D
b. Two out of three 25. H
 ow much of this program can you apply in practice?
a. all b. some c. very little d. none
c. Three out of four
How long did it take you to complete both the reading and the quiz? ______ minutes
d. One out of four

NCPA® is accredited by the Accreditation Council for Pharmacy Education as a provider

of continuing pharmacy education. NCPA has assigned 1.5 contact hours (0.15 CEU)
www.americaspharmacist.net of continuing education credit to this article. Eligibility to receive continuing education
credit for this article expires three years from the month published.