Colorectal Cancer on the Rise Among Under-50s and POC

Colorectal Cancer on the Rise Among Under-50s and POC

The tragic death of Chadwick Boseman at age 43 following a four-year battle against colorectal cancer underscores two important public health concerns.

First, the incidence of colorectal cancer has risen dramatically among adults under age 50 in the U.S. and in many countries around the world. Second, African Americans have a much greater likelihood of being diagnosed and dying from the disease at any age. Both issues are important to the public health community and efforts are ongoing to address them.

Origoinally published in The Conversation.
Originally published in The Conversation

Colorectal cancer remains a major source of cancer incidence and death in the U.S. The American Cancer Society estimates that in 2020, about 147,950 people will be diagnosed with colorectal cancer and 53,200 will die from the disease, making it the fourth most prevalent form of cancer and the second leading cause of cancer mortality.

As a scientist conducting basic research on colorectal cancer, I have been generally aware of these sobering trends.

Colorectal cancer cases rise among adults younger than 50

In 2017, Dr. Rebecca Siegel and colleagues published detailed and compelling statistical data clearly bringing the issue into sharp focus, stimulating greater coverage in the media.

Analysis of trends in colorectal cancer incidence and mortality have clearly shown a decline in the general U.S. population overall during the past few decades. Unfortunately, this has not been the case for young adults.

For example, incidence has decreased by an average of 4% per year between 2007 and 2016 in those over 65 years of age, in contrast to an increase of 1.4% per year during the same period in those under 50. The observed decrease in older adults is likely due to preventive screening, which is recommended and advocated for people over 50 and has been undertaken by a larger fraction of the population.

Similarly, colorectal cancer mortality has declined by 3% per year between 2008 and 2017 in those over 65, while it has increased by 1.3% per year in those under 50.

The American Cancer Society predicts 17,930 new cases of colorectal cancer within the under-50 population and 3,640 deaths in 2020. Expectations are that the fraction of cases occurring in young adults will increase even more over the next decade, and may carry over to those over 50.

I have met a number of young people, including several in their 20s and 30s, who had been diagnosed with colorectal cancer and were in the midst of fighting it. I have also met parents who lost young adult children to the disease, and were still trying to understand how this could have happened.

I have been struck by the intensity and complexity of emotions displayed by these people, including anger, resentment, embarrassment, hopelessness, fear and resolve. While a cancer diagnosis at any age is scary and disorienting, it extracts a particularly powerful psychological and social toll on young adults.

What is causing the increase in young adults? We do not know for certain. Several studies have indicated that the disease in young people is different with regard to the specific location of the tumor within the colon or rectum.

Also, the pathology, genetics and response to treatment differ. Lifestyle trends, such as overweight and obesity, lack of physical activity and changing diets, have been suggested to play roles. Studies have indicated that obesity is associated with increased risk of early-onset colorectal cancer in women.

While these trends may contribute, they are not fully explanatory. Physicians have told me anecdotally that many of their younger patients are thin, fit, physically active and in general good health, suggesting that something else must be going on.

What could that something else be? One intriguing possibility may lie in the billions of microbes, collectively termed the microbiota, that live on and within our bodies. Preliminary findings reported at the 2020 Gastrointestinal Symposium recently indicated that there may be differences between the microbiota within tumors from younger versus older colorectal cancer patients.

African Americans and colorectal cancer

Black Panther star Chadwick Boseman died of colorectal cancer at age 43.
(Source: Wikimedia Commons)

The death of Boseman has also underscored the long-standing racial disparity for colorectal cancer. African Americans suffer from high incidences and mortalities, regardless of age. Incidence in African Americans was 18% higher than in whites during 2012-2016, while mortality was 38% higher during the same period. For reasons we do not yet know, incidence in younger African Americans has been relatively stable in contrast to that in younger whites.

Increased incidence and death from colorectal cancer in African Americans is likely a consequence of lower rates of screening, as well as environmental, socioeconomic and lifestyle factors. Reduction of the disparities may depend upon addressing these factors.

Screening can prevent colorectal cancer

Screening for colorectal cancer not only detects the disease but is also highly effective in preventing it. Screening can readily identify precancerous growths called polyps, as well as early-stage cancers. These often can be removed before they progress to life-threatening stages.

Any of a number of methods for colorectal cancer screening are now available, including colonoscopy, flexible sigmoidoscopy, imaging and several stool-based tests.

In addition, research is underway to find new methods for colorectal cancer screening based upon analysis of easily obtained body fluids such as blood and urine.

(Source: Wikimedia Commons)

Based upon the knowledge that about 90% of colorectal cancer cases occurs in those 50 and over, the U.S. Preventive Services Task Force currently recommends that screening should begin at age 50 for those who have no predisposing symptoms. This population is experiencing the decrease in colorectal cancer incidence and death that is currently being observed overall.

But screening is not typically recommended for those under 50, and most health insurers do not pay for screening in this group.

This lack of screening, combined with a general lack of awareness about colorectal cancer and its symptoms among young people can result in late diagnoses. Later diagnoses can often result in more advanced stages of the disease, when it is harder to treat and significantly more lethal.

Recently, the American Cancer Society recommended lowering the screening age to 45, in order to catch a good percentage of the younger people whose risk may be increasing. Health-related professional organizations such as the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention have yet to adopt them. This may change, as discussions are ongoing.

There is also a need to increase screening in the African American community. At present, recommendations vary. In contrast to the U.S. Preventive Services Task Force and the CDC, the U.S. Multi-Society Task Force recommends that screening in African Americans should begin at age 45 rather than 50. I hope these influential organizations will reach a consensus on this issue.

Sorting out the causes of age and race disparities in colorectal cancer incidences and mortalities, and understanding the nature of the disease more thoroughly, will take time.

As Boseman’s untimely death reminds us, colorectal cancer is a difficult and emotional disease for all people at any age. Awareness of signs and symptoms, along with engagement in screening as appropriate, will lead to the eventual eradication of the disease as a major form of cancer.

The Conversation
Vaccinating a Nation: a Guide to Achieving Herd Immunity

Vaccinating a Nation: a Guide to Achieving Herd Immunity

Flu season is here, and the media is filled with news about the new Covid vaccines, so this is a good time to have a sort of primer explaining the profound importance of vaccination for communities as well as individuals. [email protected], the online MSN program from the School of Nursing and Health Studies at Georgetown University, has kindly allowed DailyNurse to share their guide to the essentials of herd immunity and tips for addressing vaccine-hesitant patients and loved ones.

What is Herd Immunity?

Also referred to as “community immunity,” herd immunity is a public health term used to describe a case in which the potential for person-to-person spread is significantly reduced due to the broader community’s resistance against a particular pathogen.

A Glossary of Important Vaccination-Related Terms

  • Active immunity: Immunity as a result of the body’s antibody creation after exposure to disease-causing pathogens, either through natural infection or vaccination.
  • Herd immunity threshold: Also called the “critical vaccination level,” this is the approximate percentage of a population that needs to be vaccinated in order to reach herd immunity status.
  • Immunity: Resistance to a particular pathogen, or disease-causing bacteria, through antibodies.
  • Inactivated vaccine: A vaccine using a killed form of the disease-causing germ. This vaccine usually requires multiple doses over time to form immunity. Examples include the DPT and Hepatitis A vaccines and the flu shot.
  • Live attenuated vaccine: A vaccine using a weakened form of a germ to produce an asymptomatic infection and generate an immune response similar to a natural infection, without sickness. Examples include the MMR and chickenpox vaccines.
  • Natural infection: Contraction of a disease through person-to-person transmission or interaction with disease-causing bacteria.
  • Passive immunity: Immunity after receiving disease-fighting antibodies from an external source.
  • R0 (Pronounced “r-naught” or “r-zero”): The reproductive number of a disease that describes the average number of additional cases a single infected person creates.
  • Subunit vaccine: A vaccine using a component of the germ (such as a specific protein) to produce an immune response. This vaccine does not contain a live germ. Examples include the shingles and HPV vaccines.
  • Vaccine: A controlled simulation of natural infection meant to trigger antibody creation that helps fight against the disease later, without sickness.

Why is Herd Immunity So Important?

When enough community members are immune to a virus so that it inhibits spread, even those who are not vaccinated will be protected. The “herd” collectively provides insulated safety to all members, which is important for those who are too high-risk for certain vaccinations.

For example, the yellow fever vaccine should not be administered to individuals who are pregnant, have a weakened immune system, or have specific allergies, according to the CDC guidelines on who should not be vaccinated.

For these individuals, it is important that their community has built an immune response to the yellow fever so they are not at risk of infection and transmission. Individuals who are too high-risk to get a vaccination are often more likely to contract the illness and experience serious symptoms.

Some other reasons why people cannot get certain vaccinations include:

  • Age
  • Allergies
  • Pregnancy
  • Recent blood transfusion
  • Underlying medical conditions like lung or heart disease
  • Weakened immune system

Elke Jones Zschaebitz, DNP, ARPN, FNP-BC, and faculty member at Georgetown University School of Nursing & Health Studies, likens herd immunity to a perimeter fence that ensures the safety of the broader community.

“It’s like a little nuclear circle,” she said. “So that our babies that can’t get vaccinated yet, or our pregnant mothers, or our elderly with immune systems [that] are not as robust, or people who have certain kinds of conditions that they don’t have the correct immunity, will have protection from the active pathogen that could possibly harm or kill them.”

HITs and R0s: the Science Behind Herd Immunity

Herd Immunity: Few vaccinated
Herd Immunity: all vaccinated

In a community where no one is immune to a virus, a disease can spread rapidly and lead to an outbreak. As individuals acquire immunity, either through infection or a vaccine, the disease spreads more slowly because fewer people can pass it on.

In a community where enough members are vaccinated, the disease will stop spreading because the virus will not be able to find susceptible hosts.

The herd immunity threshold (HIT) varies depending on a variety of epidemiological factors. The primary consideration is the infectiousness of a disease. Infectiousness is measured by the Basic Reproduction Number or reproductive ratio—often referred to as R0 (“r-zero”). R0 refers to the number of cases expected to occur on average in a susceptible population as a result of infection by a single individual at the start of an epidemic before widespread immunity starts to develop. So if one person develops the infection and passes it on to two others, the R0 is 2. Herd immunity helps R0 drop below 1.

Here are some examples of R0s for a few well-known infectious diseases:

  • Measles R0: 12-18
  • Polio R0: 5-7
  • Ebola R0: ~2

Numbers for COVID-19’s R0 vary —The Atlantic reported a range of about 1.5 to 5.5 in February, while more recent estimates from WHO place COVID-19’s R0somewhere between 2 and 4 (PDF, 2 MB). The herd immunity threshold (HIT) varies depending on a variety of epidemiological factors. The primary consideration is the infectiousness of a disease, often referred to as R0; herd immunity helps R0 drop below 1.

“The higher R0 is, you’ll have to have really, really high [levels of active immunity], or it’s still transmissible and the vulnerable population will still get it,” Thompson-Brazill said.

A September 2020 report in Nature Reviews Immunology expects COVID-19’s herd immunity threshold to equal 67%, if R0 is 3. However, the Government Accountability Office cautioned researchers against reaching any conclusions regarding herd immunity for COVID-19 (PDF, 276 KB), as much is still unknown about the contagiousness of the disease.

The Role Clinicians Play in Herd Immunity and Vaccination

Zschaebitz and Thompson-Brazill have years of experience in various health care settings— from travel clinics and trauma units to international research. Some of the ways that clinicians increase herd immunity and vaccination include:

  • participating in global research to genotype communities and help produce viable vaccines.
  • administering vaccines so patients can stay up-to-date on immunization schedules and travel requirements.
  • educating patients on the importance of vaccination and specific information related to different vaccines.

How to Talk to Patients, Family, and Friends About Vaccination

Thompson-Brazill shared her experience speaking with patients who are vaccine-hesitant and said she has learned that one of the roles clinicians play in herd immunity is educating patients about why vaccines are safe and normative for society.

Zschaebitz also shares the importance of herd immunity with patients — often through the retelling of her own experiences genotyping Maasai tribal women for an HPV vaccine.

“We were interested in preventing deaths of cervical cancer because in certain countries women just die,” she said. “Declining a vaccination is sort of a first-world problem because people in other nations would walk for miles to get what we have and what we take advantage of.”

Thompson-Brazill and Zschaebitz’s tips for speaking to vaccine-hesitant friends and family:

Tip #1: Avoid pointed questions that could make someone defensive.

Instead of: “Why wouldn’t you get the shot?” Try: “What about the shot worries you?”

Tip #2: Use storytelling as a way to share your experience.

Instead of: “I can’t believe you are not going to vaccinate your children” Try: “I chose to vaccinate my kids because…”

Tip #3: Refer people to credible, reliable sources.

Instead of: “Why would you believe that? That’s just a hoax!” Try: “The CDC has a lot of useful information about vaccines and potential risks. Have you read what they have to say?”

Tip #4: If you do not know how to respond, recommend an expert who does.

Instead of: “I can’t talk to you about this; we will never agree.” Try: “Have you shared your concerns with your clinician? They will be able to answer your questions.”

A Herd Immunity FAQ

Is it possible to achieve herd immunity without a vaccine?

Because the herd immunity threshold is so high, achieving herd immunity without a vaccine is unlikely, according to the American Lung Association. The likelihood depends on the disease’s R0, because a lower threshold would be easier to reach naturally. However, the severity of a disease could also mean that many individuals in a community would succumb to a disease before broader immunity is obtained.

Is herd immunity effective against all diseases?

No, not all diseases can be overcome with herd immunity. For example, herd immunity cannot be achieved for Clostridium tetani, the bacteria that causes tetanus. Although infection is avoidable via individual vaccination, the “herd” cannot provide protection. For example, the immunity of others will not prevent an individual from contracting tetanus after stepping on a rusty nail.

Can you still get the flu after a flu shot?

It is possible to become sick with a strain of influenza that the vaccine was not developed to protect against. However, the CDC says that the flu vaccine will minimize the severity of symptoms among those who do get sick. Other reasons someone could experience flu-like symptoms after getting a flu shot include contracting a different respiratory illness and exposure to the flu virus shortly before vaccination.

Why do I need to get vaccinated for diseases we already have herd immunity for?

Some immune responses weaken over time, which is why booster shots are so important. Additionally, vaccine refusal can lead to waning community immunity. For example, in 2019, measles outbreaks in New York and Oregon threatened the United States’ 20-year measles elimination status, according to a press release from HHS on measles outbreaks in 2019.

Is immunity from a natural infection stronger than immunity from a vaccination?

Yes. Natural immunity, the result of antibody production after natural infection, is often more effective and longer-lasting than acquired immunity via a vaccine. However, acquired immunity is safer. Some cases of natural infection can be accompanied by symptomatic illness and severe outcomes like pneumonia, liver cancer, and even death, according to an article on vaccine safety from the Children’s Hospital of Philadelphia.

Reliable Information Sources on Vaccines and Vaccination

Both Zschaebitz and Thompson-Brazill recommend using nationally recognized, expert-led sources to learn more about vaccines, like the CDC, FDA, and NIH. Some of the additional resources available include:

  • CDC Immunization Schedules External link : The CDC-recommended vaccination series and timing schedule for children, adolescents, and adults.
  • The CDC Yellow Book External link : A set of travel health guidelines, including country-specific vaccine recommendations and requirements.
  • Questions About Vaccines, FDA External link : The FDA’s collection of information regarding specific vaccines and approvals.
  • The Power of Herd Immunity, TED Talk by Romina Libster External link : Health researcher Romina Libster tells the story of an H1N1 outbreak in her town and the role of herd immunity.
  • Vaccines by Disease, HHS External link : Vaccine-specific answers to questions such as: “Why is this vaccine important?” and “What are the side effects of this vaccine?”

DailyNurse would like to thank the Georgetown School of Nursing and Health Studies and the [email protected] site for allowing us to share this guide.

Soap-ology: Quick Facts About Soap and How it Protects You from Infection

Soap-ology: Quick Facts About Soap and How it Protects You from Infection

Take plain liquid soap, and apply in a dime-sized drop on your hands; rub with water over palms, fingers, and up to one’s elbows for at least 20 seconds, then rinse thoroughly with clean water. It lacks the dramatically biting, corrosive, “ah, we’re killing germs!” odor of 79% rubbing alcohol or chlorine bleach, but spending less than a minute manipulating an unassuming bottle of hand soap at the sink deploys one of the most effective weapons in our arsenal against viral and bacterial infections. Is soap really that powerful?

Nurses know that the efficacy of hand-washing has long been established by science and that ordinary hand soap—unaccompanied by any additional “germ-fighting” anti-bacterial ingredients—easily destroys more viruses and bacteria than even the costliest hand-sanitizers. But how does it work? Here are some facts that might help your patients understand why they need to spend quality time at the sink.

How Does Soap Work?

Soap is a surfectant. When combined with water, surfectants help the water to spread out and cover surfaces—whether hands, counter-tops, dishes, or clothes—so they can be thoroughly cleansed. In effect, surfectants are a tool for removing germs (i.e., bacteria, viruses, fungi, and protozoa that can cause disease).

As we go about our business, germs on the surfaces and people we touch adhere to the oils on our hands. Water on its own cannot penetrate oils, but rubbing your hands with both soap and water breaks down the oils, which carry germs away as you rinse your hands. The key is in the action of surfectants against oil and dirt. Soap molecules have hydrophilic heads that cling to water molecules and hydrophobic tails that avoid water molecules. When mixed with water, soap molecules form into tiny hydrophobic balls called micelles. As the micelles move across the surface being cleaned, they attract and absorb oils and fats (along with the germs and dirt clinging to those oils and fats). When you rub your hands with soap and water and rinse them under the tap, the clean water carries soap, oils, and germs down the drain.

Soap v COVID-19

breaks down coronaviruses. During the process of hand-washing, according to National Geographic, soap “pries open the coronavirus’s exterior envelope and cause[s] it to degrade. These soap molecules then trap tiny fragments of the virus, which are washed away in water.”

Hand-Washing is an Ancient Practice, but Hand Hygiene is a Modern Development

Humans have been using soaps made from fats, oils, and salts for millennia, but even the efforts of Florence Nightingale failed to convince many people that hand-washing reduces the spread of infection. In fact, it was a 1980s series of food-borne and other infectious outbreaks that prompted the CDC to establish hand hygiene guidelines!

Quote: “Soaps were not to be found in early Ancient Roman baths; even Cleopatra was confined to essential oils and fine white sand (as an abrasive) for cleansing.” –Open University, The History of Soap-Making

Liquid v Bar?

Everyone has at some point faced a gray, gunky bar of soap sitting in a scummed dish and wondered. Quis custodiet ipsos custodes? Or in this case, “who cleans the cleaners?” Despite the dire optics, scientists believe that any soap—yes, even that nasty lump sitting beside your brother’s bathroom sink—is more sanitary to use than no soap at all. In two studies—one in 1965, and another in 1988—researchers actually applied biological contaminants to bars of soap and found that bacteria did not adhere to users’ hands after the washing process. The 1988 study stated, “After washing, none of the 16 panelists had detectable levels of either test bacterium on their hands.” No evidence has emerged to contradict these studies, and the CDC recommends either bar or liquid soaps as a defense against infection.

Regular v Antibacterial?

There is no need to waste money on “anti-bacterial” soaps. The Minnesota Department of Health bluntly states, “Antibacterial soaps are no more effective than plain soap and water for killing disease-causing germs outside of health care settings. There is no evidence that antibacterial soaps are more effective than plain soap for preventing infection under most circumstances in the home or in public places.”

Hand Sanitizer or Soap and Water?

Alcohol-based hand sanitizers are a very convenient substitute for soap and water, but they do not serve as a full-time alternative. Scientists at the CDC decidedly prefer old-fashioned scrubbing: “Soap and water are more effective than hand sanitizers at removing certain kinds of germs… Although alcohol-based hand sanitizers can inactivate many types of microbes very effectively when used correctly, people may not use a large enough volume of the sanitizers or may wipe it off before it has dried.” They also warn, “When hands are heavily soiled or greasy, hand sanitizers may not work well.”

Healthcare providers are an exception, though. The CDC notes that “hand sanitizers work well in clinical settings like hospitals, where hands come into contact with germs but generally are not heavily soiled or greasy.” They recommend that HCPs use sanitizers with 60-95% alcohol “unless hands are visibly soiled,” and add that “an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water.”

Are “Scrubbing Bubbles” Really a Thing?

A soap bubble is made up of two layers of soap molecules with a thin layer of water between them. But does it have a practical use during the cleaning process? From a hygiene standpoint, lather is a useful visual cue as you scrub your hands and it can help create more friction as you rub a surface, but it does not play an active role in cleansing. Even though it is known that hard water creates less lather than soft water, cleaning with either is equally effective. However, most people find lather appealing, so if lather encourages hand-washing it does have value, as long you remember to rinse thoroughly!

4 Ways to Keep the Hearing-Impaired in the Conversation During the Pandemic

4 Ways to Keep the Hearing-Impaired in the Conversation During the Pandemic

While wearing a face mask can be uncomfortable for some people, the mandate is particularly difficult for the deaf and hearing impaired. 

Research performed on a variety of mask types showed that while surgical masks only reduce noise by about five decibels, cloth masks reduce sound by approximately 21 decibels. Additionally, masks muffle high-frequency pitches, which are typically the most difficult for the hearing-impaired community to register. 

This makes communication increasingly difficult for the hearing-impaired community, and miscommunication in medical centers was a leading cause of hospital readmission before the pandemic. 

As wearing masks is essential to the protection of both patients and medical staff during the pandemic, institutions are working to find a solution that will safely improve communication with hearing-impaired patients. Here are four things you can do to communicate with the hearing impaired across the barrier of a mask:

1. Use a Face Mask with a Window

One of the biggest problems with most masks is that they conceal the mouth, which makes it impossible for the hearing impaired to read lips. A solution to this is to wear a face mask with a transparent window.

Face masks with windows also make it easier for the hearing impaired to see your facial expressions, which further guides the conversation.

One drawback with these is that some types of window face masks fog up quickly during conversations. To reduce fog, purchase anti-fog vinyl windowed face masks, or you can clean them with lens wipes for eyeglasses.

2. Reduce Background Noises

Another way to make conversing easier for the hearing-impaired community is to reduce background noise. If you can’t turn down the noise, suggest moving to a quieter room to talk.

As some people are embarrassed by hearing impairment, making the suggestion yourself removes the burden from them.

3. Practice Conversation Etiquette for the Hearing Impaired

Practicing basic communication skills can also significantly improve conversation comprehension with the hearing impaired and can be done with a mask.

Before you begin speaking, be sure the hearing-impaired person is listening to you. You can tap them on the shoulder or call their name to get their attention. Once you have their attention, stand directly in front of them and speak slowly and clearly.

If they ask you to repeat, don’t repeat with the same words. Some words have higher frequency pitches than others, so rephrase what you said and use short sentences.

Your facial expressions can also help increase comprehension, and despite wearing a mask, your eyes and even your smile will be apparent. If you’re asking a question, a slight tilt of the head or a raised eyebrow can provide further communication hints to the listener.

If you’re having an extended conversation with a hearing-impaired person, check that they understand each phrase before continuing the discussion.

4. Bring Basic Written Communication Tools

If you know that you’re about to meet with a hearing-impaired individual, come prepared with a whiteboard or notebook. Bringing simple, low-tech communication options will make them feel more at ease, and it also makes it easy to write down instructions or important information.

You can also use speech-to-text transcription apps on your phone. Many of these apps also allow you to save the conversation for reference at a later date.

Masks are likely here for the long run, so take some time to learn how to communicate effectively with the hearing impaired. Don’t be afraid to ask them about their preferred communication methods and adjust to their needs accordingly.

Diabetes Nurses: On the Frontlines of a Long-Term Pandemic (Part Two)

Diabetes Nurses: On the Frontlines of a Long-Term Pandemic (Part Two)

Diabetes Awareness Day is on November 14: are you up to speed on one of our longer-running pandemics? The second part of our two-part interview with diabetes specialists Debra Dudley, RN, CDN, BS and Lori Weiss, BSN, RN, CPN, CDCES focuses on the challenges of caring for diabetics, advances in treatment, and reliable sources of diabetes information for nurses. Click to see Part One of this interview.

DN: What are the greatest challenges nurses face when working with diabetic patients?


Debra Dudley, RN, CDN, BS and Lori Weiss, BSN, RN, CPN, CDCES
Diabetes specialist Debra Dudley
Diabetes specialist Debra Dudley, RN, CDN, BS

Debra Dudley: “One of the greatest challenges I have consistently faced over the course of my 50-year career is the lack of time. Time is more essential than ever because the nursing shortage has left many of us overworked. I would love to have daily visits with each patient – even if it’s just a few minutes – to help guide them on their journey because there isn’t always going to be a teachable moment with them during infrequent interactions. This leads to long-term consequences because so many of our diabetic patients return with the same issues. We aren’t able to dedicate the necessary time to provide them with the appropriate education on adequate self-care.”

Lori Weiss: “Time remains the most significant challenge for nurses because they are busy, they are experiencing an increased patient workload, and those patients often have complications that are compounded by their diabetes. Patient safety is imperative, and nurses must balance safety with efficiency in order to treat as many people in need as possible. In order to overcome these obstacles, processes must be implemented that improve workflows and simplify the ability for nurses to do the right thing.”

DN: What technological advances have had the greatest impact on diabetes treatment?

D. Dudley: “There have been significant developments in technology over the course of my career, especially when you consider that early in my career we would place tablets into tubes of urine to measure blood sugar. From an outpatient perspective, the evolution of the continuous glucose monitor has been the most important. It allows a person to check their blood sugar every five minutes, identify if the blood glucose is trending up or down, and make an adjustment based on that trend. There are also mobile applications that help with carb counting, meal planning and exercise tracking – and many of those are free to download.

As far as the inpatient setting, the eGMS insulin dosing software system has been amazing. Once a nurse inputs a blood glucose reading, its algorithms automatically calculate insulin adjustments in real-time. It takes into account a patient’s current blood glucose, their food intake, and how they have reacted to previous doses. This reduces the amount of time a nurse has to spend adjusting doses because they no longer have to reach out to a patient’s provider to make a dose change. Before using this technology, our staff was making a minimum of 3,000 calls per month to providers just for dose adjustments. The amount of time wasted processing dose adjustments was both staggering and frustrating. The use of the Glucommander eGMS has reduced our amount of monthly calls by 95% – from over 3,000 to 150 – and alleviated a significant amount of nurse burden.”

“It’s not uncommon now for patients to inform their nurse or provider of a new app that is helping them manage their diabetes.”

—Lori Weiss, BSN, RN, CPN, CDCES
Diabetes nurse Lori Weiss
Diabetes specialist Lori Weiss, BSN, RN, CPN, CDCES

L. Weiss: “While many of the foundational concepts and approaches to diabetes education and support have remained the same, the tools and resources at our disposal continue to change. Outpatient technology has experienced the highest volume of technological advancements. The most notable [developments] have been the personal and professional Continuous Glucose Monitors, the variety of insulin pumps designed to meet pediatric and adult patient needs, and the explosion of digital and mobile solutions. This has provided patients with more access to information and a deeper understanding of how their decisions impact their disease. It’s not uncommon now for patients to inform their nurse or provider of a new app that is helping them manage their diabetes.

Although the outpatient setting has been most affected by these advancements, the inpatient setting has been able to leverage technology as well. As a Certified Diabetes Care and Education Specialist (CDCES), it is difficult to stay current with all the changes in diabetes care and nearly impossible for a busy bedside nurse to keep track. The eGMS insulin dosing software system has provided busy bedside nurses with an easy and effective way to care for patients. It increases patient safety by eliminating human dosing calculations, streamlines workflow because the algorithms automatically calculate insulin adjustments in real-time, and reduces adverse outcomes associated with hypoglycemia and hyperglycemia.”

DN: What are the most useful sources of information for nurses providing care for diabetic patients?

L. Weiss: “There are many reputable sources both online and in print to assist nurses caring for diabetic patients, but I find the best sources of information to be from the American Diabetes Association and the American Association of Diabetes Care and Education Specialists. The ADA issues its annual “Standards of Medical Care in Diabetes” to help guide nurses and physicians on how to best treat patients with diabetes and glycemic management issues. This is available for free online and includes best practice information on topics that range from nutrition therapy to pharmacologic approaches and recommendations for use of technology. The ADCES provides online courses, practice tools and documents, and webinars from industry experts to share a wealth of knowledge in an ever-changing field.”

Click here to see Part One of this interview.

Debra Dudley, RN, CDN, BS: Debra’s nursing career has spanned 50 years and she has spent the past 25 specializing in diabetes education and glycemic management. She is currently the Clinical Diabetes Educator for AdventHealth Waterman in Tavares, Florida, and has extensive experience in Pediatrics, NICU, and Maternal Child Health. Debra is an industry leader in providing support for those with a diagnosis of diabetes or pre-diabetes and improving their self-management through informative discussions, classes, and support groups.

Lori Weiss, BSN, RN, CPN, CDCES: After spending more than 20 years on the frontlines as a nurse at health systems in Wisconsin and Dallas, Lori Weiss is now applying her field expertise at the insulin management software company, Glytec, where she serves as the Clinical Project Lead. Lori understands the complex processes, risks, and challenges providers face titrating insulin.

Diabetes Nurses: On the Frontlines of a Long-Term Pandemic (Part One)

Diabetes Nurses: On the Frontlines of a Long-Term Pandemic (Part One)

Diabetes nurses work on the frontlines in the fight against an ongoing epidemic/pandemic that will continue to afflict over 13% of the US population long after COVID-19 recedes into the background. The diabetes pandemic has been mounting rapidly in the early 21st century. In 2003, 194 million adults worldwide between the ages of 20 and 79 had diabetes. By 2025, it is estimated that some 333 million of the world’s adults will be diabetic.

Nurses have long played a vital role in diabetes care, and studies suggest that patients fare better and have lower glucose levels when nurses are closely involved in the treatment of diabetes. As expert communicators and patient educators, nurses help America’s 27+ million diabetes patients understand how the disease and its complications affect the body, explain the treatment plan, keep them motivated, and advise them on adapting their diet and lifestyle to keep the disease under control.

As November is American Diabetes Month, this is a good time to take a look at how nurses are fighting this disease and assess the latest developments in treatment. DailyNurse asked Debra Dudley, RN, CDE, BS and Lori Weiss, BSN, RN, CPN, CDCES to share their first-hand knowledge about the key issues facing nurses on the frontlines of one of the world’s longest-running pandemics. Debra Dudley has specialized in diabetes care and glycemic management for 25 years and is currently the Clinical Diabetes Educator for AdventHealth Waterman in Tavares, Florida. Lori Weiss, a Clinical Services Coordinator for the insulin management software firm Glytec, spent over 20 years as a nurse and is an expert on the process of titrating insulin. This is Part One of a two-part interview. Click here to see Part Two.

DailyNurse: How did nurses come to take a leading role in diabetes treatment?

Diabetes nurse specialist Debra Dudley, RN, CDE, BS
Diabetes specialist Debra Dudley, RN, CDE, BS

Debra Dudley: “The role of the nurse has really evolved from basic bedside care to a leader in diabetes treatment and education during the mid-1990s. At that time, providers realized they needed to change their methodology of treating people with diabetes from provider disease management to patient self-management. In doing so, nurses were tasked with educating people with diabetes about the disease and how to treat it. This role is critically important because it helps improve long-term health, lower hospital admissions and reduce the chronic complications associated with poor glucose control.”

DN: What are the most important areas of knowledge for nurses who work with diabetic patients?

D. Dudley: “It’s important to understand that diabetes is probably the only chronic disease that puts the patient in charge of their own healthcare. Each time a patient measures their blood glucose, it is their responsibility to make a decision about if and what they need to do about it. Whenever a patient eats or exercises, they need to make an informed decision on how it will impact their blood sugar. Nurses need to understand that poor blood glucose control is the cause of significant adverse reactions, and communicating that to their patients is critical in helping them manage the disease.”

Diabetes is probably the only chronic disease that puts the patient in charge of their own healthcare.”

—Debra Dudley, RN, CDE, BS

Dudley, continued: “A toxic blood glucose level is 180 milligrams per deciliter (mg/dL), and the body cannot make healthy new cells in a toxic environment. As a result, many patients with diabetes develop wounds that won’t heal, experience repeated hospital admissions and have a higher risk of infection. In fact, diabetes causes 80,000 amputations, 60,000 people to lose kidney function, and 5,000 people to go blind every year. The broad impact poor glycemic management can have on an individual is alarming, and it’s important for nurses to process that information and find effective ways to communicate it with their patients.”

Nurses must understand that insulin, while commonly used, is one of the most dangerous and mismanaged drugs.”

—Lori Weiss, BSN, RN, CPN, CDCES
Diabetes nurse specialist Lori Weiss, BSN, RN, CPN, CDCES
Diabetes specialist Lori Weiss, BSN, RN, CPN, CDCES

Lori Weiss: “I’m often amazed at how limited a nurses’ knowledge is about diabetes, diabetes medications and available resources to care for people with diabetes. But, when I stop and consider how much general information bedside nurses need to process on a wide range of topics, it makes sense why they lack this specialized clinical knowledge. Nurses must understand that insulin, while commonly used, is one of the most dangerous and mismanaged drugs. Insulin is associated with 50% of all medication errors, therefore, properly dosing it in the hospital and providing adequate guidance on self-administration is crucial for patient safety. Additionally, the adverse health effects of poor glycemic management include a higher risk of infection, increased length of stay in the hospital and a greater chance for readmission.”

DN: How can nurses assist in preventing diabetes?

D. Dudley: “The only way we can achieve prevention is through education. We must educate our patients, our community and our country as a whole on how their decision making and behavioral patterns impact their health. Over 30 million people in the United States are affected by diabetes, which means one out of every three patients a nurse will see over the course of his or her career will be impacted by the disease. Through education, we can help patients and community members understand the potential outcomes of their choices, empower them to make the decision that lead to desired results, and positively change healthcare as a whole.”

L. Weiss: “Nurses, and especially Certified Diabetes Care Education Specialists, can assist in preventing diabetes by helping patients process and understand information that can directly impact their management of blood glucose. For those living with diabetes, nurses can assist them in navigating the continued advancements and challenges associated with diabetes to help them enjoy a high-quality life and manage their diseases.”

Click here to see Part Two of this interview.

Debra Dudley, RN, CDN, BS: Debra’s nursing career has spanned 50 years and she has spent the past 25 specializing in diabetes education and glycemic management. She is currently the Clinical Diabetes Educator for AdventHealth Waterman in Tavares, Florida, and has extensive experience in Pediatrics, NICU and Maternal Child Health. Debra is an industry leader in providing support for those with a diagnosis of diabetes or pre-diabetes and improving their self-management through informative discussions, classes and support groups.

Lori Weiss, BSN, RN, CPN, CDCES: After spending more than 20 years on the frontlines as a nurse at health systems in Wisconsin and Dallas, Lori Weiss is now applying her field expertise at the insulin management software company, Glytec, where she serves as the Clinical Project Lead. Lori understands the complex processes, risks, and challenges providers face titrating insulin.

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