On this episode of The Huddle we talk to Mary Lou Perry, who brings more than 30 years of experience in the area of diabetes nutrition clinical practice and was appointed to the ADA Professional Practice Committee last March. Mary Lou shares how others can be a part of the committee, a few key highlights from the 2023 ADA Standards of Care, and examples of how the updated standards can be applied in practice.
Resources:
To read the full 2023 Standards of Care, visit: https://diabetesjournals.org/care/issue/46/Supplement_1
To watch an ADCES webinar that dives a bit deeper into the Standards of Care, visit: http://send.adces.org/link.cfm?r=5gLLYpGIeV6Y9dpuQo-W2A~~&pe=IajtqA5LETl6XmGrk0YTISnsQijzMKrfWkc79cPqpTRNp3eEShKQUAVzFBrLt-EYJga4sPUlv60Ad-aq--2vbw~~&t=VmwSIkiOmBxB5rwPQvGKrw~~
To apply to be a part of an ADA committee, visit: https://diabetes.org/about-us/who-we-are/applications/national-committees-call-applications
For ADA public comment, visit: professional.diabetes.org/SOC
sacha_uelmen:
Hello and welcome to ADCES's podcast, "The Huddle: Conversations with the Diabetes Care Team." In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues, and updates that elevate your role, inform your practice, and ignite your passion. I'm Sasha Uelmen, the Director of Diabetes Education and Prevention Programs at the Association of Diabetes Care and Education Specialists.
Today we're joined by Mary Lou Perry, who brings more than 30 years of experience in the area of diabetes, nutrition, clinical practice, and holds memberships in ADA, ADCES, and the Academy of Nutrition and Dietetics. She has served on the item writing and item review committee of the credentialing arm of CDCES and is active in the Academy of Nutrition and Dietetics Diabetes Practice Group, serves on the editorial board of Diabetes Spectrum, and last March was appointed to the ADA Professional Practice Committee.
Welcome, Mary Lou. It’s so great to have you with us on The Huddle.
mary_lou_perry:
It's a pleasure to be here. Thanks, Sasha.
sacha_uelmen:
Thank you. Can you listeners a little more about you and your work in diabetes care and education?
mary_lou_perry:
Sure. I work in an outpatient university health care system in collaborative diabetes cardiovascular clinic, and our UVA diabetes care and education ADA program is elsewhere. Our clinic manages individuals with diabetes and heart disease, or either sub-clinical heart disease or heart disease together, so management, education, and support are provided by our interprofessional team. We've been practicing collaboratively for almost twenty years, even before we had cardiorenal protective glucose flowing agents.
sacha_uelmen:
Oh, wow. What a unique clinic to work in. How fun.
sacha_uelmen:
How did you come to be part of the P. P. C.?
mary_lou_perry:
You know, as with everything, it begins with an invitation and encouragement from a colleague. So a colleague encouraged me to apply, and because of my clinical work in cardiovascular disease and expertise in weight management, she thought I'd be a good fit. So, I went online, looked at the application, and completed it.
You had to write a letter of intent and send that in and then just waited. I had no idea or really any expectations that I would be part of it, but again, I just felt like if you don't enter, you can’t win. So, I decided to put my hat in the ring, and voila here I am eight months later, I'm still going strong.
sacha_uelmen:
Alright. Well, tell me a little bit about the makeup of the committee. Who else is on that committee?
mary_lou_perry:
Yeah. The standards of care have about seventeen sections, so there are experts in all of these areas within the section and there are currently about sixteen physician members and about six non-physician members, and then again, some invited content experts from various fields, which include ophthalmology, neurology, mental health, advocacy and fatty liver disease. Additionally, there are some non-physician providers as well. So there's a nurse practitioner. There's a pharmacist. There's an RDN, physician's assistant, and myself.
sacha_uelmen:
Excellent. Tell me a little bit more about the process of updating the standards of care and how volunteers are involved.
mary_lou_perry:
Yeah, and this was something that I just started to become part of. I know that this is a two-year commitment when you serve on the professional practice committee. And so there's a lot of work involved and I think I was surprised about the amount of work. It wasn't bad, but undertaking that was pretty big for a dietician, and this was something I'd never done before, so I'd never really had any practice in serving on this type of committee. But as with anything, you go along and you kind of learn it as you go along, and so within those seventeen sections, the chair of the committee appoints various kind of leads and co-leads within each of those sections. And so the leads and the co-leads meet and essentially write the sections together. But before we do that, we look at the previous year, look at the literature, and scan the literature and see if anything else anything has come up in the last year that would warrant a change in the recommendation, or would warrant a change in some of the narrative. So sometimes there isn't always a change in the recommendation, but there's new things that might be worth mentioning that also can be part of the section update.
So we spend, oh gosh, a good three or four months just kind of meeting regularly, kind of doing work on our own. And then in July we meet in person as a group, the entire committee to address and to talk about our section updates and discuss them as a large committee. So, I think that really kind of solidifies kind of where we're going with this. And it's such a great opportunity to meet face to face with other people that have been working behind the scenes, so we have this great opportunity to listen to what other members of the committee are saying and how they are updating their section.
And we're also look for consistency in language and consistency in tone. So that's very helpful to meet as a group.
sacha_uelmen:
Oh yeah. Let's get into the meat of the issue. What are some of the new recommendations this year in the standards of care?
mary_lou_perry:
Well, I think people are always asking that question: “so, what's new?” And I would say there are over a hundred new recommendations, and I won't go through all of them, but to give you a sense of kind of where this whole process has gone, the standards were first started to be developed in 1989. And if you go back and look at diabetes care in 1989 and actually count the pages and the standards of care, you'll find four pages in the standards of care, and there were ten citations.
sacha_uelmen:
Oh, wow!
mary_lou_perry:
And as an example, the section on children and adolescence was one sentence. So kind of fast forward now if you look in the standards of care in diabetes care 2023, there is almost 300 pages of text there. over 2,000-in fact there’s 2,976 citations. A far cry from those ten citations that were originally part of the 1989 standards of practice. And that section on children and adolescence has gone from one sentence to 23 pages, so it has gotten a lot larger. And, I wouldn’t say more complicated, but just more comprehensive because we know so much more about diabetes and there's some much more happening in the field of pharmacology, but also just in the field of technology and managing diabetes. So it would make sense that our recommendations are getting broader, longer, and potentially more complicated. But remember we're looking at diabetes across the spectrum. The life span of an individual with diabetes. We’re looking at screening. We're also looking at diagnostic and any therapeutic actions known to favorably affect the health outcomes of people with diabetes.
So, to answer your question: kind of what's changed over the last year? Again, you know, there's a hundred new recommendations and I think as I think about the changes, I think then this is what I've heard from other people too, who’ve not only served on the committee but have read the standards, that there's a real appreciation for the tone in the standards of care, in the language in the standards of care. And we've been very purposeful and intentional about trying to be consistent across the board with language. You know, we don't call it telemedicine. We call it telehealth. And so there are certain kind of words that we're referring to consistently, and obviously certain ways that we phrase language in the field of diabetes care and education. So again, I think the tone is changed, but I also think there's been a lot more involvement and a lot more recognition.
Probably one of the biggest things I think at least for me is to see the social determinants of health mentioned. And not only are they mentioned, they are kind of incorporated throughout the entire standards of care. And kind of within that perspective are this recognition around the disparities in health care, and looking at how we as diabetes care and education specialists can advocate for our patients and work to really for health equity for all people, not just people with diabetes. So there's just kind of push there in the standards of care. And there've been a number of other recommendations, but I think again, it's the tone of language and the social determinants of health that I think have been, have undergone some of the biggest changes—not in terms of words, but really in terms of intention within the standards of care.
sacha_uelmen:
Yeah, that's so important today. And I know you had mentioned when we were talking that you've got some themes that kind of emerge that really helped kind of summarize some of the changes that have occurred this year. Did you want to share a little bit more about those?
mary_lou_perry:
Yeah, and people might see this differently I think, depending on what kind of provider you are. You might look at these standards or see them differently. But as I looked at them, and as a member of the professional practice committee, we did read and look at every standard in every section. And so as I thought about that, there were several themes that emerged and they all start with an S. So that might be at least it was an easy way for me to remember what are some of those overall themes that are
occurring in the standards of care. Again, all of them begin with an S. Obviously, one is the standards, or, is the social determinants of health. The other S is the expanded screening that we see as far as sleep and psychological screening, screening for food insecurity, screening for naffold. Additionally, there are specific lower targets and blood pressure as well as cholesterol lowering and primary and secondary prevention.
Another S is just what I see as a simplified medication selection. As we're looking at individuals with type two diabetes, there’s no longer this kind of complicated care path or algorithm. We’re really asked to look at not only the social determinants of health, and looking at lifestyle being the bedrock of care for people with type two diabetes, but actually looking at: what is it that you're really trying to do? Are you going after cardiometabolic prevention? So the changes really have to do with looking at the medications within the context of cardiorenal metabolic prevention, but also looking at efficacy of blood glucose lowering and considering weight.
I also think the other S would be moving out of silos, and although that's not a specific standard, I just see just the sense of I think cardiologists and nephrologists and nephrologists and primary care providers are kind of working together and no longer kind of working in their separate silos. But because we all share this common intention around glucose lowering and prevention of cardiorenal complications, there's this kind shared patients, and no longer does the patient just belong to one person, but the patient is shared by everybody and there's this shared responsibility between and among providers. So I think that's also an important component of the standards of care. So all of those Ss, which are again social determinants of health, expanded screening for sleep health for psychosocial health for a peripheral artery disease, specific lower targets, simplified medication selection, and then the final S we talked about is moving out of those silos of practice.
sacha_uelmen:
Oh yeah. And you got me thinking when you were saying that, even out of those silos of that inner disciplinary care team, including the dietician. And you get to do that in your role every day, so that's exciting.
mary_lou_perry:
It is. And I heard something on a webinar yesterday from the, I think it was the cardiometabolic congress, and they in this webinar they emphasized the importance of the interprofessional team or multiprofessional team. Just this kind of sense that these providers, these physicians really can't do good diabetes care on their own. That they really want to encourage all professionals, and especially those allied health professionals, to be part of those intraprofessional teams, and just the important role that all of us play in diabetes care and education. And not only knowing those standards, but being able to meet those standards and getting not only our providers, but our patients, much more familiar with what do the standards of care look like? And how does that translation happen not only within our own practice, but within the person’s standards of care with their own shared goals with their particular team.
sacha_uelmen:
Yeah. And you know, the standards of care also address prediabetes and fatty liver disease, and a lot of people we see have this now. Can you share a little bit more about updates in that area?
mary_lou_perry:
Yeah, again a great question. And again, I think there's a lot more attention around the issue of prevention this year, prevention of diabetes. And recognition and prevention and even stratification of fatty liver. So let me first talk about the prevention of diabetes. I think there's also been not only a call to action and looking at being much more aggressive and intentional around prevention, and particularly recognizing that there are a number of people that are at a significantly higher risk of developing type two diabetes. And so those are individuals that we really want to target in our health care teams. And those are individuals that have had a history of gestational diabetes. Those are individuals with a high BMI over 35. And those that have prediabetes, A1Cs six and above. And so also where we're asking and using many of our healthcare workers to be part of that prevention team, and so utilization of our community health workers become much more important, and that becomes especially important in these under-resourced population and areas to utilize those community health providers.
Also getting to the other thing that you mentioned, Sasha, was just this fatty liver disease and kind of the whole explosion of fatty liver disease. And one of the statistics I think that was really surprising for me to read was that recent studies estimate that 70% of people with type two diabetes have non-alcoholic fatty liver disease. And so we know that a lot of our clinicians are underestimating and under-appreciating this complication that's found in type two diabetes. And we're really encouraging our providers to implement screening strategies that actually can identify individuals that are higher risk of developing fibrosis. And so, even though there are 70%, and again, that is pretty significant number when we're talking about individuals with type two diabetes, of those individuals we 70% already have some fatty liver disease. But there may be some additional benefit in taking those individuals and stratifying risk, so we can actually identify individuals who may be at risk of developing fibrosis and having poorer outcomes. And that's also addressed in the standards of care in section four, and there's a special larger section within section four on fatty liver disease that outlines how we stratify risk and how we calculate risk.
And just the mention of saying that it’s so prevalent in type two diabetes, and how the prevalence not only of fatty liver disease, but identifying those individuals that have fibrosis have significantly worse outcomes, significantly higher risk for liver cancer as well as liver fibrosis. So very important to identify those individuals early on.
sacha_uelmen:
Absolutely.
mary_lou_perry:
You also mentioned something about the prevention and I, you know, I think about it’s such a big change that has happened or that has occurred in pharmacology or in medicine this year, I mean, we've seen the use of the GLP1s and the use of GLP1s not only in managing diabetes, but the benefit that these GLP1s have in decreasing body weight and the importance of decreasing body weight in the prevention of diabetes. And so in the section on weight management or the section on diabetes, care is I think given to the language of recognizing that every person is an individual and our goals can vary across our patients,. And so we are still encouraging our patients that weight losses of two to three per cent really still make a metabolic difference. They clearly have cardiometabolic benefits. But the higher the weight loss, say 10% and even beyond 15%, have disease mitigating factors, and even have shown remission of diabetes. So I think we're starting to see because we can now recommend and have tools to treat obesity that we can now start recommending higher weight losses and supporting our patients with those higher weight losses and using the GLP1s.
sacha_uelmen:
Oh yeah, having medications in that tool kit for weight loss is just so important. I mean as dieticians, you see it all the time too it is hard, it’s very hard to lose weight beyond you know lifestyle change. There's so many different factors to that, so it's awesome to have new tools in the arsenal for that.
mary_lou_perry:
Absolutely. And you know, I think it's important for, even if a member of the diabetes care and education team don't write these prescriptions, at least they're aware that these medications are out there, and at least they know how to look at that simplified medication chart and see how those decisions are made about what are you looking at when you're looking at the person with diabetes? Are you looking at cardiorenal risk reduction? Are you looking at efficacy of blood glucose change? Are you looking at weight reduction? So I think for every provider from every discipline should be familiar with at least what we have to offer our patients.
sacha_uelmen:
That's such a good point. I know when I was working clinically, a lot of people came to me and asked, I wasn't prescribing, but they’d say, “what do you think of this medication?” or “what do you know about that one?” or maybe “my primary care suggested this, but I'm a little bit scared. Have you seen other people on it?” So I agree. Regardless of our role in prescribing, it's important that we understand the different medications that our patients are going to be asking us about so that we can give them that perspective, and kind of ease their concerns if they've been recommended something that they're unsure of and really be able to share with them side effects and what the risks and pros and cons are.
mary_lou_perry:
That's a great point, and they often come to the dietitian and to the nurse first, and they are often comfortable asking us these questions, and so being able to at least be familiar with some of these medications, and know a little bit about them, it's really helpful.
sacha_uelmen:
So Mary Lou, and final thoughts? This has been so informative.
mary_lou_perry:
I guess there's a couple things that I would say, and first and foremost there are many people that often say “I wish I could provide some feedback to the professional practice committee. I have something that I want to include or they missed something.” And I will tell you that the professional practice committee really encourages yearlong public comment. So, if any of your listeners out there have a comment they want to provide to the Professional Practice Committee, they accept these comments all year long, and if you would like to make a comment you can go to professional.diabetes.org/soc. I would also encourage listeners to, if you haven't, downloaded the app for the standards of care keep it on your phone. It's readily available. And also keep it on your hard drive. Both of these are both free. And also there's an abridged copy for primary care providers, which is where most diabetes care is provided. So use those resources that are out there.
sacha_uelmen:
Thank you so much. This has been so helpful and also think of you made me think of one more call to action is for our members to consider joining the professional practice committee like Mary Lou did. You don't always need that nudge. Maybe you can go to that application yourself.
mary_lou_perry:
Absolutely.
sacha_uelmen:
Well this has been really great. Thank you for listening to this episode of The Huddle. Make sure to download the resources discussed on today's episode. You can find them linked in the shownotes at diabeteseducator.org/podcast. And remember, being an ADCES member gets you access to many resources, education and networking opportunities. Learn about the many benefits of ADCES membership at diabeteseducator.org/join. The information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult your healthcare professional for any medical questions.