I would like to take you on a journey through the pyramids: some historic,some familiar, some controversial, and some conceptual. I will share with you five pyramids of diabetes education: points that I have found important in my own journey as a diabetes educator. I will aim to challenge you a bit to rethink a few of the traditional diabetes education paradigms and envision some new possibilities. Hopefully, you will find a few hidden treasures in these pyramids.

To begin our journey, we will need to go back in time. The Mayan Pyramids of Mexico? Or perhaps to the Egypt, where the first early accounts of diabetes were written in the Ebers papyrus? No, that is too far back. Instead, we will jump into Boston, where we have our own “pyramid”: our landmark Citgo sign with its red triangular logo beaming high above Kenmore Square and Fenway Park, home to our beloved Red Sox. It also marks the site of a less well-known address, 81 Bay State Road, which served as both home and office for Dr. Elliott P. Joslin for 50 years.

Joslin lived for 92 years and had worldwide influence. As noted in his obituary, he was best known for “his inauguration of diabetes education for the diabetic patient.”1  He was a prolific writer. Between 1916 and 1959, he published 10 editions of a textbook for physicians, as well as 10 editions of his Diabetic Manual for “the mutual use of doctor and patient.”2  I continue to be fascinated to read his writings and be reminded of his commitment to education, both of patients and professionals. Many of his messages were ahead of his time. It is also interesting to note at this time of celebrating outstanding educators, researchers, and clinicians that Joslin was the first recipient of the American Diabetes Association (ADA) Banting Medal for Scientific Achievement in 1941.

Although Joslin never spoke of a “diabetes pyramid,” he often wrote of the triad of diabetes care: diet, exercise, and insulin. “I look upon the diabetic and his chariot as drawn by three steeds named Diet,Insulin, and Exercise. It takes skill to drive one horse, intelligence to manage a team of two, but a man must be a very good teamster who can get all three to pull together.”

This image of three horses being handled by a driver in a chariot is represented on the Joslin Clinic's Victory Medal, which is given to those who live successfully with type 1 diabetes for 50 years.

Before we explore the five pyramids of diabetes education, just a few words about perhaps the most popular and controversial of pyramids: the food pyramid. Is the food pyramid an effective tool? Is it useful in diabetes education? Can it teach balance and moderation, or does it just confuse the public and lead to even worse eating habits? To consider these questions,let's review a bit of food pyramid history.

Earlier this year, the 6th edition of the U.S. Dietary Guidelines was published. The guidelines form the basis of federal food policy, nutrition education, and research funding. They have been updated every 5 years since their first release in 1980. But it was only about 15 years ago, in 1992, that the food pyramid, a graphic designed by the U.S. Department of Agriculture(USDA) to help illustrate some of the key messages of the guidelines, was released (Figure 1).

The three key concepts this pyramid was intended to convey are: variety,moderation, and proportionality. It is important to recognize that the pyramid was never designed to be a stand-alone tool. By some measures, this food pyramid was extremely successful. More than 80% of Americans recognize it. It has been adapted in hundreds of ways so that we have food pyramids in different languages, for different stages of the life cycle, for vegetarians and various ethnic cuisines, even for junk foods.

Yet it has been the subject of a great deal of recent controversy. Dr. Walter Willett of Harvard Medical School published his own pyramid that included quite radical changes to the original and has received a great deal of media attention. His 2001 book Eat, Drink and Be Healthy3 criticized the USDA pyramid as being incorrect, built on shaky science, and possibly a cause or contributor to the rising epidemic of obesity. This added to mounting pressure for the government to take a critical look at the pyramid and see if it needed drastic revision.

In spring 2005, a much-anticipated new food guidance system was released by the USDA (Figure 2). Although it remains in the shape of a pyramid, this version is even less of a stand-alone tool than the previous graphic. In addition to the three key messages of the original pyramid, it was designed to also emphasize personalization, gradual improvement, and physical activity. Individualization is achieved with an online version(www.mypyramid.gov)that leads users to specific recommendations for food servings based on weight, sex, and activity level. One improvement is that it can be used to highlight healthier (at the bottom) and less healthy (at the top) food choices that are present in each group.

Figure 1.

Original USDA Food Pyramid

Figure 1.

Original USDA Food Pyramid

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However, despite the improvements in the food pyramid, I miss the simple message of the previous version. I am concerned that it will not help an already nutritionally challenged and confused public, much less reach the people who really need it.

Figure 2.

USDA MyPyramid

I happen to be one of the few who actually liked the original pyramid. I liked the original 1980 nutrition guidelines that were designed as simple public health messages. For example, the message used to be “eat less fat.” Now, the messages aim to be so nutritionally accurate (and in some cases modified to reflect industry interests), that I fear it ends up confusing instead of helping. Today's message about fat goes something like this: “Eat less fat if it is saturated and trans, but more if it is omega-3, monounsaturated, or polyunsaturated, but not too much of the omega acids should come from fish containing methylmercury and not too much of the mono- or polyunsaturated because you'll get too many calories.” It is not surprising that so many people just throw up their hands and ignore nutrition recommendations altogether.

A number of years ago, we adapted the original UDSA pyramid at Joslin for even easier carbohydrate teaching (Figure 3). All carbs were put together at the bottom of the pyramid, yet the message of keeping sweets limited was visually displayed by marking them in a small corner section. The milk group was drawn to cross over between the carbohydrate group and the protein group. Many educators and patients found this a simple tool to quickly sort foods into carbohydrate, protein, and fat categories and give messages about variety, proportionality, and moderation.

But with the rising epidemic of obesity and concern about overconsumption of many carbohydrate foods, critics have pointed to the food pyramid as the culprit. Is this justified? Did the food pyramid cause the obesity crisis? As someone who has put much energy into designing and writing patient education materials, I almost wish the answer were yes. Imagine any illustration that could make such a major impact on behavior. I mean, if the pyramid caused the obesity epidemic, then fixing the pyramid could solve the problem of obesity.

Clearly, though, the obesity epidemic has multiple causes. A study of Americans' food consumption habits4  showed that only 45% consume three servings of vegetables a day, 28% eat the recommended two servings of fruit, and 27% eat three dairy servings daily. There is, as one might expect, a huge amount of overconsumption from the“limit” section of the pyramid, with large amounts of added fats and sugars, particularly in the form of soft drinks and other sweetened beverages. Consider the fact that soft drink consumption has increased 135%since 1977. The average daily intake of teenaged boys who drink sodas is 2.2 cans.5  The risk of obesity rises 60% for each daily serving.6  So truly,it is not fair to blame the pyramid for the nation's poor eating habits.

Former ADA President Francine Kaufman has done an amazing job, both through her excellent book Diabesity and her remarkable personal efforts to make small but significant changes in the food environment. She had called attention to the excess consumption of sweetened beverages and soft drinks and has successfully gotten soft drinks removed from vending machines in the Los Angeles public schools, a success that is now being repeated across the country.

In her book, Kaufman writes, “Reversing the trends of physical inactivity and unhealthy eating will require coordinated efforts from local,state, and national governments, public and private industry, community and religious organizations, schools, and the health care system. We must create an environment that supports healthy lifestyles. Only when we have this kind of support will we truly have the freedom to make the right choices.”7 

Figure 3.

Joslin's adapted food pyramid

Figure 3.

Joslin's adapted food pyramid

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Marjorie Cypress, 2004 recipient of the ADA Outstanding Educator in Diabetes Award, spoke last year about moving from a treatment paradigm to one of prevention and urged us all to become even more involved at a grass-roots level to bring about small changes. Take the opportunity to see what can be done in your own community, workplace, schools, and health care institutions to advocate for healthier food choices and safer public spaces for physical activity. Advocate for:

  • Smaller portions

  • Better choices in vending machines

  • Better choices for food served at meetings

  • Reviewing snack options sold in hospital gift shops

  • Increasing access to fresh fruits and vegetables

  • Sidewalks and safe, well-lighted stairwells and parks

As Cypress said, “Diabetes educators have a strong and persuasive voice. When we band together, we can be heard.”8 

Now, on to the five points I have found important as a diabetes educator. These might just as well be called “pillars” of diabetes education. But since I've been seeing nothing but pyramids lately, I've decided to call them the five pyramids of diabetes education. And in the spirit of the KISS principle (keep it short and sweet), I have narrowed them down to just five words: counsel, challenge, coach, contribute, and collaborate.

Counsel

The first pyramid stands for counsel. If I were constructing a single diabetes education pyramid, this would be at the bottom, because counseling,clear communication, and education are the base of what we do. But I continue to be concerned that just because we may educate and teach does not mean our patients learn or change their behaviors. The recent increased emphasis on measuring and monitoring self-care behaviors will help keep us on the right track. I also urge educators to put increased emphasis on listening first and tailoring their message to what their patients really want and need instead of teaching a standard curriculum.

Two years ago, Barbara Anderson gave a wonderful address about communicating as the 2003 recipient of the ADA Outstanding Educator in Diabetes Award. She reminded us to “observe, understand, respect, and then converse. It's all about listening first and then individualizing from what you hear.”9  The message of the importance of patient-centered communication that is based on active listening is not new. However, educators are being challenged to adapt these skills they had been refining for one-on-one counseling for application in group settings.

Another important message about counseling can also be represented by a pyramid. Visualize a Mayan pyramid with many small steps. Diabetes education is about not getting to the top, but rather taking each gradual step in the right direction.

I encourage you to take inspiration from two more former recipients of the Outstanding Educator in Diabetes Award, Martha Funnell in 1999 and Robert Anderson in 2000, both from the University of Michigan, and shift your paradigm of teaching from traditional to empowered. Funnell and Anderson's many articles and excellent book The Art of Empowerment10 guide educators to move from traditional roles in which we are the diabetes experts, teaching classes, following outlines, and offering solutions to a more empowered approach in which we serve more as behavior change experts,facilitators, and listeners and teach based on where patients are and what they need.

Funnell has written that “the more I listen rather than talk, the more I ask rather than tell, the more I help patients to explore their own problems rather than advise, and the more I resist labeling and categorizing patients, the better able I am to facilitate their learning.” And Anderson reminds us that “our role is not to change our patients'behavior, but to inspire, inform, support, and facilitate their efforts to identify and attain their own goals.”10 

Challenge

The second pyramid represents both the challenges we face and the opportunities we have to stretch and challenge ourselves to come up with new solutions.

The challenges we face in diabetes care and education are many(Table 1). The epidemic continues to grow with 18 million people in the United States now having diabetes, and 40 million having pre-diabetes. Of particular concern is that the highest risk groups for developing diabetes are also the fastest growing populations. Targets for diabetes control are not being met, and recent studies have shown that significant improvements in diabetes control have not been shown during the past 10 years.11,12 It is true that racial and ethnic minorities receive a lower quality of care than nonminorities, and an estimated 90 million Americans have inadequate literacy skills.13 Education programs continue to close, often for financial reasons because the costs for delivering quality diabetes care are not generally covered, given limited reimbursement and poor collection practices. And, we need a more diverse group of diabetes educators. One recent survey14  showed that 70% of diabetes educators practice in urban and suburban areas, and 84%are white. This is not reflective of the populations we need to serve.

Table 1.

Challenges Facing Diabetes Educators

Challenges Facing Diabetes Educators
Challenges Facing Diabetes Educators

Some of these challenges are complex and require multidimensional systems changes. But I would like to address one challenge we face on a daily basis in my work setting: the need to enhance educator skills in practice management. For our discipline to thrive and grow, we need to provide better training for diabetes educators in business, practice and program management, and marketing skills. Many educators who work for outpatient clinics and ambulatory centers need training to think like someone in private practice.

Several years ago, I presented an abstract in which I reported on data from an educator time study (Table 2).15 In general, diabetes educators are not efficient at spending their time in billable activities. Even though the educators are completely busy and are accounting for > 8 hours of work time a day, only 3.5 hours are spent in billable patient care activities. Those of us who work in health care systems that rely on patients to pay for the service or on third-party or Medicare reimbursement must become more efficient at doing what is billable and spend less time on phones, charting, tracking down no-shows, and performing other nonbillable tasks.

Table 2.

Educator Activity Audit

Educator Activity Audit
Educator Activity Audit

Educators in ambulatory settings need to adopt the practice patterns and approaches of those who work in private practice to help ensure the survival and growth of their diabetes programs. Even the highest quality program delivered by the best educators cannot survive if it is not running in a cost-efficient manner.

The challenge is not only to think outside the box, but also to brainstorm alternate, maybe even crazy, solutions to some of the problems we face. The Continuous Quality Improvement process, a required element of ADA-recognized education programs, encourages this. Do not just jump to the first solution you think of; alternate ideas may be more effective and efficient.

Diabetes education will be changing. I see it being delivered in alternate settings, such as churches, grocery stores, and workplaces. We will use alternate methods and more technology, such as phone-based and interactive internet programs. And, we'll have a wider range of educators, including community health workers and trained peer counselors. Let's be the group that drives these changes to increase access while maintaining quality.

Coach

The third pyramid is for coaching. For me, the enormity of the diabetes and obesity epidemics clearly means we cannot be the sole providers of diabetes education. Perhaps thinking about coaching or training others to provide diabetes education, a bit like a pyramid scheme, could help us spread the word more effectively than trying to touch each patient individually. Joslin recognized this when he wrote, “the number of cases is so great... that their care must rest in the hands of the general practitioner. It is ridiculous to expect that the treatment of [all] diabetics should be under the supervision of a specialist.”

Dr. Leo Krall, a passionate advocate for diabetes education and one of my important early mentors, wrote in the 1985 edition of Joslin's Diabetes Mellitus about a “pyramid of training”(Figure 4). Krall, the 1980 recipient of the ADA Outstanding Physician Clinician Award,wrote that “ideally, the teaching of educators is a simple pyramid,where each level is an immediate contact with the next with education broadly expanding to the patient.”16 To update this pyramid idea for 2005, I might add “diabetes educators” to the physician segment at the top and add lay health educators, promotoras (lay health workers), and peer heath counselors to the mid-level section.

Figure 4.

Krall's education pyramid. Krall wrote, “Ideally, the teaching of educators is a symple pyramid, where each level is an immediate contact with the next with education broadly expanding to the patient.” Adapted from Ref.EF1616 .

Figure 4.

Krall's education pyramid. Krall wrote, “Ideally, the teaching of educators is a symple pyramid, where each level is an immediate contact with the next with education broadly expanding to the patient.” Adapted from Ref.EF1616 .

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For the past 2 years, I have been part of a unique project to train a group of health care workers who have rarely been the target of any diabetes education efforts: medical office assistants. The program is called Joslin Diabetes SmartStart and is based in New York City and Detroit. The program is delivered by five certified diabetes educators who provide no direct patient care but do give ongoing inservice education, resources, and support to primary care provider offices. In 2 years, we have enrolled 1,600 primary care providers, bringing kits of diabetes education resources to their offices. We have delivered a 2-hour diabetes training program to > 2,500 medical office staff workers. It is exciting to see that even this small intervention can make a difference. After the 1st year of data collection, outcomes improvements included a decrease in A1C of 0.6%, a decrease in patients'feelings of hopelessness and depression, and an increase in physicians'confidence.

My proposed paradigm shift, then, is to move from thinking of ourselves mainly as patient educators to thinking of ourselves as educators of other providers or “educator educators.” I am not recommending that we turn medical assistants into “diabetes educators.” But we must provide a wider group of professionals with the basic skills to understand diabetes and provide simple messages regarding standards of care and risk reduction to patients. This includes spending more time mentoring young students to enter the field, especially those representing minorities and rural areas.

Contribute

The fourth pyramid, contribute, means both recognizing and honoring the contributions of others and looking for ways you can contribute to your profession. I love the tradition of medals Joslin started to honor those who lived with insulin first for 25 years, then for 50 years, and recently for 75 years. He even had a medal designed to acknowledge the contributions animals have made in the name of scientific research. Some of the educators I have worked with have implemented creative ideas to recognize patients' efforts and successes, from issuing certificates to posting a “Wall of Fame”in the clinic, to encouraging patients to celebrate their anniversary of living well with diabetes.

Your own contributions are also important, be they your time, ideas, money,or energy, because the more you invest, the greater the return. As my friend and mentor Marion Franz, 1985 recipient of the ADA Outstanding Educator in Diabetes Award, has put it, “If you see a void... jump in!” One of the most lucrative investments I made was in joining and actively volunteering for the ADA. You don't have to be on a board or a committee to contribute to the ADA. All it takes is a letter to share your ideas, suggestions, or concerns. When I chaired the Education Recognition Committee, we made policy changes based on the letters, suggestions, and real-world experiences of educators in the field who took the time to contribute by expressing their ideas and needs. In the words of Anne Daly, 1997 recipient of the Outstanding Educator in Diabetes Award, “ADA is my ADA, it is your ADA, and it is our ADA. Find a niche that fits you and your interests.”17 

Collaborate

And the final pyramid: collaborate. Joslin recognized the importance of this when he wrote, “Experience, the nurse, the doctor, the parents,grandparents, brothers and sisters working together will finally bring success.”18 Diabetes education is all about working together. I have gained many riches from the multidisciplinary work I have done through ADA committees and projects. These activities always include physicians, educators, and lay representatives. We each bring a unique perspective to the team. Collaboration is sharing those ideas and learning to think in new ways.

To summarize, then, the five pyramids of diabetes education are:

  • Counsel: Effectively guide and communicate with people about diabetes.

  • Challenge: Look at the problems we face and think outside the box to explore creative, alternative solutions.

  • Coach: Help others become messengers of diabetes education, and mentor others to enter the field.

  • Contribute: Give what you can to keep advancing diabetes education: your time, ideas, money, and energy.

  • Collaborate: Work together to achieve the best results.

When all these pyramids come together, amazing possibilities can be realized.

I'd like to close with a quote from Methodist minister John Wesley that appears at the end of a short book titled Elliott P. Joslin, MD: A Centennial Portrait.1  It captured the essential ingredients of Joslin's long career and offers important words for us all to live by:

Do all the good you can, By all the means you can, In all the ways you can,In all the places you can, At all the times you can, As long as ever you can.

John Wesley's Rule

Editor's note: This article is adapted from the address Ms. Maryniuk delivered as the recipient of the American Diabetes Association's Outstanding Educator in Diabetes Award for 2005. She delivered the address in June 2005 at the association's 65th Annual Meeting and Scientific Sessions in San Diego, Calif.

Melinda D. Maryniuk, Med, RD, CDE, is the associate director of Affiliate Programs and Services at the Joslin Diabetes Center in Boston,Mass.

1.
Barnett DM:
Elliott P. Joslin, MD: A Centennial Portrait
. Boston,Mass. Joslin Diabetes Center,
1998
2.
Joslin EP:
A Diabetic Manual
. Philadelphia, Pa., Lea &Febiger,
1918
3.
Willett WC:
Eat Drink and Be Healthy: The Harvard Medical School Guide to Healthy Eating
. New York, Free Press,
2001
4.
Goldberg JP,Belury MA, Elam P, Finn SC, Hayes D, Lyle R, St Jeor S, Warren M, Hellwig JP:The obesity crisis: don't blame it on the pyramid.
J Am Diet Assoc
104
:
1141
–1147,
2004
5.
California Center for Public Health Advocacy [article online]. Available from http://www.publichealthadvocacy.org/resources/Soda%20Fact%20Sheet11.04.pdf
6.
Ludwig DS,Peterson KE, Gortmaker SL: Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective observational analysis.
Lancet
17
:
505
–508,
2001
7.
Kaufman FM:
Diabetsity: The Obesity-Diabetes Epidemic That Threatens American and What We Must Do to Stop It.
New York, Bantam Books,
2005
, p.
221
8.
Cypress M: Looking upstream.
Diabetes Spectrum
17
:
249
–253,
2004
9.
Anderson BJ:Cowboys and horse whisperers: changing paradigms of diabetes education and care.
Diabetes Spectrum
16
:
269
–272,
2003
10.
Anderson B,Funnell M:
The Art of Empowerment: Stories and Strategies for Diabetes Educators
. 2nd ed. Alexandria, Va., American Diabetes Association,
2005
11.
Saydah SH, Fradkin J, Cowie CC: Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes.
JAMA
291
:
335
–342,
2004
12.
American Association of Clinical Endocrinologists: Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus Conference Recommendations: Position Statement. 2005 [article online]. Available from http://www.aace.com/pub/odimplementation/PositionStatement.pdf
13.
Rothman RL, DeWalt DA, Malone R, Bryant B, Shintani A, Crigler B, Weinberger M, Pignone M:Influence of patient literacy on the effectiveness of a primary care-based diabetes management program.
JAMA
292
:
1711
–1716,
2004
14.
Zrebiec J: A national study of the certified diabetes educator: report of a job analysis conducted by the National Certification Board of Diabetes Educators.
Diabetes Spectrum
18
:
181
–185,
2005
15.
Maryniuk MD, Moore T, Weinger K, Blair E, Connor D, Hare J: Diabetes educator productivity: an outpatient time study of daily activities [Abstract].
Diabetes
50
(Suppl. 2):
A75
,
2001
16.
Krall LP:Education: a treatment of diabetes. In
Joslin's Diabetes Mellitus
. 12th ed. Marble A, Krall LP, Bradley RF, Christlieb AR,Soeldner AR, Eds. Philadelphia, Pa., Lea & Febiger,
1985
, p.
469
17.
Daly AE: The best of times, the worst of times: now is the time.
Diabetes Spectrum
15
:
277
–279,
2002
18.
Joslin EP:
A Diabetic Manual.
5th ed. Phildelphia, Pa., Lea &Febiger,
1934