Nutrition411: The Podcast, Ep. 4

Demystifying Diabetes

Lisa Jones, MA, RDN, LDN, FAND

This podcast series aims to highlight the science, psychology, and strategies behind the practice of dietetics. Moderator, Lisa Jones, MA, RDN, LDN, FAND, interviews prominent dietitians and health professionals to help our community think differently about food and nutrition. 


In this episode, Lisa Jones interviews Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM, and Sandra Arevalo MPH, RDN, CDN, CDE, CLC, FADA, on diabetes management, including common diabetes misconceptions, the future of diabetes management, and interventions in the promotion of health. 

Additional Resources:

Priscilla Thomas

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM, is the co-owner and President of Syntric Solutions and an independent consultant for TLC-MD (Maryland). 

Sandra Arevalo

Sandra Arévalo MPH, RDN, CDN, CDE, CLC, FADA, is an independent consultant and Director of Community Health & Wellness at Montefiore Nyack Hospital, and a spokesperson for the Academy of Nutrition and Dietetics and the American Diabetes Care & Education Specialists (New York, NY).

Lisa Jones, MA, RDN, LDN, FAND

Lisa Jones, MA, RDN, LDN, FAND, is a registered dietitian nutritionist, speaker, and author (Philadelphia, PA).


Moderator: Hello, and welcome to Nutrition411 The Podcast, a special series led by registered dietician and nutritionist, Lisa Jones. The views of the speakers are their own and do not reflect the views of their perspective institutions.

Lisa Jones, MA, RDN, LDN, FAND: Hello, and welcome to Nutrition411: The Podcast, where we communicate the information you need to know now about the science, psychology, and strategies behind the practice of dietetics. Today, my guests are Sandra Arevalo and Priscilla Flowers Thomas. Welcome.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Hi, thank you for having us today.

Sandra Arevalo, MPH, RDN, CDN, CDE, CLC, FADA: Hi Lisa. Thank you so much.

Lisa Jones, MA, RDN, LDN, FAND: First, I want to introduce Priscilla. Priscilla is the co-owner and president of Centric Solutions, a healthcare and IT consulting company. Her focus is to help persons at risk for or with diabetes get the care they deserve. Ms. Thomas has over 40 years of experience in a variety of healthcare settings, developing and overseeing the implementation of chronic disease prevention and management programs for diverse populations. Welcome, Priscilla.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Thank you, Lisa.

Lisa Jones, MA, RDN, LDN, FAND: And now I want to introduce Sandra. Sandra is an independent consultant and director of community health and wellness at Montefiore Nyack Hospital. Her commitment is to provide health information and promote disease prevention among the most underserved and diverse families. With over 15 years of experience, she is a recognized national expert and speaker on diversity, health education, diabetes, nutrition, chronic diseases, and social determinants of health. Her work has been featured in national and international TV, numerous printed media outlets, radio, and peer-reviewed journals. She is a spokesperson for the Academy of Nutrition and Dietetics and the American Diabetes Care and Education Specialists. She has received numerous nominations and awards, including Mom on a Mission next to Michelle Obama in 2017 and the Garden State Diabetes Educator of the Year award in 2018. Welcome, Sandra.

Sandra Arevalo, MPH, RDN, CDN, CDE, CLC, FADA: Thank you, Lisa.

Lisa Jones, MA, RDN, LDN, FAND: And first I want to start with Priscilla. If you want to share a little bit first about your area of expertise and your background?

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Okay. Thank you, Lisa. So, a little bit about my background. My parents are both from North Carolina and so my passion for diabetes prevention and management actually stems from seeing family members develop diabetes, not have access to diabetes care and education, and unfortunately go on to develop the devastating complications, such as blindness, heart disease, and chronic kidney disease. So, I wanted to be able to translate the evidence-based guidelines into practical, actionable steps, to break the cycle.

I took the nontraditional path to become a RD, started out actually as a RN, and then realized that I had interests in nutrition and stress management and physical activity, so I became a CDCES then an RD, and then a certified case manager. All my experiences, I believe have really led me to my current position as a consultant project manager for a nonprofit organization. So, I would say far as my area of expertise, it's really partnering with a variety of organizations and stakeholders to solve problems related to chronic disease prevention and management that disproportionately impacts communities of color.

Lisa Jones, MA, RDN, LDN, FAND: Thank you, Priscilla. I loved hearing that because you really have a dynamic and diverse background and that combination of the nursing background and the nutrition background really sounds like it allows you to serve your clients really well. So, thank you for sharing. And Sandra, how about you? Is there anything else you want to share about your expertise and background?

Sandra Arevalo, MPH, RDN, CDN, CDE, CLC, FADA: Sure. So, similar to Priscilla, when moving into diabetes was to see the need of so many people out there who need more education basically, on diabetes care. So, being a Latina myself, I've been specializing myself in providing diabetes care and education to Latinos, but also other minorities because unfortunately, it is the minorities were mostly affected by high hemoglobin A1Cs and just poor outcomes of diabetes. So, seeing all these results, similarly to Priscilla, is what has moved me into working with the poorest communities and the most underserved to be able to provide education, but also to work with older dieticians and other professionals, trying to find better ways to bring the message across to all these people who actually need to learn more about diabetes.

Lisa Jones, MA, RDN, LDN, FAND: No, that's excellent. I love that you're both on a mission, the mission and ... which will keep you busy for a long time. I love the populations that you serve, so thank you for sharing that. And I want to move into our first question. Both of you have amazing backgrounds, over the course of the years, many things have changed in the area of diabetes care. So, if you can talk about, specifically, what changes have you experienced in this particular area? I want to hear from Priscilla.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: I think as you say, Sandra and I are both on a mission. We're both on a mission to make diabetes management something that's accessible and affordable to people that are disproportionately affected. So, some of the changes that I've seen, and just to give a high level, is increased focus on creating the infrastructure to ensure that access to affordable DSMES is available to all patients, especially those at the highest risk. The next is the implementation of interventions to actually address the low number of referrals and low participation for DSMES.

So, I know it's important for us to increase the number of referrals, but I think even the bigger challenge is that we want to make it easier for patients to participate in DSMES. So, one intervention that finally got a lot of traction during COVID was the elimination of restrictions that helped to facilitate the delivery of DSMES via telehealth or audio-only. These methods were very popular with a lot of our patients. There is still some uncertainty about delivering DSMES in these formats after the public health emergency. But I think it's important that we are providing these services in these formats, tracking the data and evaluating those outcomes, so we can show the effectiveness and actually support continued availability.

Lisa Jones, MA, RDN, LDN, FAND: Thank you. I think if this was what, a decade ago? We wouldn't even have some of these, which I think is fantastic because I'm curious to see moving forward because there's probably some of your patient population that prefer to have it continue the way it is.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Yeah. I think that's the biggest thing, I mean, COVID, there were a lot of negative things from COVID, from people who got seriously ill in the hospital and actually died from it. But one thing, I think it forced change in the healthcare system. There was an interest in telehealth prior, but there were so many restrictions that it really made it impossible to do and it wasn't anything that was really appealing. I think COVID actually forced that change and I'm hoping that because it has ... I really believe because it has started, we can't go backward.

Lisa Jones, MA, RDN, LDN, FAND: We can't.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: So, we can't go back and say that we can't do telehealth and we can't do audio-only at all, but it will be what does that look like? Fortunately, some of the changes will not be able to be permanent changes. So, I think a lot of that is going to be us advocating. The patients liked it, they found it convenient. They don't have to worry about leaving work to attend the session. So, how do we continue to advocate for this, particularly for communities of color, that are already disproportionately affected and they need as many resources and as much access as they can get.

Lisa Jones, MA, RDN, LDN, FAND: I think that's providing easier access, so hopefully continuing to advocate will allow that to still remain an avenue.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Right, I agree.

Lisa Jones, MA, RDN, LDN, FAND: Thank you. How about you, Sandra? How about the changes that you've experienced throughout your career in this particular area?

Sandra Arevalo, MPH, RDN, CDN, CDE, CLC, FADA: I think that the most recent that have been getting my attention are the advances in technology and also in education methods. I'm going to start with technology, so you just referred to virtual visits and all of that. So yes, the use of some virtual apps that allows patients to see their doctors through the computer, or through their phone, definitely has helped to shorten a lot of distances between providers and patients. But not only that, I feel that right now we have the insulin pens, the glucose monitors, the continuous glucose monitors, so many things that actually help patients keep track of their diabetes, that make their life a lot easier than having to carry the old vials and injections and needles and all of that. So, I love that.

The only problem with that is that it's still expensive, as we well know. Obviously, insurances are a problem because they not all pay for the insulin pens, and then what about the uninsured people who don't have any access to this technology, unfortunately? So, there is still an issue, but I like how it's advancing and how it's advancing to help the patient with diabetes.

Now, in regards to education methods, I think that we've made a lot of progress, just simply with the use of language, for example. We don't say diabetic patient anymore, but patient with diabetes. We're becoming more personable and I personally don't like to treat the patient or the disease. I like to treat people, I like to treat the person. So, that has helped me get to the level of care that I really want for my patients. Also, there are many different methodologies now, we're moving away from that patient-doctor relationship, where the doctor lectures the patient. Now it's all more about education, about how you can live your one-on-one.

We have many more diabetes education specialists who have the ability to teach the patient and find out about social determinants of health and treat the person as a person, and help them in the full context of what life is like and not just the disease. We have more support groups. We have more diabetes self-management education groups, and even diabetes prevention programs. So, the more we move away from that lecturing one-on-one, the happier I get, because I feel that people are finally starting to get the message across, and all these innovative ideas are very welcome in my world.

Lisa Jones, MA, RDN, LDN, FAND:

That's great. You mentioned the technology and also treating, treating the patient really as a person cause before it was like, back in the day, it was let's put everyone in the bucket, either you have diabetes or not. I remember saying the diabetic patient and I like the new language much better.

Sandra Arevalo, MPH, RDN, CDN, CDE, CLC, FADA: Absolutely, yes.

Lisa Jones, MA, RDN, LDN, FAND: If somebody has a heart attack, you're not saying the heart attack patient or the cardiac patients. But for some reason, specifically with diabetes, it was always the segregation of diabetic and non-diabetic, which I always thought was interesting. I like the new language, so thank you for sharing that for-

Sandra Arevalo, MPH, RDN, CDN, CDE, CLC, FADA: Yeah, and I feel that for a lot of cultures, we need that personal touch. Maybe there are some cultures that don't require that, but at least some of the cultures that I deal with, like the Latinos, the Haitian, the African people from Africa, we require that warmth, that you're not just a patient, you are a person who I'm here to help, and I'm here to learn about you as much as I hope you can learn from me. I think that that personal touch really opens a lot of doors and people get to understand a little bit better of how to manage their diabetes and especially how to live with their diabetes, they are not seeing ... For example, I don't like to call diabetes a disease. I just call it a condition. I say, "You know what? Disease is when you're sick. If you don't feel sick right now, you're not sick. You just have a condition."

We all have to learn to live with different conditions. So, we had to change the way we were living during COVID, we're going back to normal or a new normal. If the electricity goes off at home, you're going to have to adjust to that. So, that's what I tell my patients as well, is like, "When you get a diagnosis of diabetes, this is not the end of the world, you're still a healthy human being that just has a condition. And now you just have to relearn how to live with this condition, a long and healthy life."

Lisa Jones, MA, RDN, LDN, FAND: That's excellent. That's a really good example. Excellent language to use, which goes nicely into our next segue, which is really what are some misconceptions about diabetes that you hear? Whether it be from other dietician colleagues, patients themselves, or patients' family members, anything that you want to share about that?

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: So Sandra, thank you for talking about the personal care for diabetes. A person with diabetes is more than their diabetes, so they could be a mother, a father, they could be a daughter, a singer, there's more to them than just their diabetes. Diabetes is just one aspect of who they are. The other thing I'll talk about is when you talked about the advances in technology and some of the challenges. Some of those are the same challenges with telehealth. Telehealth is great, however, we also saw that there were large populations that weren't able to participate in the telehealth. Either they didn't have the technology, so they didn't have a computer or smartphone, or they didn't have access to the internet, reliable access to the internet. So, even though telehealth, is great to be able to offer that. We still have to realize that there are some challenges and barriers that we have to address.

So, I would say one of the biggest misconceptions for me that I think people have is that patients with uncontrolled diabetes are just non-compliant. So, when I hear that, it just makes my skin crawl. So, we tend to blame suboptimal management only on the person with diabetes, but we don't do this for other, as Sandra said, conditions. So, for my years in healthcare and working with diverse populations, I know it's not always true that people just don't want to do the right thing. Sometimes what we're asking them to do is unreasonable. Sometimes they don't have the resources to do what we're asking them to do, and then sometimes life just gets in the way. They've got too many other competing priorities that they can't really focus on what they need to do to take care of themselves.

So, I've never met anyone who said, "I'm content with poor management of my diabetes, and I want to have my foot amputated or I want to go blind." Most people do not want those complications. So, I think the biggest thing, when I think about when you say somebody is not compliant, you put all the blame on them. There is some individual responsibility for behavior change, but there's also system responsibility, for us to make sure that we have systems and services in place that help people to actually manage their conditions.

I think we really have to do a better job of mitigating the barriers, so people with diabetes can have the resources and the confidence to manage their condition and reduce their risk of complications. So, there is some responsibility on us as healthcare professionals, as a society to make sure we're helping people who have diabetes, because we know it's very hard to manage. We know it takes a lot of time and we know they're doing this in addition to their everyday life. So, how do we make this easier for them and help them to be able to achieve the control that they deserve?

Lisa Jones, MA, RDN, LDN, FAND: Priscilla, you bring up such a great point. And it sounds like to me, like there is some type of some sort of stigma around it too. I remember when I used to do home care and we used to get consults, one of the consults we'd always get was of course they can't control their blood sugar. It's uncontrolled because they're probably not do ... Go in their house, look to see what they're doing. They're most likely not following the diet. And then we'd get to the house and it wasn't that, it was maybe the medication, there was other factors involved. So, I love what you're saying about that. It's really coming up with the whole picture and then working together as a team. It's not just on the patient, their responsibility, it's a team effort.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Yeah, because it could even be that their medication needs to be adjusted. They are not able to do that.

Lisa Jones, MA, RDN, LDN, FAND: No.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: That has to be done by the provider. So, I think with diabetes, I agree there is this stigma. I think there is more of the stigma with type two diabetes because of the behavioral health component, that there's this perception that people can control their ... not that they can control their diabetes, but that the control of their diabetes is all based on what they do, when we know there's a lot of other factors that come into play as far as diabetes management.

Lisa Jones, MA, RDN, LDN, FAND: Yeah, that's great. And we all know it's not always easy to change your behavior. Something as simple as drink more water, what goes into that?

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Exactly. I agree.

Lisa Jones, MA, RDN, LDN, FAND: Sandra, how about you? What do you think about some common misconceptions that you may be hearing in this area as well?

Sandra Arevalo MPH, RDN, CDN, CDE, CLC, FADA: Well, I think Priscilla just said the most important one because yes, we all hear that all the time from patients and providers alike. But when I think of my patients and what their misconceptions are, there is a lot of fear for insulin because when they get prescribed with insulin, they feel that's the end, it's close to dying. Like, "Okay, I failed myself. There is nothing else I can do." It's that fatalism that comes into play as soon as they hear, "You need insulin."

Something that I try to is to try to talk to my recent diagnosed patients about insulin, right from the beginning, so that whenever they're going to hit that brick, they know that insulin is just another treatment and not end of life situation as a lot of people like to put it. I think that another misconception is that when people have low literacy, there is no comprehension, it's like people don't want to waste their time basically. Like, "Oh, they don't know how to read or write or they don't know numbers," or whatever it is, so it's a waste of time.

It's not a waste of time. It takes more time to help a person with low literacy or low health literacy to comprehend a lot of the diabetes concepts, especially because some of them can be very complex, especially teaching numbers, teaching how to measure and count insulin units, or rating a food label, but it's not impossible. So, what I feel is that us as providers, as health providers, are the ones who are failing the patients. It's not the patients, because we need to find a way so that they understand what we need them to do. It's not up to them, it's up to us to help them manage their diabetes.

As Priscilla was saying, oftentimes, it has even nothing to do with the patient. It has to do with the way we want to manage their diabetes when we don't even take into consideration where they're coming from. A few years back, I had a patient with very uncontrolled diabetes and the doctor kept going up and up on the insulin it wasn't until I saw the patient and I just asked, "What's going on. We don't understand why in a spite of the amount of insulin, your numbers are not coming down," and he just basically disclosed, "I'm homeless. I have no way to deal with insulin, or needles, or anything like that. So, I don't even have a refrigerator. The first thing that I was told was that I have to put the insulin in a refrigerator. I don't even have a home, even less a refrigerator." So, who's fault is that? It's not the patients and it's not like patients feel proud to be homeless and to not have the resources, or be going through a lot of issues, as Priscilla was saying, that to them at the moment are more important than their diabetes.

So if we don't ask the questions, if we don't want to find out about the circumstances our patients with uncontrolled diabetes are living in, it is going to be impossible for us to help them. Again, it's not the patient's compliance. I call it the detective's work. I feel like we're not doing our detective's work right, so we're not finding the cause of uncontrolled diabetes.

Lisa Jones, MA, RDN, LDN, FAND: I was listening to your answer of that question. The thing I was thinking of is it goes back to what you were both saying, in the beginning, is you need to treat the patient, not the condition. I think if most practitioners remember that, then they're way ahead of somebody else that's just like, "Oh, I'm going to treat your diabetes. And here's the cookie-cutter version of what I do next." I'm just curious in that particular case that you gave an example of, what did they say? When the homeless patient was like, "I don't have a home, I don't have a refrigerator to put this in? What was their response?"

Sandra Arevalo, MPH, RDN, CDN, CDE, CLC, FADA: Well, obviously, at that point we had to include the social worker and the case manager. So, I love the Priscilla is like all in one, it's like these great twofers because just the nurse, the dietician, the educator, the caseworker, everything in one, that's a great package. Your patients are really privileged, but we had to include a whole team, to be able to help the patient. But long story short, we were able to convince the patient that he needed the support of his sister so that he could leave the insulin in his sister's house. Then sometimes when the sister wasn't available, we had to keep the insulin in one of our fridges in the clinic to make it available for the patient. So, it takes work. You just need to be willing to walk the path with your patients.

Lisa Jones, MA, RDN, LDN, FAND: Well, that's great. You came up with a treatment plan and you had a backup solution to a solution, which was nice versus just saying, "Okay, well, our time is up. You have to go now," and didn't provide the ... I've seen that before. Like, "Maybe we'll talk next time." And then the patient doesn't get there, and that's why they don't come back. And that's why they're not successful because there's not a team working with them.

Sandra Arevalo MPH, RDN, CDN, CDE, CLC, FADA: Exactly. And what you just said is very interesting because I think it has happened to all of us. It has happened to me indeed, that it's like, "Okay, next question. Oops, sorry. I have to see my next patient." That's very aggravating especially if you're not feeling well and when your diabetes is out of control, you're definitely not feeling well, no matter what you say, you're not feeling well. You're tired, you don't even want to be there, you're cranky. And being told, "Well, that's it," when you have so many other questions ... but it's very hard living in the system that we have right now. Our health care system, unfortunately, is not designed to provide that kind of care that people with diabetes need, but that's why we have diabetes care and education specialist because we have a little bit more time and we are definitely key in that team approach, especially ... I really feel that there needs to be a team approach to be able to treat the patient with diabetes right. One only person can't do it. Then even if we are diabetes educators or the doctor alone, or the nurse alone, it's impossible. You need a whole team to be able to help a patient.

Lisa Jones, MA, RDN, LDN, FAND: Yeah, so I definitely agree from what I'm hearing. So, that leads me to our next question, which I'm curious to hear because you're bringing up some issues that happen along the way. I want to hear about some successes that you think that you've had along the way, that will help other colleagues working in this particular area, the area of diabetes. What could you share with them that you've been successful and are our best practice that will be helpful to them moving forward, so they don't experience similar things?

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Want to second Sandra's comment about us failing the patient. Because I think that until we see that, then we don't have the buy-in, the compassion to be able to help find solutions. A lot of patients are told from the beginning, "If you don't follow this meal plan, if you don't check your blood sugar, you are going to end up on insulin," as Sandra said. And so there's this fear of insulin. And then by the time you end up on insulin, it's like, "Oh my God, this is all my fault." So, I think one of the things Sandra was saying is starting from the beginning saying, "Diabetes progresses and at some point, the medication you're on now may not work for you, and we may have to look at other medications." So they know from the beginning that, "Yes, I may be eating right. I may be physically active, but because of the nature of diabetes, it may actually get worse and then we've got to reevaluate the treatment plan."

I think one of the things for me has been, throughout my career, is building those trusting relationships. I'm reminded of a quote that people don't care how much you know, until they know how much you care. So, we have to work to build those relationships and that's what Sandra was talking about, talking to the person." What's going on. Why are your blood sugars going up?" I remember I once had a patient who traveled on public transportation. He arrived for his appointment and in his clothes that were not very clean. So, all of a sudden in my head, I start thinking, "Okay, does it mean that he doesn't have access to laundry services? Maybe his water was cut off." Even though I asked questions, I couldn't get a response from him, but I'm still thinking something's not right.

I remember calling his wife and his wife said, "Oh, everything is okay. He just didn't want to be late for his appointment with you." When I thought about that, I'm like, "Out of all the stuff he had going on, it was important for him to make sure he just dropped everything he was doing to get to his appointment on time with me." So that's one of the reasons I do what I do. It is hard work, there are a lot of challenges. It's not the easiest thing to do. You have to be willing to compromise because what we think is a ideal situation, and we may say to somebody, "Okay, well you need to eat vegetables with every meal." Well, if they don't have access to fresh fruit and vegetables, that's not going to work. Or if the access they have, it's very expensive and they can't afford it, that's not going to work.

So, sometimes I think we are idealistic as far as what we ask people to do and we don't give them the mercy to be able to say, "Okay, I really can't do that, but this is what I can do." So, working with them to find a solution that's going to work for them that may not be ideal. So, I think that's one of the things. And then, just looking at the fact that, as I think Sandra has mentioned, it's going to take all of us to figure this out. So, no matter what role we're in, no matter what setting we're in, if we have a patient that we're working with that has diabetes or pre-diabetes and say, for instance, they don't have access to the programming and resources, how can we make those connections? How can we make sure they get connected to the resources that they make?

But that means all of us have to be paying attention to the patients and being able to make sure we're able to offer them the services that they need at that time. Again, just thinking outside the box, being innovative, if we have patients that are not coming to our sessions during the day, maybe because they're working or they're serving as caregivers, what adjustments can we make in order to accommodate those patients? So again, I think as Sandra has said, a lot of this is really on us. We know the barriers for the most part. How can we make adjustments to make sure we're serving these patients? Because we know if we don't, it's going to impact the quality of life. And eventually, it's also going to impact us because we're going to pay for those healthcare calls, for the hospitalizations and the ED visits. So, either we pay now or we're going to end up paying later for it. So, I think those are probably some of the success that I've had, and I think may help some other colleagues working with this population.

Lisa Jones, MA, RDN, LDN, FAND: Well, thank you for sharing that. I hear a lot of compromise, being able to meet them in the middle, which I try not to be too rigid in the recommendations or the offerings. Again, it goes back to the original with treat the patient, not the condition. So, thank you. How about you Sandra, some successes on your end?

Sandra Arevalo MPH, RDN, CDN, CDE, CLC, FADA: Yeah. I think that if I can talk to my colleagues or anyone treating patients with diabetes, I will summarize success in two words, in one concept, motivational interviewing. First of all, the trainings for motivational interviewing are fun, so I like to take one every year. You might think that you already know it, and every time that I take one of those trainings, I learn something new and it's fun, and it helps to renew how you talk to patients, because there are some things that you definitely forget, but I think that it's a great skill to have because you learn how to talk to people and especially how to listen, and that opens a lot of doors to people talking to you. As Priscilla was saying, it's so important that we know how to talk to people so that they talk back at us, and taking into consideration those social determinants of health and what their needs are.

You know what? We can't do it all. We're not God, but having a team surrounding us that can help us with patients that I can say, "Okay, I need a psychologist, this patient is depressed. I need a social worker, this patient needs resources. I need a case manager. I need a doctor, an endo." It's a lot of things. Even reps, because sometimes we don't even know about other medications that might be out there because it's so much out there. So it really takes a team. So, I think motivational interviewing and a team are best practices, at least that I've learned through the years and that's what's going to help not only us, but the patients the most.

Lisa Jones, MA, RDN, LDN, FAND: Well, that's wonderful. And then when you were talking, I was thinking, I don't know, sharing is caring. That saying popped into my head. I was like, when somebody feels like they're listened to you, they're more apt to share. That's what you two do so well in your practice, it sounds like. So thank you. So with that, I want to ask you the next thing, what do you think is on the horizon for the management of diabetes in the future?

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: A couple of things. I think there's going to be increased focus on diabetes prevention in an effort to curve type two diabetes. So, we talked about the management of type two diabetes, and even with the management of type two diabetes, the outcomes are suboptimal. So, our focus, really preventing diabetes from the beginning, may help us to be able to have fewer people have diabetes, and then, therefore, we don't have the outcomes that we're getting now.

I think the integration of social determinants of health into clinical care will become standard care. Right now, it's almost like it's optional. There is more interest in it, but I think it hasn't become the mainstay that it really actually should be.

A focus on achieving health equity to improve outcomes. And then I think the other thing which I'm hoping comes soon, is the elimination of cost-sharing, copays, and high deductibles for chronic disease management. Because if you can't afford to copay or you have a high deductible, even though DSMES works great and we know it's effective, it can reduce A1C by up to 1%, which can reduce the risk for microvascular complications by 37%. So, we know it works, but if you can't afford the copay and you can't afford the deductible, then it's going to be harder to get people to be able to take advantage of these services. So, I'm hoping that on the horizon, we will see the elimination of the cost-sharing for these patients. So, it just eliminates one more barrier that they already have.

Lisa Jones, MA, RDN, LDN, FAND: Well, that would be great if they can eliminate another barrier.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: I know.

Lisa Jones, MA, RDN, LDN, FAND: That'll be ... cost-sharing.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Well, there's so many of them.

Lisa Jones, MA, RDN, LDN, FAND:

Yes, that's true. They can expand cost-sharing into other areas too, in my opinion. This is a whole nother podcast, right?

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Exactly.

Lisa Jones, MA, RDN, LDN, FAND: Sandra, how about you?

Sandra Arevalo, MPH, RDN, CDN, CDE, CLC, FADA: I only need to say, Priscilla, from your mouth to God's ears because really, if that's the future of diabetes, I think we're on the right path. I am with her. I feel that, especially for the most underserved and underinsured, there needs to be something, because those are the people who suffer the most. They are the ones who cannot afford medications. They cannot afford doctor's visits and they end up in the ER because they have no other way, they are passing out, and they're comatose. They're confused and there is nothing they can do to help themselves. You know, it's like, yes, we have some programs in some pharmacies and they offer discounts and all of that. But when you have $5 in your pocket and you have to choose between buying medication or feeding your two children, I mean, tell me what you're going to choose.

Unfortunately, people don't understand. I think of mothers often, because a lot of mothers end up in the emergency room and I think, "Oh my God, okay, you're choosing your kids over your own health, but if the diabetes kills you, then who's going to take care of your kids?" And you can tell that to a patient, but still the problem persists. It's like, if you can't afford your medication if you can't afford your insulin, or your syringes, or whatever it is, you can give them some syringes for free, but you cannot keep giving them everything.

So definitely, I think there needs to be a big healthcare reform that looks at all these issues because it doesn't just affect one person or one family, it affects all of us. As Priscilla was saying, this patient ends up comatose and amputated and can't work anymore, we're going to be paying for it. So, I'd rather pay for metformin, it's cheaper than having to pay for an amputee and all the needs of that patient, especially if it's a younger person with a family. So definitely, we need to do some thinking and do some type of healthcare reform.

Lisa Jones, MA, RDN, LDN, FAND:

Yes, that's definitely true. So Sandra, what is one bottom line takeaway that you would say for the audience, that you would say? It sounds like you already said it earlier, but maybe if it's something different than what you said earlier, or if it's the same thing, feel free to repeat it.

Sandra Arevalo MPH, RDN, CDN, CDE, CLC, FADA: Yeah, no, I think I need to insist that every patient with diabetes is a person, that deserves all of our attention and that we cannot forget that next to the diabetes, there are so many confounding factors that help to move the needle up or down in their diabetes. And we need to be aware of all of them before we treat. I'm saying "treat" because sometimes, we don't need to treat anything, we just need to show a path for the patients to be able to walk their right way to be healthier. That's the main goal, is that no matter your diabetes or any other chronic disease, call it blood pressure or whatever it is, you want to be on the right path to health and learn to live with a chronic disease and live a healthy and long life, but you need support and you need to know what your patients are going through and what pros and cons they have and help with all of them.

Lisa Jones, MA, RDN, LDN, FAND: Well said, Sandra. Sounds like they need a personalized blueprint for their path, which you provide.

Sandra Arevalo MPH, RDN, CDN, CDE, CLC, FADA: Yeah, pretty much.

Lisa Jones, MA, RDN, LDN, FAND: How about you, Priscilla? What would you say is your key takeaway?

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: So, I think the one key takeaway is that understanding that all patients with diabetes deserve affordable access to DSME services and resources. So, there are a lot of things we can ... First of all, it's going to take all of us to figure this out, no matter where we are, no matter what our role is, we can make sure that if we have a patient that we're working with, that has diabetes, that they're referred to DSMES services, can utilize our problem-solving skills, to identify challenges and barriers, and then try to think outside the box and be flexible to develop innovative solutions. Thinking about if you're not a CDCES, maybe becoming a CDCES so you can actually provide those services, and/or establishing an accredited or recognized program at your practice.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: I'm always saying that the floodgates are going to open up and we're going to see all these referrals. So, we're going to need healthcare providers that are going to be able to serve these patients. So, just being ready and being prepared, doing what we can to help patients with diabetes reduce their risk for complications, for those that are at risk for diabetes, diabetes prevention, and then also just making sure that we are providing the resources that they need.

Lisa Jones, MA, RDN, LDN, FAND: Thank you. Thank you so much, Priscilla.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: You're welcome.

Lisa Jones, MA, RDN, LDN, FAND: And that's a great takeaway for our audience. And Priscilla and Sandra, thank you so much for being on our show today and sharing your insights with us. There's so much information here. I feel like this could be a two-part podcast, so maybe we'll have another episode in the future, diabetes, and bring you back on. So again, thank you. It was a pleasure.

Priscilla F. Thomas, MS, RN, RDN, LDN, CDCES, CCM: Thank you.

Sandra Arevalo MPH, RDN, CDN, CDE, CLC, FADA: Thank you, Lisa, for the invitation.

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