Over the past 20 years, we have learned that diabetes is a particularly complex disease. The need for counseling and education, the role of self-management, the many complications, and the need for daily decision making together call for a variety of specialists among members of the health care team.1 Because of the complexity of the disease, the role of advanced practice providers has emerged. Individuals in advanced practice inherently teach, counsel, and listen. These skills are of paramount importance in helping people with diabetes learn self-care behaviors and achieve treatment goals.2 

Twenty years ago, I entered the world of diabetes fresh from graduate school as a certified nurse practitioner. I was hired to be the trial coordinator for the Diabetes Control and Complications Trial (DCCT) at Henry Ford Health System in Detroit, Mich.3 

As trial coordinators, we entered a new era of diabetes care. New technologies were available to support the clinical management of diabetes. Blood glucose meters now allowed patients to test blood glucose levels, rather than urine, at home. Insulin pumps were also now available. Intensive diabetes management was the new catch phrase, and we sought to determine how best to accomplish intensive therapy and whether it would make a difference in long-term outcomes for people with diabetes. The concept of diabetes as a self-care disease was emerging, with the understanding that patients provided 90% of their own diabetes care.

The trial coordinator role was being defined daily as we learned that we needed to provide patients with support and education and to empower them to be their own best advocates for their health care needs. Trial coordinators not only were able to provide the needed support and education, but also had the time and clinical expertise that turned out to be crucially important to the outcomes of both the patients and the study. Little did we know at the start of this landmark trial in 1982 that in our role as DCCT coordinators, we would help to define advanced practice in diabetes two decades later.3 

Today, the roles of advanced practice nurses, dietitians, and pharmacists are well recognized. The three articles that precede this one (p. 32, p. 37, and p. 41) offer case studies illustrating the role development that has led over time to advanced practice in diabetes. The authors (my colleagues Geralyn Spollett, MSN, C-ANP, CDE; Claudia Shwide-Slavin, MS, RD, BC-ADM, CDE; and Peggy Yarborough, PharmD, MS, BC-ADM, CDE, FAPP, FASHP, NAP) share from their respective professional viewpoints the intricate roles that members of their disciplines play on the diabetes care team and in the advanced clinical management of diabetes. Each demonstrates without a doubt that when an advanced practice clinician is involved with patient care, the patient receives high-quality care that integrates self-care management with a high level of clinical expertise. Patients become part of the health care team, making decisions and incorporating the care into their lifestyle.

So what is the future of advanced practice in diabetes care? There is an explosion in the rates of diabetes and obesity in the United States. Diabetes care providers are being called on to provide optimal outcomes using a cost-effective approach. Now that the Board Certified—Advanced Diabetes Manager credential has been developed, increasing numbers of advanced diabetes managers will serve as role models and leaders of diabetes care teams, functioning as consultants, educators, managers, clinicians, and researchers. The direction of diabetes care continues to evolve in response to both changes in state-of-the-art treatment of diabetes and the professional growth of each of the disciplines involved in the diabetes care team.5 

Research supports the need for intensive diabetes management in all people with diabetes.3,6 This requires a great deal of patient education, support, and clinical management expertise. Advanced diabetes practitioners have professional skills to deal with the complexity of decision making and intervention beyond the traditional roles of their disciplines. Because of their expanded role, they can effectively meet the needs of diabetes patients undergoing intensive management. Today and in the future, advanced practitioners will collaborate with other health care professionals to provide the best diabetes care available and to support the changing needs of people with diabetes.

Kruger DF: Our changing health care environment.
Diabetes Spectrum
Kruger DF, Childs B: Advanced practice nurses in diabetes care.
Clinical Diabetes
The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
N Engl J Med
Ahern J, Kruger DF, Gatcomb P, Petit W, Tamborlane W, for the DCCT Research Group: The Diabetes Control and Complications Trial (DCCT): the trial coordinators perspective.
Diabetes Educ
Funnell M: Alphabet soup, or more? American Diabetes Association Professional Section Quarterly, Summer, 2002, p. 3
U.K. Prospective Diabetes Study Group: Intensive blood glucose control with sulphonylurea or insulin compared to conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).