Protecting Diabetes Counseling Rights

“Diabetes Educator” Regulations—a Threat to Nutrition Professionals and Public Health

  • The American Association of Diabetes Educators (AADE) is engaged in an initiative to gain legal recognition for “Diabetes Educators” as a new profession. In doing so, AADE is initiating bills that would negatively affect many healthcare and nutrition providers who already perform diabetes counseling of various kinds.
  • AADE bills seek a new, disease-based profession to benefit holders of private diabetes educator credentials, including its own Board Certified Advanced Diabetes Management (BC-ADM). According to AADE:

“The main barrier to gaining provider status for Qualified Diabetes Educators is that there is no legal definition or scope of practice for diabetes educators. Other healthcare professions have licensure or registration requirements and a professional scope of practice that give them a legal standing for recognition by the Centers for Medicare & Medicaid Services”  (AADE Overview of the State Licensure for Diabetes Educators Effort accessed 8_6_14)


Defining “Diabetes Educators” as a new profession is a radical departure from our nation’s entire approach to healthcare licensure.
It would for the first time in history create a disease-based scope of practice, rather than the traditional profession-based scope of practice.  In other words, it would carve out a scope of practice specific to diabetes – a disease that is already within the scope of practice of many healthcare professions. Such a carve-out would conflict with the scopes of those professions, and would set up unavoidable conflict with many providers operating under profession-based scopes.

Because any disease-specific scope bill would fundamentally conflict with states’ established profession-specific approach to healthcare practice scope, this issue must be discussed in-depth with legislators and affected profession stakeholders at the table.

Why should these bills concern nutrition practitioners?
AADE supported or sponsored bills and laws vary. Some seek licensure of a new profession, “Diabetes Educator”, as stated above, while others seek to get a foot in the door for legal recognition of Diabetes Educators by introducing new coverage for diabetes and pre-diabetes through Medicaid that specifically names credentialed Diabetes Educators as qualified providers but also leaves out many nutrition care providers who are qualified to provide these services. When additional training is needed for areas already withih a scope of practice, continuing education, already required of all professionals, is and has always been sufficient. Creating a separate scope and removing a skillset from an existing scope serves private self-interest, not the public.
We support voluntary specialty certification in Diabetes Education; many health professionals seek specialty certifications or continuing education to increase skills in an area of practice that is key to their work. But these new bills and laws variously:
  • create a disease-based scope of practice (diabetes) for the benefit of those holding particular private credentials; this is a stepping to stone to licensure for diabetes educators
  • restrict use of various titles in advertising diabetes-related services as a law in IN does
  • exclude qualified providers from providing Medicaid-covered diabetes care (know as Diabetes Self Management Training or DSMT—see glossary below) as a bill in NJ would do
  • expand the scope of Medicaid-covered DSMT to include pre-diabetes care as a bill in NJ would do
  • limit access to Medicaid covered, pre-diabetes education by placing provider restrictions beyond what has been proven to be necessary and effective 
  • adds burdensome, time consuming and costly requirements for professionals already licensed or credentialed 
  • creating precedent-setting limitations such as in Medicaid coverage of pre-diabetes or creation of a disease-based scope (diabetes) which if allowed, can be expanded upon by those seeking greater limitations on providers
  • steers consumers to the specific approach of the private, certification groups which is based on the idea of a lifetime dependence on medication and its side-effects; diabetes can be cured for many people with education and support for lifestyle change
These are limitations and definitions that have never existed before. If “Licensed Diabetes Educator” becomes a reality, what’s next: Licensed Cancer Educator? Licensed Cardiovascular Disease Educator?

Understanding the existing diabetes counseling landscape
Many providers currently have the right and the training to provide counseling and/or education to people with or at risk for diabetes.

  • Individualized counseling for those diagnosed with diabetes or pre-diabetes regarding nutrition and diet, lifestyle planning, exercise or medication use is governed by whatever occupational regulations exist in a given state for professionals who counsel individuals with any medical condition.
  • General education for those diagnosed with diabetes or pre-diabetes, or simply for prevention-at-large, when the information is not customized to an individual’s diagnosed medical condition, is legal in all states.
  • Group counseling as “Diabetes Self Management Training” is a covered benefit under Medicare when it meets specific conditions (see glossary below) and can be provided by a broad range of professionals both licensed and unlicensed, with training and under supervision
  • Diabetes Prevention Programs (standardized curriculum, tested by CDC) delivered by a broad range of providers with and without credentials including licensed healthcare providers, health coaches and community workers have been proven by CDC, NIH and others to be 58% effective at preventing pre-diabetes from moving to diabetes
  • Diabetes Self Management Training is a specific approach that is based on an outdated idea that Diabetes cannot be cured and a lifetime of medication and blood glucose monitoring is the only way. Yet with proper guidance, many are able to cure their diabetes and eliminate the need for medication through significant lifestyle change. DSMT does not present this option and it is not part of most certified diabetes educator curriculums. Legislation that effectively pushes all consumers toward this one approach is not good public policy and is not in the best interests of public or fiscal heath.
Glossary of Diabetes Education Terms
American Association of Diabetes Educators (AADE)
AADE offers training and an associated private credential, the Board Certified Advanced Diabetes Management (see below). They are the primary group seeking to gain provider status and occupational regulations for diabetes educators. AADE along with the American Diabetes Association sets the criteria and approves organizations for Diabetes Self Management Treatment programs approved for the Medicare DSMT benefit.
American Diabetes Association---private association offering education (but not a credential) to both the public and professionals, and is one of two associations setting the national standards for DSMT qualifying programs, along with American Association of Diabetes Educators.
“At risk for diabetes”—most Americans eating a standard American diet and not exercising enough are at risk for diabetes. However often the term “at-risk for diabetes” is used interchangeably and we believe inaccurately, in new legislation in place of “pre-diabetes, since most Americans are at-risk for diabetes. This language substitution actually increases the captured scope of practice in diabetes-specific regulations.
Board Certified Advanced Diabetes Management (BC-ADM)---private credential of theAmerican Association of Diabetes Educators
Certified Diabetes Educator (CDE) private credential of the National Certification Board for Diabetes Educators [NCDBE] 
Diabetes Education 
This is a generic term many providers use to describe education they may provide in practice about one or more aspects of diabetes, pre-diabetes, or diabetes prevention and not necessarily limited to those with a particular diagnosis.
National Certification Board for Diabetes Educators (NCDBE)
NCDBE offers training and a private credential, “Certified Diabetes Educator” (CDE).
NCDBE. The organization’s website states that NCDBE is neither positive nor negative on state licensure; they do not favor AADE’s approach. However they do have a model bill for states considering licensure, naming the NCDBE credential as the only recognized private credential qualifying for licensure. The NCBCDE model bill is specific for those providing DSMT as defined below, and not all qualified practitioners meet criteria for taking the program to earn NCDBE’s credential
National Diabetes Prevention Program (NDPP)
NDPP is a standardized Diabetes prevention curriculum tested over ten years by NIH and CDC. It has a proven effectiveness rate of 58% across all ethnic groups, is delivered by approved program sites such as YMCA’s and faith-based groups at a cost of approximately $275-300/participant. Trained, but not necessarily credentialed staff delivers the standardized and validated curriculum.
Diabetes Self Management Education (DSME)
This is the term used by ADA and AADE for DSMT (see below)
Diabetes Self Management Training (DSMT) 
This is the term the Centers for Medicare & Medicaid Services (CMS) uses for the Diabetes Self-Management Training benefit available to Medicare beneficiaries. DSMT is delivered:
  •  by a multi-disciplinary team and covers many aspects of living with diabetes over many weeks, including diet, exercise, medication management, goal-setting and problem solving, choosing and using glucose monitoring device, etc
  •  in a program that has been accredited by either the American Diabetes Association or the American Association of Diabetes Educators
  •  after a written referral is made from a physician or other qualified medical provider including a nurse practitioner or physician assistant.
  •  by a spectrum of providers of varying levels and types of training, including lay leaders, as long as the program has at least one primary instructor who is licensed as a registered nurse, dietitian or pharmacist

Essential Health Benefits (EHB) Under the Affordable Care Act, the mandatory Essential Health Benefits package includes:

“Counseling for a healthy diet (intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease by primary care clinicians or by referral to other specialists such as nutritionists or dietiticians)”

Pre-Diabetes-Pre-diabetes” is a medical diagnosis given to people with a Fasting Blood Glucose level of 100-125 mg/dl. Very effective, evidence-based programs to prevent diabetes in this population utilizing non-credentialed but trained personnel have been lauded by CDC, NIH, and the American Diabetes Association