Guidelines for Diabetes Education (2011)

Agada Health Sciences

Team Dr. Shanmuga Sundar, MD., DM Ms. Sripriya Ravi, M.Sc., M.Phil., MS

Mission statement
It is the Mission of the Education Department at Agada Health Sciences

to share knowledge in a coordinated manner such that the person with diabetes is a proactive participant in his treatment. to empower the person with diabetes such that he/she is able to apply the principles of self care effortlessly in his/her lifestyle. to enable persons at risk for diabetes not only in prevention /delay the onset of diabetes but also apply the principles of a healthy lifestyle so that they maintain a good quality of life.

Table of contents A. B. C. Introduction Standards of Care Diabetes Self Management Education a) b) c) Knowledge Skills Behavioral change

d) Group education module - Knowledge and behavior change

(1) (2) (3) Presentation Outline Evaluation

e) Individual Sessions Knowledge, Skill and behavior change

(1) (2) Assessment Guidelines for care
(a) (b) (c) (d) (e) Type 1 Type 2 Pregnancy with diabetes Children with diabetes Elderly with diabetes

(f) Co-Morbid Conditions Hypertension, Obesity and depression (g) (h) Chronic Complications of Diabetes Smoking Cessation 3

(i) (j)

Guidelines for Sick days Oral Health and Diabetes

(k) Complementary Therapies in the management of Diabetes (l) (m) (n) (o) Sleep Disorders and Diabetes Guidelines for treatment of hypoglycemia Guidelines for self monitoring of blood glucose Foot Care Guidelines

D.

Appendices

I II III IV V

Clinical RecommendationsBiochemical Markers AADE 7 Self management outcome behaviors Annual Follow up Plan Guidelines for self monitoring of Blood Glucose Guidelines for treatment/prevention of hypoglycemia Evaluation of Outcome of Group Education Module Blood Glucose lowering agents

ii vi vii ix xii

VI VII

xiv xvi xvii

VIII Insulin Administration

4

Technique IX X Foot care inspection and guidelines for foot care Checklist for the person with diabetes
E. References

xviii

A.

Introduction

Diabetes education is the key to ensuring self-care by the person with diabetes. The goal is to offer structured education to every person and their family in accordance to that persons cultural, linguistic, cognitive, and literacy needs. Within the structure of the Agada diabetes care program, the diabetes educator is charged with the overall responsibility of discharging quality comprehensive diabetes education to the person with diabetes. In addition, every core member of the diabetes care team is charged with the responsibility of providing reinforcement and accurate diabetes education as it relates to his/her role in the team: physician, nurse, diabetes educator, dietician/nutritionist, psychologist, and physical therapist. Specialized elements of diabetes education and reinforcement are expected from additional members of the diabetes care team: podiatrist, ophthalmologist, and relevant specialists. The Diabetes Educator plays a key role in coordinating with the team and ensuring that the principles of care offered by each member is well understood and applied skillfully by the patient. The guidelines offer a consistent approach to patient management, set basic standards of care based on the National Standards for Diabetes Self Management Education, (American Diabetes Association) and provide scope of measurable outcome behaviors. Group and individual approaches are adopted by the educator to maximize learning, instill motivation and inspire behavior change. A key component of the education department is a proposed triangular model of imparting knowledge, equipping with relevant skills and promoting behavior change. Knowledge alone does not make a person efficient in his tasks. Adding the skill component elevates knowledge to the next level of efficiency. In patient management where psychological concerns play a major role, attitudinal and behavioral changes are warranted. Knowledge and skill alone would not help if the attitude of the patient is adverse to change. In such cases the educator adds the promoting behavior change component, wherein knowledge and skill added with behavior change consequently leads to positive 6

change in behavior. This triangular model helps the educator to map and measure the efficacy of her methods and tools of education.

B.

Standards of Care
-Care of patient is uniform across all health care professionals in the

Standards established by the department of education ensure that

team - The quality of care is a measurable component - The evaluation of patient behavior is a measurable outcome Standard 1 Diabetes education would be provided by qualified and trained professionals with academic and/or experiential background from the field of nutrition and dietetics/Psychology/Social work/Public Health/Nursing (physician assistants). Standard 2 The diabetes education department would have documentation of its organizational structure, mission statement and goals and would recognize education as an integral part of diabetes management. Standard 3 The diabetes educational needs of the target population would be determined and resources identified to meet the same. Standard 4 The team of diabetes educators and allied health care professionals would obtain continuous medical education in the field of diabetes self management and education Standard 6 A written guidelines of care reflecting current evidence and practice guidelines with criteria for evaluating outcomes will serve as a framework for diabetes educators to practice. Standard 7 An individual assessment and education plan will be developed collaboratively by the participant and instructor(s) to direct the selection of appropriate educational interventions and self-management support strategies. This assessment and education plan and the intervention and outcomes will be documented in the education record.

Standard 8 A personalized follow-up plans for ongoing self management support will be developed collaboratively by the participant and instructor(s). Standard 9 Measurement of attainment of patient-defined goals and patient outcomes would be done at regular intervals using appropriate measurement techniques to evaluate the effectiveness of the educational intervention. Standard 10.The effectiveness of the education process would be measured and opportunities for improvement would be determined using a written continuous quality improvement plan that describes and documents a systematic review of the entities process and outcome data.

C.

Diabetes Self Management Education

Diabetes Self Management Education as identified by the American Association of Diabetes educators contains nine core content areas. They include

1. 2. 3. 4. 5.

Describing the diabetes disease process and treatment options Incorporating nutritional management into lifestyle Incorporating physical activity into lifestyle Using medication(s) safely and for maximum therapeutic effectiveness Monitoring blood glucose and other variables and interpreting and using results for self - management decision - making Preventing, detecting and treating acute complications Preventing, detecting and treating chronic complications Developing personal strategies to address psychosocial issues and concerns Developing personal strategies to promote health and behavior change On the basis of the above guidelines the educator sets standards for education of the patient categorizing her presentation into three components imparting knowledge, equipping with relevant skill and promoting behavioral change.

6. 7. 8. 9.

10

A). Knowledge
Objectives

To empower the patient/person with diabetes/at risk with current information relevant to his condition To update on treatment options To dispel myths and fears To establish a continuous channel where knowledge is shared with the common goal of management of diabetes and its related conditions.

Methodology Group sessions with diabetic educator, nutritionist, Mental health counselor, exercise physiologist, persons with diabetes Individual sessions with diabetic educator, nutritionist, mental health counselor, exercise physiologist with the aim of filling in knowledge gaps and individualizing needs for education Topics Covered o o o o o o o Diabetes disease process, etiology, pathophysiology and epidemiology. Classification and types Diagnostic criteria Persons at risk Prediabetes - Prevention Complications Acute and chronic management - prevention Blood Glucose and lipid goals Treatment options Medications Insulin Diet Exercise Diabetes Self care management Skills to be mastered

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B).

Skills

Objectives

To enable patient to take control of the disease in acute situations To ensure the patient makes informed choices. To empower persons with diabetes / family member with skills that allow them to lead a normal lifestyle

Skill Set
1.

Understanding Prescription - The patient should be able to read the prescription and understand the
a. b. c.

type of medication and its mechanism of action Timings of the medication in relation to food. drug/drug and drug/nutrient interaction

2.

Understanding lab work - The patient should be able to read the lab results and
a. b.

Understand if BG targets have been achieved Correlate with corresponding complication/morbidity Successfully monitor his blood glucose using a glucometer Record the date in conjunction with diet/exercise/medication/hypoglycemia/extraordinary situations Take decisions on altering insulin/drug corresponding to BG levels Take decisions on altering meal/exercise patterns based on corresponding BG levels

3.

Ability to monitor Blood glucose The patient should be able to

a. b.

c. d.

4.

Ability to administer insulin The patient should be able to

a. b. c.

Recognize the type of insulin prescribed and its mechanism of action Read markings in the device correctly and adjust doses Administer insulin comfortably as directed by educator The patient should be aware of hypoglycemia as a possibility

5.

Ability to recognize symptoms of hypoglycemia and act accordingly

a.

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b.

The patient should be aware of the methods of preventing hypoglycemia The patient and family member should be aware of the symptoms of hypoglycemia The patient and family member should be able to recognize the symptoms of hypoglycemia. If the patient is unable to recognize the symptoms of hypoglycemia, he should be aware of a asymptomatic hypoglycemic episode and so be prepared by constant BG monitoring

c.

d.

e.

f.

The patient should be aware of the cut-off value for treatment of hypoglycemia with symptoms The patient and his family member should be aware of the treatment schedule for hypoglycemia.

g.

6.

Ability to recognize symptoms of DKA and HHS and act accordingly

a. b. c.

The patient should be aware of DKA/HHS as a possibility The patient should be aware of the methods of preventing DKA/HHS The patient and family member should be aware of the symptoms of DKA/HHS The patient and family member should be able to recognize the symptoms of DKA/HHS. The patient and his family member should be aware of the treatment schedule for DKA/HHS

d.

e.

7.

Ability to make healthy choices while travel, special occasions The patient should be able to
a. b. c. d. e. f.

Identify food groups and make healthy choices Identify type of carbohydrate in a given food to make healthy choices Identify the type of fat in a given food to make healthy choices Exercise portion control Practice spacing of meals Read the nutrition label in foods and understand the type of carbohydrate and fat present 13

8.

Ability to take care of sick days The patient/family member should be aware of the effects of various sick conditions and take action as advised by educator.

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C). Behavioral Change

Objectives

To assess for behavioral issues that affect self care of diabetes and plan appropriate intervention To screen for depression and provide counseling/referral wherever applicable To address psychosocial concerns of the patient thus promoting ideal self care behavior To set practical and realistic goals suitable to patients lifestyle

Methodology The educator should apply any of the following models as applicable or evolve her own model based on experience to help patient in being successful in diabetes self management.
A. The Health belief Model: The educator interacts with the patients and discusses

his/her health beliefs and values. Exploration of past experiences with health, success and failures as perceived by the patient could provide the educator an important tool in assessing the educational needs; and strategize to promote adherence.
B. The Stages of Change Model: The educator through multiple Interactions with

the patient helps him/her to understand the reasons behind A need to change behavior. Comprehension of why he should change and what will be the outcome of the change ,how he can change would enable the patient in making decisions with regard to a change towards a healthier lifestyle.
C. The Common Sense Model: The educator facilitates logical step wise thinking by

helping the patient to identify the condition, contemplate the cause, time line of the condition (how long it would last), consequences and effectiveness of treatment.
D. Social Learning: Group education sessions enable patients to learn from peers

through discussion. Through social learning a patient is bound to develop confidence in the applying the skills imparted by the educator.
E. The Social Cognitive Model : Within in the group session the educator acts as a

facilitator by creating an environment for successful experience, identifying role 15

models when they share experiences, skillfully summarizes, acknowledges health beliefs and assures that they can be managed, encourage people to be explicit and be alert to emotional utterances and body language.
F. The Dual Processing Model: In this model, the patient is allowed to understand

the condition on his own terms allow him to discover his own solutions. Evaluation of outcome: The educator schedules follow-up and evaluates for change in behavior with respect to set goals. The Educator evaluates for self -management outcome behaviors as outlined by the American Association of Diabetes Educators.

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D). Group Education Module

Objectives: At the end of the group education module the persons attending the module should be able to

Understand the process of Diabetes, in its pathophysiology and classification Recognize the symptoms of diabetes Identify the risk factors of diabetes

entirety - epidemiology, etiology,

Read lab results and understand the numbers involved Correlate prevention of complications of diabetes with good blood glucose control Comprehend his role in the treatment plan with respect to adherence to recommendations. Equip himself with skills required in dealing with acute situations Obtain a broad perspective of treatment options

Presentation The Basic Patient Education Module (BEM) would be delivered to a group, to persons on their first visit to the centre. The module would be delivered in approximately 45 minutes - 1 hour during the time post meal pre-consult with physician. It would be delivered by a Diabetes Educator, using audio-visual aids. A simple and clear presentation would be the emphasis. The educator would be presenting the module in local language/English depending upon the preference of the audience. Outline
3.

Introduction to Diabetes
a. b. c. d. e.

Disease process, Pathophysiology Etiology and Epidemiology Classification Risk Factors Acute complications
i. Hypoglycemia

17

ii. HHS iii. DKA f.

Chronic complications
i. Micro vascular complications ii. Macro vascular complications

4.

Diagnosis
a. b.

Criteria for diagnosis of diabetes Pre-Diabetes Attitudes, Wishes and Needs Diabetes related fears/doubtsPeople with diabetes often associate diabetes with complications such as blindness or amputation. Fear of loss in quality of life, become barriers in self care. The group session would address such issues and aim to dispel unwarranted fears.

5.

Diabetes Self-Management Education

a.

b.

Significance of Self-Care- The educator outlines the roles that the patient has to play in his treatment and the importance of his role given the fact that diabetes is a chronic disorder. The educator elaborates the principles of self care enabling the patient to take ownership and manage his disease efficiently.

c.

Dietary Guidelines- Diabetes runs in the family. The group education module addresses healthy eating guidelines for the entire family. Exercise and physical activity recommendations- Exercise is the cornerstone of treatment of Diabetes. The educator outlines the role of exercise in reducing blood sugar and prevention of complications. She also highlights the importance of basal physical activity throughout the day. A combination of moderate intensity aerobic activity (150mins/week), resistance training (3x/week) in the absence of contraindications; and overall increase in physical activity is recommended.

d.

e.

Oral hypogylcemic agents- The educator discusses briefly about the drugs available in the market and their mechanism of action Insulin- The educator mentions that Insulin is a natural hormone that might be required in some cases to improve outcomes. The educator 18

f.

also highlights that during the natural progression of the disease insulin might be the best treatment option with minimal side effects.
g. i.

Prevention of complications

Foot care The educator mentions the importance of foot care. She indicates the absence of feeling couples with not visually inspecting the foot can cause severe damage due to delayed wound healing.

ii. Regular and frequent check-up The educator highlights the importance of

early diagnosis in prevention of complications of diagnosis. She emphasizes the participation of the patient in regular follow up so that he can prevent complications.
iii. Self monitoring of blood glucose- Type 1 children and pregnant women with

diabetes are recommended to monitor their BG at least 1x /day. A chart is provided for the same. They are also asked to maintain their BG records corresponding to their medication, diet and exercise. Other persons are recommended to monitor regularly and the benefits of BG monitoring is highlighted.
iv. Hypoglycemia Persons with diabetes are advised with regard to the possibility of

hypoglycemia. They are given information about the causes of hypoglycemia so that they can prevent it. Symptoms of hypoglycemia and treatment methods are mentioned , which would be reinforced with a handout
v.

Sick Day rules The educator emphasizes the need to continue medication when the person is sick irrespective of his intake of food. The need to drink plenty of nonsugary fluid is encouraged. BG monitoring is recommended. A hotline number in case of emergency is also provided.

Conclusion :

The educator summarizes the important points and highlights

the participation of the patient in his treatment.

E).

Individual sessions
19

The Diabetes educator interacts with the patient individually in order to better understand his/her educational needs. Accordingly she tailors an educational module to suit the person with diabetes or at risk. During individual sessions the diabetes educator aims to Listen and learn Focus and prioritize Be sensitive to age and cultural factors Empower through self care Set practical and realistic goals together with the patient

During individual sessions the diabetes educator tries not to be Judgmental Censorial Fear inducing Talkative

Guidelines for specific conditions have been outlined. However, these guidelines may be used as a baseline for education and does not limit the educator in trying to improvise, update or innovate her methods according to the needs of the patient.

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(1). Assessment of patient

Astute assessment of he patient is the key in planning an intervention. The components to be taken into consideration while assessing the patient include
a.

Anthropometric
i. Height indicates the skeletal growth of the patient and is useful

marker of growth and development in children. Height used in correlation with weight in other indices indicates the patients nutritional status
ii. Weight is assessed as current weight, usual body weight and %

change in body weight. Indicators using height and weight such as the Ideal body weight and BMI provide useful information for intervention.
1.

IBW- Height in cms 100 X 0.9 (men X0.8 (women)

2. 3.

BMI- weight (kg)/Height (m2) Healthy - < 23 kg/m2 % change in weight or % of usual body weight help in assessing nutritional status or treatment progress.

iii. Waist Circumference indicates the extent of abdominal obesity

of the patient , thereby highlighting the risk profile of the patient Healthy WC < 85 cm for men and < 8o cm for women
b.

Clinical signs and symptoms Presentation with classic diabetic symptoms such as polyurea, polyphagia, polydipsia and loss of weight provides input with regard to the treatment protocol.
i. Blood Pressure has to be measured every routine visit, five

minutes after the patient has sat down.

c.

Diabetic history :
i. Knowledge about the type and stage of diabetes (years from

onset)
ii. Presence of co-morbid conditions

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iii. Presence of complications iv. Hypoglycemic episodes v. Assess for Hypoglycemia unawareness d.

Diabetes Knowledge/awareness
i. Basic knowledge about causes, symptoms, risk factors and

treatment of diabetes, hypoglycemia is assessed

e.

Diet history A detailed diet history of a normal meal pattern of the patient is taken by the dietitian for estimation of nutrient intake. The dietitian estimates the meal pattern, timings of meals and cultural concerns.

f.

Lifestyle factors Lifestyle of the patient with regard to his educational, financial, employment status is estimated by the physicians assistant /Educator/nutritionist

g.

Psychosocial issues A mental Health counselor screens the patient for psychosocial stress and/or depression associated with or independent of disease condition. A subjective analysis of stress levels and a depression screen is used.

h.

Lab work Initial testing and periodic monitoring of HBa1C, FPG, PPBG,

Microalbuminurea, serum creatinine, urine albumin, lipid panel is essential to check for onset and stage of complications.
i.

Health literacy/numeracy- The health literacy and numeracy of the patient is assessed using a standardized tool (Newest Vital Sign). Initially the tool would be used as a test for validity among the present population. With validation and/or modification it would be used to assess the educational need to the patient.

j.

Current Diagnosis- The current diagnosis along with co-morbidities and complications help the educator in prioritizing her goals 22

k.

Physicians prescription- The educator ensures that the prescription is well understood by the patient with regard to any drug/drug interaction, drug nutrient interaction and timing of medication with respect to each other and with respect to food.

23

Guidelines of care (a)Type 2 Diabetes Mellitus Objectives: By the end of the session, the patient should be able to:

describe and state which type of diabetes they have. identify the dynamics of the natural history of type 2 diabetes. identify that self-care is important-specifically, the role of diet, weight loss, and physical activity in management of type 2 diabetes. state the meaning the following glucose tests and the importance of maintaining goal levels: fasting glucose, postprandial glucose, hemoglobin A1C.

describe the role of consistent follow up in the management of type 2 diabetes.

Indications:

Any patient with newly diagnosed type 2 diabetes OR new to the clinic. Teaching requested by patient. A lack of understanding is suspected.

Audience:

Patient & at least one family member

Taught by:

Physician Physician assistant Diabetes educator Nurse

Materials: Introduction to Type 2 Diabetes books/pamphlets Method/Topics to be covered: Describe glucose metabolism (include role of insulin, glucagon, fat cells) Describe the concept of insulin resistance and beta cell insulin secretion dysfunction. Describe the role of diet, weight loss, and exercise in controlling blood sugar. 24

Describe fasting glucose, postprandial glucose, hemoglobin A1C: Explain the need for consistent follow up with physician and rest of diabetes care team to meet glycemic goals. The frequency of follow up will be defined by the patients specific needs. The educational needs of the elderly, young adults and pregnancy have been discussed later in this manual.

25

(b).

Type 1 diabetes-disease process and treatment options

Objectives: By the end of the session, the patient OR if younger than 16yrs patients parent should be able to:

describe and state which type of diabetes they have. identify the dynamics of the natural history of type 1 diabetes. identify that self-care is important-specifically, the effect of diet and physical activity on blood glucose levels in patients with type 1 diabetes. state the meaning the following glucose tests and the importance of maintaining goal levels: fasting glucose, pre-meal glucose, postprandial glucose, hemoglobin A1C.

describe the acute complications of type 1 diabetes (DKA & hypoglycemia) and acute management of those complications. describe the role of consistent follow up in the management of type 1 diabetes.

Indications:

Any patient with newly diagnosed type 1 diabetes OR new to the clinic. Teaching requested by patient. A lack of understanding is suspected.

Audience:

Patient & at least one family member

Taught by:

Physician Physician assistant Diabetes educator Nurse

Materials: Introduction to Type 1 Diabetes books/pamphlets Method/Topics to be covered: -Describe glucose metabolism (include role of insulin, glucagon) 26

-Describe the concept of autoimmunity and absence of insulin secretion. -Introduce the concept of how diet and exercise impact blood sugar levels in type 1 diabetes. -Explain the dynamics of insulin. -Describe fasting glucose, pre-meal glucose, postprandial glucose, and hemoglobin A1C In case of women of marriageable age discuss need for planned pregnancy Explain the need for consistent follow up with physician and rest of diabetes care team to meet glycemic goals. The frequency of follow up will be defined by the patients specific needs. Special needs for children and during pregnancy have been discussed later in this manual.

27

Prediabetes - Disease Overview & Prevention

Objectives: By the end of the session, the patient should be able to:

Describe and state what form of prediabetes they have. Identify the dynamics of the natural history of prediabetes. Identify that self-care is important to prevent development of type 2 diabetesspecifically, the role of diet, weight loss, and physical activity in management of type 2 diabetes.

Describe the role of consistent lifestyle behaviors and follow-up in the prevention of type 2 diabetes. Describe the cardiovascular effects of the prediabetes state.

Indications:

Any patient with newly diagnosed prediabetes/metabolic syndrome OR new to the clinic. Teaching requested by patient. A lack of understanding is suspected.

Audience:

Patient & at least one family member

Taught by:

Physician Physician assistant Diabetes educator Nurse

Materials: Pre-diabetes/Metabolic Syndrome patient books/pamphlets Method/Topics to be covered: -Describe glucose metabolism (include role of insulin, glucagon, fat cells) -Describe the concept of insulin resistance and beta cell insulin secretion dysfunction.

28

-Describe the role of diet, weight loss, and exercise in preventing development of type 2 diabetes. -Explain the need for consistent follow up with physician and rest of diabetes care team to meet glycemic goals. The frequency of follow up will be defined by the patients specific needs. -Explain the need for at least 150minutes of at least moderate exercise per week + weight loss as advised by physician.

29

(d).

Pregnancy & Diabetes

Objectives: By the end of the session, the patient should be able to: Understand the significance of diabetes during pregnancy and its effect on pregnancy outcomes Recognize the importance of self glucose monitoring Adjust meal patterns and insulin dosages wherever necessary Understand the significance of postpartum follow up with an endocrinologist/diabetologist Understand the principles of prevention of diabetes in the case of gestational diabetes Understand the need for pre-pregnancy screening, assessment and monitoring and planning pregnancy Gestational Diabetes Indications: All Indian women are at high risk and practically every one should undergo screening Additional risk factors include BMI > 30 kg/m 2 Previous macrosomic baby weighing > 4.5 kg Previous GDM Family history of diabetes first - degree relative with diabetes Family origin with high prevalence of diabetes Audience:

Patient & at least one family member 30

Taught by:

Physician Physician assistant Diabetes educator Nurse

Materials: Glucometers, diet records Method

Discuss the glycemic targets to be achieved for a safe pregnancy Teach Blood glucose monitoring techniques and recommend daily measuring fasting and 1hr after food Initiate diet and physical activity to achieve BG control Follow-Up with Insulin if targets not achieved Clear instructions to reduce insulin doses immediately post partum is required Due to increased risk for diabetes GDM patients should be advised on lifestyle modification and screening for diabetes every 2 years

31

Chronic Diabetes in Pregnancy Indications T1 /T2 DM patients who are pregnant/ planning for pregnancy Methods The educator discusses

the importance of pre-pregnancy counseling, consequences of unplanned pregnancies, and importance of achieving glycemic goals before conception. The need to assess for complications at the beginning and each trimester And revises hypoglycemia and sick day rules Strategies to cope with morning sickness and risk of hypoglycemia The need to change to insulin in T2DM if on OHA The need to change ACE inhibitor treatment before pregnancy and change to other antihypertensives The decrease in insulin requirement immediately post partum Importance of nutrition and meal planning in pregnancy outcomes The need for frequent contact with the diabetic health care team and increase in insulin requirements as pregnancy progresses Medications to be avoided Ace inhibitors, ARBs, Statins, B-blockers during 1st trimester, OHAs other than metformin and glibenclamide Screening Retinal screen prior to pregnancy underscores the need for treatment before pregnancy or increased surveillance during pregnancy. If Nephropathy screening reveals presence of microalbuminurea, women are advised of the risk for hypertension and preeclampsia during pregnancy Screening for hypo or hyperthyroidism is essential as these conditions can affect the fetus and neonate Women with long duration T1DM and older T2DM should be screened for heart disease, with arresting and exercise ECG prior to pregnancy, so that informed decisions can be made.

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Children with diabetes Objectives: By the end of the session the child/parent(s) should be able to Indications Any child with type 1 or type 2 Diabetes Mellitus Audience Patient and family members (both parents preferable), care givers, teachers, coaches Taught by

Understand the importance of self care Understand the significance of insulin its role, spacing and frequency of meals, and importance of exercise Recognize the symptoms of hypoglycemia and correspondingly its prevention and treatment when necessary. Demonstrate optimal insulin injection technique Describe the need of rotating and inspection of injection sites Interpret blood and urine glucose and insulin dosages

Physician Physician assistant Diabetes educator Nurse

Materials- Pamphlets on insulin injection technique, hypoglycemia, and carbohydrate content of foods Method

Discuss the need for others involved in caring for children and adolescents (teachers, coaches, other family members) to be able to recognize and treat mild, moderate and severe hypoglycemia

33

Provide education on adjusting insulin and carbohydrates to enable safe participation in physical activities generally and specific c sporting events Understand the need to organize food patterns around the childs food preferences and his or her relationship with insulin treatment Discuss the need to individualize food intake and insulin therapy in relation to the childs age and lifestyle Consider the existing food pattern and choose an appropriate insulin profile Appreciate age-related problems including, for example, toddler food refusal, peer pressure, omission of insulin by teenagers, religious and cultural influences, insulin abuse and hypoglycemia, fast foods, food fads

Describe the importance of the amount and types of carbohydrates and their effects on blood glucose levels Describe guidelines on the distribution of food to prevent hypoglycemia and hyperglycemia Recognize changes in weight patterns and assess total energy intake and physical activity Describe the importance of healthy eating and an increase or reduction in energy intake to stabilize weight gain or maintain growth percentile lines Design a suitable age-appropriate weight-reducing programme for a growing child (including lifestyle changes and provision of adequate nutrients)

Psychosocial influences

Recognize the emotional trauma present when the diagnosis of diabetes is made, begin education when the family is ready, and pace education according to the familys wishes

Discuss the need to encourage consistent and continuing support from the extended family/carers, peers and pediatric multidisciplinary team Discuss behavioral themes, and strategies to promote acceptance and agreement for sharing responsibilities for a management plan especially when the child exhibits difficulties or distress

Discuss the need to facilitate the total integration in all activities of children and adolescents at nursery, school and college; they should not be excluded from any sports or activities because of diabetes

34

Know the strategies for minimizing trauma in blood testing and coping with refusal Recognize the fear that children, adolescents and their parents have of hypoglycemia, and the impact this has on tightening blood glucose control Understand the detrimental behavioral and health effects of both hypo- and hyperglycemia Know that different environmental circumstances (for instance due to school activities, camps, day trips, sleepovers, or sports days) can increase the likelihood of hypoglycemia

Promote the need for all children to be involved in all sports at all levels

Adolescents/young adults

Recognize the substantial changes in insulin and nutritional management which need to be made during the pubertal phase Discuss risk-taking behaviors in adolescents, including (where culturally appropriate):

contraception alcohol and its effects on blood glucose smoking, diabetes and vascular disease eating disorders and insulin misuse drugs

Discuss strategies to educate school and college personnel, faith/community leaders, sports leaders, etc. Appreciate the problems encountered by teenagers Recognize the increased incidence and prevalence of mental health issues, such as depression and eating disorders, and know when to make an urgent referral to mental health services

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Diabetes In elderly Objectives At the end of the session the elder /family member should be

Free from hyperglycemic symptoms Able to prevent undesirable weight loss Able to avoid hypoglycemia and other adverse drug reactions Achieve a normal life expectancy Able to maintain general well - being and good quality of life Able to acquire skills and knowledge to adapt to lifestyle changes independent and adopt self care

Method The educator should be aware of the issues involved in elder care such as/but not limited to

Increased risk for Hypoglycemia/HHS Increased risk for falls/injuries Restrictions on activity Limited scope for heavy physical exercise Possibility of depression/neglect affecting self care Urinary incontinence Persistent pain Cognitive impairment Financial issues Worsening co-morbidities/complications Polypharmacy

The educator should be able to achieve objectives with a detailed assessment, addressing issues with empathy and prioritizing her advice. Care plan for initial management of diabetes in an elderly person.

Establish realistic glycemic and blood pressure targets- weigh potential Vs risks Maintain Zero tolerance to hypoglycemia 36

Estimate fear of Hypoglycemia Provide an estimate of cardiovascular risk over 5 years Ensure consensus with patient, spouse or family, GP, informal carer, community nurse or hospital specialist Define the frequency and nature of diabetes follow - up Organize glycemic monitoring by patient or carer Refer to social or community services as necessary Provide advice on stopping smoking, increasing exercise and alcohol intake

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(g).

Co-Morbid Conditions

Objectives: By the end of the session, the patient should be able to:

Understand the relationship between hypertension, obesity and depression in accelerating complications and affect outcome of self care behavior Recognize BP goals, weight markers and depressions symptoms Understand the importance of routine BP checking Understand the inter relationship between the three conditions Work towards setting realistic goals and take small steps in reaching those goals.

Indications:

Hypertension Any patient with a systolic BP >/= 130 mmHg and a diastolic BP of >/= 80 mmHg measured at least twice on different days. Obesity Any patient with a BMI of > 23 kg/m2 and/or WC > 85cm (men) and 80 cm (women) Depression Any patient who scores more than ________ in the depression scale

Audience:

Patient & at least one family member

Taught by:

Physician Physician assistant Diabetes educator Nurse

Materials: Exercise guidelines/meal planning guidelines/tips to lose weight/Low salt recipes Method: Hypertension

38

Describe the relationship between hypertension, diabetes and kidney disease and cardiovascular diseases. Review the reasons for behavior change- cessation of smoking, alcoholism, drug abuse. Review the reasons for weight reduction and dietary modifications Review the need for stress counseling and refer to specialist.

Obesity Describe the relationship between obesity, diabetes and cardiovascular diseases. Review the reasons for behavior change choosing healthy foods, reduction in total calories, and regular exercise Set realistic goals and schedule frequent follow-ups Suggest guidelines for low calorie food options Suggest guidelines for exercise Suggest guidelines for behavior change Screen for depression and refer to specialist

Depression Describe the relationship between depression and diabetes self-care management. Refer to counselor for behavior change.

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(g).

Chronic Complications of Diabetes:

Overview of complications & risk reduction strategies Objectives: By the end of the session, the patient should be able to:

Appreciate the importance of early detection of complications. Understand the role of frequent screening with physical examination & biochemical testing for early detection of complications. List the different benefits of preventing uncontrolled clinical markers such as hemoglobin A1C level, fasting glucose, hyperlipidemia, and blood pressure readings.

State that blood sugar control, smoking cessation, influenza/pneumococcal immunization, daily foot/dental/skin care, hypertension, and weight control, can successfully reduce the risk of complications.

Indications:

Any patient with newly diagnosed diabetes OR new to the clinic. Teaching requested by patient. A lack of understanding is suspected.

Audience:

Patient & at least one family member

Taught by:

Physician Physician assistant Diabetes educator Nurse

Materials: Complications of diabetes patient books/pamphlets Method: Describe the relationship between diabetes and atherosclerosis (CAD, MI). Describe the relationship between diabetes and micro vascular complications including nephropathy, retinopathy, and neuropathy. 40

Describe the need to control blood pressure to avoid kidney and heart complications. Describe the risk of infection in diabetics, especially foot infections. Explain the need for regular screening for early detection of the above with: at least annual urine micro albumin, lipid profile, full eye exam, foot examination, dental care.

Introduce the idea that patient should be very careful with the feet. Describe the need for regular follow up, following treatment & dietary advice, and self care for prevention of complications.

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Smoking Cessation Objectives The patient should be able to quit smoking gradually or immediately. Target audience Smokers who visit the clinic and their family member(s) Materials Self-help booklets,Internet resources, community resources, pharmacotherapy Methods Assess the patient thoroughly for smoking habits,duration ,number of cigarettes/day, smoking cessation (ex-smoker) in years Counsel the patient with regard to the realtioship between smoking and diabetes nd increased risk for complications. Discuss the positive implications of quitting Discuss the possibility of weight gain and consequent increase in risk for diabetes. Present strategies to quit smoking and arresting weight gain. Encourage exercise Schedule frequent follow-ups. Provide information through booklets/pamphlets.

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(h).

Sick Day Rules Discuss with patient the necessity to continue medications/insulin irrespective of poor intake. Emphasize the importance of drinking non- sugary fluid periodically/frequently Highlight the significance of Blood glucose monitoring very 3-4 h Increase Insulin dosages if symptoms of hyperglycemia Decrease insulin only with documented symptoms/BG records show hypoglycemia Call the physician when symptoms of worsening vomiting, abdominal pain, breathlessness (deep and labored breathing), and altered mental consciousness occur.

Treat underlying infection.

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Oral health and Diabetes

Objectives: The patient should be able to Understand the increased risk of oral disease and gun disease in people with diabetes Understand the importance of oral health and hygiene. Indications Persons with diabetes Audience Persons with diabetes and their family members Instructor Physician, Physician assistant Diabetic educator Nurse Method Discuss the increased risk of dental caries in people with Diabetes Discuss the increased risk of fungal infections of the mouth and some of the predisposing factors Discuss consequences of poor dental hygiene Discuss gum diseases, such as gingivitis and periodontitis, their causes, treatment and consequences

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(j). Complementary therapies in Diabetes Management Objectives The patient should be able to analyze specific complementary therapies with regard t the benefits and risks Indications Persons with diabetes Audience Persons with diabetes and family members Taught by Physician assistant Educator Nurse Person with diabetes Method The educator identifies different complementary therapies being practiced in the region. analyses the risks and benefits of those therapies and products presents scientific evidence to substantiate her position is sensitive to cultural and religious beliefs, limited to the safety of the patient.

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(k). Sleep disorders and diabetes Objectives The patient should be able to understand the risks of sleep apnea, obesity, cardiovascular disease and hypertension. The patient should be able to take corrective action to relieve/reduce risk Indications Elderly patients with diabetes Obese/overweight patients with diabetes Persons with diabetes with pre-existing COPD Taught by Physician Physician assistant Nurse Diabetes educator Method The educator discusses the risk of snoring with sleep apnea. The methods of assessment of sleep apnea Treatment options Benefits of weight loss.

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Appendices No. Title I II III IV V Clinical RecommendationsBiochemical Markers AADE 7 Self management outcome behaviors Annual Follow up Plan Guidelines for self monitoring of Blood Glucose Guidelines for treatment/prevention of hypoglycemia Evaluation of Outcome of Group Education Module Blood Glucose lowering agents Page No. ii vi vii ix xii

VI VII

xiv xvi xvii xviii

VIII Insulin Administration Technique IX X Foot care inspection and guidelines for foot care

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Appendix I Clinical Recommendations- biochemical markers Table 1 : Glycemic recommendations for many non pregnant adults with diabetes Category
Pre-prandial capillary plasma glucose Peak postprandial capillary plasma glucose (ADA) Average Bedtime glucose HbA1 C

Normal Adult values (mg/dl) < 100 (AACE,ADA) < 140 (AACE,ADA) < 120 <6 %

Recommendations for adults with diabetes(mg/dl) 70 - 130 <180 (ADA, Joslin) 90- 150(Joslin) < 7%

Goals should be individualized based on*: duration of diabetes age/life expectancy co morbid conditions known CVD or advanced micro vascular complications hypoglycemia unawareness individual patient considerations More or less stringent glycemic goals may be appropriate for individual patients. Postprandial glucose may be targeted if A1C goals are not met despite reaching pre-prandial glucose goals. Mozilla Firefox.lnk Postprandial glucose measurements should be made 12 h after the beginning of the meal, generally peak levels in patients with diabetes

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Table 2 : Glycemic Recommendations for children

Plasma Blood glucose range (mg/dl) Before meals Toddlers, preschooler (0-6 years) 100-180 Bedtime/ove rnight 110-200 A1C % <8.5 Rationale Vulnerability to hypoglycemia Insulin sensitivity Unpredictability in dietary intake and physical activity A lower goal (< 8.0%) is reasonable if it can be achieved without excessive hypoglycemia School age (6-12 years) 90-180 100-180 <8 Vulnerability to hypoglycemia A lower goal (<7.5%) is reasonable if it can be achieved without excessive hypoglycemia 90 -130 90-150 <7.5 A lower goal (< 7.0%) is reasonable if it can be achieved without excessive hypoglycemia

Adolescent s and young adults (1319 years)

Key concepts in setting glycemic goals Goals should be individualized and lower goals may be reasonable based on benefit-risk Assessment. Blood glucose goals should be modified in children with frequent hypoglycemia or 49

hypoglycemia unawareness. Postprandial blood glucose values should be measured when there is a discrepancy between pre-prandial blood glucose values and A1C levels and to help assess glycemia in those on basal/bolus regimens. (Position Statement care.diabetesjournals)

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Table 3 : Glycemic recommendations for diabetes in pregnancy Category (Capillary BG)

Fasting 1 hr post prandial 2 Hr post prandial

Recommendations (mg/dl)
60-99 100-129 (Venous plasma) 100-139 (glucometer) 100-119

Table 4 : Lipid Panel recommendations Category

LDL-cholesterol HDL- cholesterol Triglycerides

Recommendations (mg/dl)
< < < < 100 (if no diagnosed CVD) 70 (if diagnosed CVD) 40 (men); > 50 (women) 150

Table 5 : Blood pressure targets Category Target(mm Hg)

Adults > 18 yrs of age 130 -180 People with proteinurea >1g 125/75 Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate.

Table 6: Definitions of abnormalities in albumin excretion Category

Spot collection Normal Microalbuminurea Macro(clinical)albuminurea

Values mcg/mg creatinine

<30 30-299 >/= 300

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Appendix II
The AADE 7 self - management outcome behaviors. 1 Healthy eating Making healthy food choices, understanding portion sizes and learning the best times to eat are central to managing diabetes. Diabetes education classes can assist people with diabetes in gaining knowledge, teaching food choice skills, and addressing related barriers 2 Being active Regular activity is important for overall fitness, weight management and blood glucose control. Collaboration between patients, providers and educators best addresses barriers, and helps develop an appropriate activity plan that balances food and medication with the activity level 3 Monitoring Daily self - monitoring of blood glucose provides people with diabetes the information they need to assess how food, physical activity and medications affect their blood glucose levels. Monitoring includes: blood pressure, urine ketones and weight. Education is offered about equipment choices, testing times, target values, and interpretation and use of results 4 Taking medication Diabetes is a progressive condition. The health care team will be able to determine which medications people with diabetes should be taking and help them understand how the medications work. Effective drug therapy in combination with healthy lifestyle choices, can lower blood glucose levels, reduce the risk for diabetes complications and produce other clinical benefits 5 Problem - solving Assistance to make rapid informed decisions about food, activity and medications, and develop coping strategies 6 Reducing risks Effective risk reduction behaviors such as smoking cessation, and regular eye, foot and dental examinations reduce diabetes complications and maximize health and quality of life, available preventive services. These include smoking cessation, foot inspections, and blood pressure monitoring, self monitoring of blood glucose, aspirin use and maintenance of personal care records 7 Healthy coping Health status and quality of life are affected by psychological and social factors. Coping: a persons ability to self manage their diabetes is related to their skills. Identifying the individuals motivation to change behavior, set achievable behavioral goals and provide support.

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Appendix III
Annual Follow-up plan 1. Comprehensive foot exam a. For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation (10-g monofilament plus testing any one of: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold). b. Provide general foot self-care education to all patients with diabetes. c. A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet, especially those with a history of prior ulcer or amputation. d. Refer patients who smoke, have loss of protective sensation and structural abnormalities, or have history of prior lower-extremity complications to foot care specialists for ongoing preventive care and lifelong surveillance. e. Initial screening for peripheral arterial disease (PAD) should include a history for claudication and an assessment of the pedal pulses. Consider obtaining an ankle-brachial index (ABI), as many patients with PAD are asymptomatic. f. Refer patients with significant claudication or a positive ABI for further vascular assessment and consider exercise, medications, and surgical options. 2. Hba1c a. Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). b. Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. c. Use of point-of-care testing for A1C allows for timely decisions on therapy changes, when needed. 3 Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic blood pressure 130 mmHg or diastolic blood pressure 80 mmHg should have blood pressure confirmed on a separate day. Repeat systolic 53

blood pressure 130 mmHg or diastolic blood pressure 80 mmHg confirms a diagnosis of hypertension.

4 Lipid panel - In most adult patients, measure fasting lipid profile at least annually. In adults with low-risk lipid values (LDL cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl, and triglycerides <150 mg/dl), lipid assessments may be repeated every 2 years. Nephropathy screening o o Perform an annual test to assess urine albumin excretion in type 1 diabetic patients with diabetes duration of 5 years and in all type 2 diabetic patients starting at diagnosis. Measure serum creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion. The serum creatinine should be used to estimate GFR and stage the level of chronic kidney disease (CKD), if present.

6 Screening for retinopathy Adults and children aged 10 years or older with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes. Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist. Less-frequent exams (every 23 years) may be considered following one or more normal eye exams. Examinations will be required more frequently if retinopathy is progressing Women with pre-existing diabetes who are planning a pregnancy or who have become pregnant should have a comprehensive eye examination and be counseled on the risk of development and/or progression of diabetic retinopathy. Eye examination should occur in the first trimester with close follow-up throughout pregnancy and for 1 year postpartum. 7 Screening for neuropathy All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests. Screening for signs and symptoms of cardiovascular autonomic neuropathy should be instituted at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes. 54

Appendix IV
Guidelines for self monitoring of blood glucose Self-monitoring of blood glucose (SMBG) should be carried out three or more times daily for patients using multiple insulin injections or insulin pump therapy. For patients using less-frequent insulin injections, non-insulin therapies, or medical nutrition therapy (MNT) alone, SMBG may be useful as a guide to the success of therapy. To achieve postprandial glucose targets, postprandial SMBG may be appropriate. Continuous Glucose Monitoring may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. Demonstration of BG monitoring
Objectives: By the end of the session, the patient should be able to: Perform self-monitoring of blood glucose using a blood glucose meter as evidenced by demonstration of the technique. State goal fasting and post-prandial blood sugars. Indications:

Any patient with newly diagnosed Type 1 Diabetes OR Any patient with known Type 1 Diabetes who is new to the clinic Any patient with new requirement of self-monitoring of blood glucose. Diabetic patient who is new to insulin. Teaching requested by patient. Incorrect glucose monitoring suspected. Audience:
Patient & at least one family member Taught by:

Physician Physician assistant Diabetes educator Nurse Materials:

Glucometer Glucose Test Strip Lancing Device Sink, soap, & water 55

Glucose log book

Method: Review reasons for glucose self-monitoring Review specific physician recommendations regarding frequency & timing of blood glucose testing by patient. (Have patient repeat recommendations back to you to fully assess understanding).

Review the following definitions: Fasting glucose level Pre-prandial glucose level Postprandial glucose level Review extra reasons for checking blood sugars: Symptoms of hypoglycemia , Illness Review parts of the glucometer: display monitor, buttons, test strip slot, batteries Direct patient through the capillary blood glucose monitoring demonstration: Perform control test with manufacturer solution. Have patient wash hands thoroughly with soap and water. Remove a glucose test strip & place in glucometer test strip slot (this usually turns on the meter) Remove end cap from lancing device. Place fresh lancet on lancing device and replace end cap. Recock the lancing device. Identify puncture site: sides of the end segment of the fingers are the best sites. Stroke down the fingers towards point of puncture site. Place end cap against puncture site& push lancet release button. Remove the lancing device. If a drop of blood doesnt appear, stroke the finger toward. Hold the tip of the test strip in the drop of blood until the meter tells you it is full. Put the device away. Wipe puncture site with clean tissue and hold pressure until the bleeding stops. Remove end cap of lancing device and replace used lancet in protective cap by placing the cap upside down on a firm surface. Once the blood glucose reading is complete, grasp the test strip and remove from the glucometer. Emphasize the following maintenance points: Clean lancing device weekly. Only use a lancet once. Dont use the same end cap on another person. Emphasize the following directions 56

Wash and dry your hands before and after testing Insert test strip into meter Prick your fingertip with a lancing device Apply blood sample to the test strip Read result Record result in your log book.

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Appendix V
Guidelines for treatment of Hypoglycemia
Objectives: By the end of the session, the patient should be able to: define the ranges of euglycemic blood glucose levels and the benefits of near normal glucose levels. describe the typical symptoms of hypoglycemia manage hypoglycemic episodes. Indications:

Any patient with newly diagnosed diabetes OR new to the clinic. Diabetic patient who is new to insulin. Teaching requested by patient. Hypoglycemic events suspected. Elderly Audience:
Patient & at least one family member Taught by:

Physician Physician assistant Diabetes educator Nurse Materials: nil

Method:

Review patients medications. Identify to the patient which ones are most likely to cause hypoglycemia (i.e. Insulin, oral secretagogues). Review definition of hypoglycemia: Blood glucose < 70 (caveat patients with chronically elevated blood sugars may experience hypoglycemia at higher glucose levels) Blood glucose 60-70 Mild Hypoglycemia Blood glucose 45-59 Moderate Hypoglycemia Blood glucose < 45 Severe Hypoglycemia Review prevention of hypoglycemia: Eat regular meals. Follow appropriate medication guidelines, especially when a meal is missed. Stay alert for the first symptoms. Keep sugar or sweet handy. Wear emergency identification.

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Review common symptoms of mild-moderate hypoglycemia: shaking, sweating, looking pale, hunger, weakness/fatigue, headache, impaired vision (double vision/tunnel vision), difficulty communicating, difficulty absorbing new information, unusual information (anxiety, giddiness, confusion, irritable behaviors such as arguing, crying, yelling, or fighting), fast heartbeat Review common symptoms of severe hypoglycemia: loss of consciousness, seizure Management of mild-moderate hypoglycemia Check blood sugar with your meter (if able) Take at least 3 glucose tablets, cup fruit juice, or 15 grams of sugar Check blood sugar after 15 minutes Repeat dose of carbohydrates if blood sugar is still low Management of severe hypoglycemia Requires immediate medical attention Take 30+ grams of glucose or sugar if able Have someone administer emergency injection of glucagon Meanwhile, someone should check blood sugar with meter (if able)

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Appendix VI
Evaluation of Outcome Of group education module A ten point questionnaire is used to measure the comprehension of the patient. The questionnaire has conceptual questions based on the topics covered by the group education module. Memory based questions have not been used. Group education Module Evaluation of understanding by patient Please tick the correct answer
1.

2.

3.

4.

5.

6.

Diabetes is caused by less amounts of _____________ produced by the body. a. Sugar b. Insulin c. Urine d. Sweat e. Dont know You are at risk for diabetes if a. your weight is higher than normal b. your height is higher than normal c. your spouse has diabetes d. Dont Know You may have diabetes if you have a. Excess thirst b. Excess hunger c. Excess urine d. Loss of weight e. None of the above symptoms f. All of the above g. Dont Know Complications of diabetes include(more than 1) a. Stress b. Kidney disease c. Foot infections d. Fever e. Blindness f. Dont know Treatment of Diabetes involves a. Doctors efficiency b. Your active participation c. Both d. Dont Know Hypoglycemia is a. High blood sugar b. Low blood sugar c. None of the above d. Dont know 60

You can treat hypoglycemia by a. Immediately eating 3 tsp of sugar b. Not eating at all c. None of the above d. Dont know 8. When you fall sick and are not able to eat well you a. do not stop your medication/insulin b. measure your blood glucose every 4 hours c. drink plenty of non-sugary liquids d. All of the above e. Dont know 9. When you read the nutrition label of a food item you look for a. Protein and vitamin content b. Type and content of fat and carbohydrate c. Preservatives added d. Dont Know 10. If you are making a healthy choice you would choose a. Poori with potato b. Whole wheat chapathi with subji c. Dont Know Answers
7. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

B. Insulin A. Weight is higher than normal F. All of the above A, b and e- Stress, kidney disease and blindness C- Both B Low Blood Sugar A. immediately eating D. All of the above B. type and content of fat and carbohydrate B. Whole wheat chapathi with subji Scores:
1.

3 poor comprehension- educator to reinforce concepts during individual sessions 4- 7 fair comprehension- Educator to assess the need and fill in the gaps. 8- and above- Good comprehension- Educator to reinforce important concepts as needed by the patient.

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Appendix VII
Blood Glucose lowering agents Objectives: By the end of the session, the patient should be able to:

State the medication they are using, including dosage, time, compatibility with other drugs and foods eaten Describe how the medication prescribed to them works and the effects on glucose control. Describe onset, peak, duration, and side effects of medication.

Indications:

Any patient with newly diagnosed type 2 diabetes OR new to the clinic. Teaching requested by patient. A lack of understanding is suspected.

Audience:

Patient & at least one family member

Taught by:

Physician Physician assistant Diabetes educator Nurse

Materials: Handout on prescribed medication(s). Method: Describe the drug pharmacodynamics & metabolism. Review the side-effects/adverse effects of medication, how to detect them, and how to manage them. Review schedule & how to take medication. Review that lifestyle modifications are mandatory along with taking medications.

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Appendix VIII
Insulin Therapy Objectives At the end of the session the patient should Free from any doubts /fears regarding use of insulin and accept insulin as part of therapy - Be able to understand the type and mechanism of action of insulin prescribed. - Be Aware of various choices in insulin therapy to cater to individual needs - Be comfortable in self injecting insulin with regard to dosage, timing, site of injection , care and storage of insulin - Be comfortable in making minor adjustments in dosage suitable to special needs such as exercise, meals special occasions, sick days etc. Indications Any patient diagnosed with type 1 Any patient with type 2 prescribed with insulin Any patient with GDm prescribed with insulin Audience Patient and at least one family member Taught by Physician Physician assistant Diabetes Educator Nurse Materials Handout,A/V aids Method Discuss with patient the importance of insulin therapy and its role in BG control Familiarize the person with diabetes with the dosage, onset peak and acrtion of the insulin prescribed Familiarize person with diabetes with the type of insulin and its components (in the case of vial, syringe etc) Demonstrate insulin injection technique- dosage adjustments, syringe markings etc Discuss alternate sites of injection Discuss signs of improper technique Discuss the risk of hypoglycemia and its prevention Discuss the importance of self administration of insulin Discuss care and use of syringe/pens Ensure the person with diabetes demonstrates good injection technique. 63 -

Appendix IX
Foot Care I. Key components of the diabetic foot examination. Inspection Evidence of past/present ulcers? Foot shape? Prominent metatarsal heads/claw toes Flat foot Muscle wasting Charcot deformity Dermatologic? Callus Erythema Pigmentations Neurologic 10 - g monofilament at four sites on each foot + 1 of the following: Vibration using 128 Hz tuning fork Pinprick sensation Ankle reflexes Vibration perception threshold Vascular Foot pulses Ankle brachial index, if indicated

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II. Foot care guidelines to patient Always wear proper footwear At risk patient are advised to wear footwear inside homes also Inspect shoes before wearing them Inspect feet thoroughly after removing shoes/footwear Do not walk bare foot inside temples when the day temperature I hot (prenoon-afternoon).Complete temple visit early in the morning or evening before night falls Dont soak your feet. Wash them well with mild soap and water every day. Dry them very well, including between the toes. Wear shoes that fit well. Buy socks designed to keep your feet comfortable (padded, minimal seams, not too tight). Use lotion on your feet, but not between the toes. Do not cut your toenails. File them instead, or have them trimmed by a foot doctor. If you have poor circulation, nerve damage, or very thick toenails, see a foot doctor regularly. Also see a foot doctor if you have corns, calluses, or bunions. If you get a cut or scratch, take care of it right away. Wash it with mild soap and warm water. Use a mild ointment. Cover with gauze and paper tape or a fabric bandage. Make sure to change this often. Call your healthcare provider right away if the area does not heal or gets red or has any drainage.

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Check List for Person with Diabetes I walk for 30 minutes everyday I check my feet everyday I take my medicines everyday as prescribed I choose healthy food everyday I space my meals within consistent times everyday. I check my BP every week I check My Blood Glucose every month I check My HBA1C every 3 months I check My eyes, heart, kidney and nerve function every year I use proper footwear I monitor my Blood Glucose regularly I can take care of myself

Name:

Signature:

Signature of Physician: Educator:

Signature of Diabetes

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References 1. Boyd E. Metzger. E.B., Buchanan A. T., et al ., 2007., Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus., Diabetes Care, Volume 30, Supplement 2, July 2. Chamukuttan, S., Viswanathan,V., Ambady,R., 2003, Cutoff Values For Normal Anthropometric Variables In Asian Indian Adults, Diabetes Care, Volume 26, Number 5 3. Funnel,M.M., Brown,L.T., et al., 2011., National Standards for Diabetes Self Management Education , Diabetes Care, Volume 34, Supplement 1, January 4. Gonzales,S.J., Saffren,A.S., et al , Depression, Self-Care, and Medication Adherence in Type 2 Diabetes: Relationships across the full range of symptom severity, Diabetes Care, Volume 30, No.9, sep.2007 5. International Curriculum for diabetes health professional education: Consultative Section on Diabetes Education; International Diabetes Federation 6. Joslin Diabetes Center & Joslin Clinic: Clinical Guideline For adults with Diabetes, 5/21/2010. 7. Standards Of Medical Care in Diabetes Care- 2011 : 2011., Position Statement, American Diabetes Association, Diabetes Care, Volume 34, Supplement 1, January 8. Textbook of Diabetes, 2011. Edited by Holt,I.G.R., Cockram, C., Flyvbjerg,A., Goldstein, J.B. Wiley-Blackwell, West-sussex,UK. 9. The HAPO study C-operative research group , Hypoglycemia and adverse pregnancy outcomes, The new England Journal of medicine, Volume 358,No.19,May 2008 10.American Diabetes Association www.diabetes.org 11.American Association of Diabetes Educators www.diabeteseducator.org 12.Joslin Diabetes Center - www.joslin.org

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