November 30, 2022
AUBURN, Alabama – Spanning the country, working with Diabetes Care and Education Specialists, health care professionals and leaders of other diabetes organizations, every day is about diabetes awareness for Dr. Jan Kavookjian. As national Diabetes Awareness Month comes to a close, she is particularly excited about some of the advances she has seen, improving the lives of the more than 37 million people in the United States living with diabetes.
An associate professor in the Harrison College of Pharmacy’s Department of Health Outcomes Research and Policy, Kavookjian is currently serving as the elected national president of the Association of Diabetes Care and Education Specialists, or ADCES. To kick off Diabetes Awareness Month, she was part of a group invited to ring the NASDAQ opening bell on Nov. 1. The event was sponsored by NASDAQ and embecta, a diabetes care company known for strong support of and collaboration with all the diabetes advocacy organizations, including ADCES, JDRF, Children with Diabetes, Beyond Type 1, Diabetes Link, Diabetes Foundation, DiaTribe, Diabetes Sisters and several others.
“The NASDAQ bell-ringing event was intended to raise awareness for the nearly half a billion persons living with diabetes in the world as well as to honor the work of each of these outcomes-impacting advocacy organizations,” said Kavookjian.
In her tenure as president, Kavookjian has a front-row seat to advancements and growth in the industry as professionals develop new ways to identify those with or at risk for diabetes and related cardiometabolic conditions.
“Being in a leadership position with a major and interdisciplinary association like ADCES has been a remarkable experience,” said Kavookjian. “I have had the privilege and honor of being part of invited presentations by the most noted and cutting-edge diabetes scholars in the world and learning about amazing new developments that are emerging that we’ll be hearing much more about in the future.”
At the top of the list is the importance of screening for both Type 1 and Type 2 diabetes, including children and family members of persons with Type 1 diabetes. And, for Type 2 diabetes, scholars are seeing multiple types of the disease and learning that treatment options need to be more individualized.
“The longstanding first line treatments for Type 2 diabetes are becoming obsolete at first line therapy as we realize diabetes is highly associated with other cardiometabolic conditions,” said Kavookjian. “Person-centered treatment decisions for blood sugar control must incorporate treatment implications for an individual’s need for attention to weight management, liver function, kidney function, hypertension and/or other co-morbid cardiovascular conditions.”
Additionally, screening for those with prediabetes (fasting blood sugar levels in the 100-125 mg/dl range) is important for prevention or delaying movement into the diagnosis range for Type 2 diabetes and its detrimental complications.
“The National Diabetes Prevention Program, or DPP, disseminated from the evidence base by the Centers for Disease Control and Prevention, has been a key collaboration for ADCES in the training of DPP workforce, known as the national DPP Lifestyle Coaches,” said Kavookjian. “I am a DPP Lifestyle Coach, and I teach DPP classes on an outreach basis with East Alabama Health’s CDC-funded DPP program.”
Another group that early identification is vital to is children. For many youth with diabetes, getting either a Type 1 or Type 2 diagnosis is life-changing and many are often not able to comprehend the extensive impact it makes.
“Recognition that the burden of diabetes disease management during developmental stages in young people is often more complex than for adults is important,” said Kavookjian. “Study findings reported at the ADA Scientific Sessions in June indicated that youth with Type 1 diabetes are two to three times more likely to report depression and suicidality than youth without diabetes.”
Among other advancements is the recognition of the importance of continuous glucose monitoring, or CGM, and the ability to use CGM to generate a time-in-range metric of blood sugar control as measure of blood sugar that is a more robust predictor of clinical and humanistic outcomes than the commonly-used A1C.
“Advancements in technology and devices for diabetes management is demonstrating a vast expansion in the literature for outcomes-impacting evidence and there is substantial movement to advocate for CGM,” said Kavookjian. “Additionally, insulin pumps and other modes of insulin delivery need to become more available for all, including persons with Type 2 diabetes and especially including the minority populations who are experiencing disparities in access to these.”
By getting patients started on these diabetes management devices, it provides a wealth of data and evidence for a patient’s collaborative diabetes care team to interpret and make decisions related to diabetes management and treatments. This is also a critical role for Certified Diabetes Care and Education Specialists.
Importance of screening
Of all the advancements she has seen this year, one thing that has not changed is the importance of screening and testing for diabetes. Of the 37 million Americans with Type 2 diabetes, approximately 8.5 million are unaware they have it. Alabama ranks among the top three states in the United States for prevalence of diabetes, and some Alabama counties have nearly three times the national prevalence rate, particularly in minority populations most at risk for diabetes.
“Persons at highest risk come from these segments of the population, and particularly if there is a history of diabetes in other members of their family, if they are carrying higher weight, if they are not physically active and/or if their eating routine is mostly high in fats, calories or carbohydrates,” said Kavookjian. “Unfortunately, screening rates are low, and all persons with these risk factors should consider getting screened for prediabetes or diabetes.”
If someone screens positive for prediabetes or diabetes, the most important thing they can do is find a program for education and training for how to manage diabetes and prevent complications. These are diabetes self-management education/training and support, or DSMES, programs that have interprofessional practitioners who are trained and certified to help someone newly-diagnosed learn about healthy eating, being active, taking medication, healthy coping and monitoring blood sugar levels, among many other things. Programs and practitioners in this space can be found at www.diabeteseducator.org/find.
Locally, East Alabama Health’s Diabetes and Nutrition Center has a robust DSMES program as well as a DPP program, with opportunities for scholarships to attend classes if the individual is someone who can’t afford it or is not covered by Medicare. For persons over 65, Medicare does pay for class attendance and getting what is needed to achieve optimal outcomes for persons with prediabetes or with diabetes.
“I want to express that these risk factors and opportunities for learning truly hit home here in the South, and we find that there are significant health disparities in our rural minority populations in terms of access to accredited diabetes education/training, outcomes-impacting diabetes management technologies and even treatments,” said Kavookjian. “I am very proud of the advocacy efforts of ADCES and how our impact, along with our partner organizations and diabetes coalitions, has put us at the forefront of influence on emerging and pending legislation addressing equal access to these important, evidence-based pathways to better outcomes and health.”
Communication is key
For Kavookjian, the key for many people comes down to person-centered communication. And, the first step with communication is getting rid of the stigma surrounding diabetes.
“Stigma prevails in diabetes as we as a society tend to blame persons for getting themselves to the diabetes diagnosis and complications, but it truly is a multi-faceted set of motivators and barriers, along with other risk factors,” said Kavookjian. “The blaming is the worst thing we can do to help someone make the changes needed to improve outcomes.”
Focusing on strengths-based communication allows patients to focus on what can be done, thinking about future strategies and encouraging and supporting even small steps towards the changes needed to reduce risks in diabetes.
“Instead of looking at and shaming about the failures, mindfully decide to look for positive things to praise and letting your family member know that you want to be their support and coach,” said Kavookjian.
A national expert in a therapy called Motivational Interviewing, or MI, Kavookjian also supports using it as a way to talk through healthy habits and self-care with diabetes patients. Originating in the 1980s in the substance use and counseling fields, MI is a communication skills set and approach that empowers a person to find internal their own motivation to engage in healthy and positive behaviors. Since then, its use has expanded to cover a variety of behaviors, conditions and populations in the context of chronic disease management or prevention.
“MI is founded on being intentionally caring and non-judgmental, listening and expressing empathy for feelings someone has, supporting their own choosing of what they can or want to do to make changes, praising movement toward change, no matter how small, and being kind about the times the person doesn’t succeed at meeting their goals,” said Kavookjian. “In the context of youth with diabetes and my recent research with the parents of youth with Type 1 or Type 2, the overall goal is to train parents how to have constructive conversations about health behavior goals with their adolescents while they are in a developmental stage for which lifelong, outcomes-impacting habits can be established to support a future with optimal health in their condition.”
For more information the Association of Diabetes Care and Education Specialists and their work in the field, visit www.diabeteseducator.org.
Auburn University’s Harrison College of Pharmacy is ranked among the top 25 percent of all pharmacy programs in the United States, according to U.S. News & World Report. Fully accredited by the Accreditation Council for Pharmacy Education (ACPE), the College offers doctoral degrees in pharmacy (Pharm.D.) and pharmaceutical sciences (Ph.D.) while also offering a master’s in pharmaceutical sciences. The College's commitment to world-class scholarship and interdisciplinary research speaks to Auburn's overarching Carnegie R1 designation that places Auburn among the top 100 doctoral research universities in the nation. For more information about the College, please call 334.844.8348 or visit http://pharmacy.auburn.edu.