DIABETES OVERVIEW Diabetes is a disease characterized by abnormal metabolism of carbohydrates, proteins, and fats.

. Newly discovered hormones and systems have increased understanding of normal physiology and the pathophysiology of diabetes. Arbitrary glycemic limits are used to diagnose pre-diabetes and diabetes. Frequently, diabetes is suspected on the basis of acute symptoms; these will be discussed later. DEFINITION Diabetes includes 4 clinical classes: Type 1 Type 2 Gestational Other specific types (e.g., caused by genetic defects in beta-cell function or insulin action, diseases of the exocrine pancreas or drugs such as steroids. Refer to: Gestational Diabetes - handouts #2 and 3 Type 1 diabetes results from autoimmune pancreatic beta cell destruction, leading to absolute insulin deficiency. It is characterized by the abrupt onset of clinical s/s associated with marked hyperglycemia and strong propensity for ketoacidosis. Type 2 diabetes is a multi-hormonal pathophysiology involving a progressive insulin secretory defect along with insulin resistance. - Refer to handout #1; Physiology Type 2 DM progresses from asymptomatic to clinical diabetes requiring pharmacologic intervention. - Obesity, weight gain and physical inactivity affect the progression of type 2 DM. SIGNS AND SYMPTOMS Symptoms include: - frequent urination - excessive thirst and hunger - weight loss - blurred vision - fatigue - Headache - poor wound healing - occasionally muscle cramps Chronic hyperglycemia may lead to growth impairment, susceptibility to certain infections, renal, retinal, peripheral vascular, connective tissue, and neuropathic syndromes. Acute life-threatening consequences of diabetes include hyperglycemia with diabetic ketoacidosis (DKA) and hyper-osmolar hyperglycemic state (HHS). - HHS was previously known as HHNS or HHNKS (hyperosmolar hyperglycemic nonketotic syndrome)

DIAGNOSIS Pre-diabetes: - Hyperglycemia not sufficient to meet the diagnostic criteria for diabetes. - It is diagnosed with a fasting plasma glucose (FPG) or an oral glucose tolerance test (OGTT). Type 1: - Generally presents with acute symptoms due to markedly elevated BG levels. - Because of the acute onset of symptoms, type 1 diabetes is detected soon after symptoms develop. - Approximately of all cases are in persons under 18 years of age. Type 2: - Often not diagnosed until complications appear because many of the symptoms are absent or have been attributed to other causes. Refer to handout #4; All About Pre-diabetes with Diagnostic Tests. Refer to handout #4 for pre-diabetes and risk factors for type 2 LAB VALUES- ABCs OF DIABETES: A = A1C (hemoglobin) B = Blood Pressure C = Cholesterol GOALS: Total cholesterol: < or = to 170 mg/dl LDL< or = to 100 mg/dl HDL > or = to 40 men; > or = to 50 women Triglycerides: < or= 150 mg/dl Blood Pressure < or = to 130/80 Blood Sugar: 70-130 mg/dl HbA1C < 7% HBA1c Normal hemoglobin A1c = 4.0 5.7% Pre-Diabetes A1c = 5.7 6.4% Diabetes A1c goal <7% Refer to handout # 15, Understanding A1C)

DIABETES SELF MANAGEMENT EDUCATION

The goal of diabetes education is to teach patients how to successfully manage their diabetes. Give a man a fish and you will feed him for a day. Teach a man to fish and you feed him for a lifetime. AADE (American Association of Diabetes Educators) 7 Self-Care Behaviors : 1. Being Active 2. Healthy Eating

3. Monitoring 4. Taking Medication 5. Problem Solving 6. Reducing Risks 7. Healthy Coping The skilled educator elicits behavior change resulting in positive outcomes. Teach them to fish! Before instructing these 7 behaviors, we need to thoroughly assess the patient; this is our detective work!

ASSESSMENT Health and medical history. Nutrition history and practices. Physical activity and exercise behaviors. Prescription, OTC meds and alternative therapies. Factors that influence learning, i.e. education, motivation, literacy etc. Diabetes self-management behaviors and previous training, actual knowledge and skills. Physical factors, psychosocial concerns. Current mental health status including substance abuse or eating disorders Occupation, financial status, etc. 1. BLOOD GLUCOSE MONITORING BG monitoring is the key to diabetes self-management and glycemic control. BGs have no practical value unless the test results are recorded and used, especially for pattern management. Pattern management: by recording BGs, patterns can be identified so that patients, caregivers, and physicians can make treatment and lifestyle changes without delay. Review of BG logs is very important. Ideally, patients should use a log diary/sheet. Verify memory in meter for accuracy. Include time, relation to meals and meds if possible, especially insulin. Check the expiration date of the test strips. Teach patients to use the glucose control solution each time they pick up new strips from the pharmacy. Instruct correct storage of meter and strips. Instruct washing hands with soap and water. If patient needs a new meter, refer to handout #5, Choosing a meter. Testing pre-meal and 2 hours after first bite of meal (post prandial) is ideal to determine the BG response to specific types and amounts of food. Encourage patient to be a detective, to analyze what caused high or low BG and document reason on log.

Are more frequent BG checks needed? Is patient following agreed upon meal plan? Is carbohydrate content consistent? Can patient or caregiver correctly assess carb content of food? Is the patient taking DM medications as ordered? How long has the patient been on oral meds? Is the patient on enough DM meds, is the dose effective? Specific times to check BG: Ideally, the first week of service, have patient test QID and continue until a pattern is determined. If BG is significantly higher in the AM than the prior HS reading, it is helpful to have an HS BG followed by a 2-3 am BG followed by a FBG in the AM to assess overnight BG response. If BGs are higher or lower than expected, is there a trend to highs or lows or are they isolated? Were there changes in activity or stressful situations? Is the patient noting possible reasons for high or low BGs? There are several good handouts and articles to read: BG Targets, Understanding Blood Sugar Results, When Should I Check My Blood Sugar, Keep Careful Records of Your BG Checks, and Managing Your BG Ups and Downs (refer to handouts #6,7,8,9,10) Staying in range - Strive to maintain a balance: food and stress increase BGs, exercise and meds decrease BGs. Follow overall plan: weight loss and exercise to decrease insulin resistance, medications, tracking and recording. More info helps the entire diabetes team (MD, RN CDE, dietitian and endocrinologist) to assist patient. Give positive feedback to patient along the way, even if its a small change; any behavior modification is good! Healthy Eating-Medical Nutrition Therapy Healthy eating is an effective, but challenging self-care behavior that improves glycemic control. It is considered by many educators/clinicians to be the most challenging of the AADE 7 behaviors to implement. It involves many basic decisions such as when to eat, what to eat, and how much to eat. Influencing these decisions are complex individual factors such as habits, emotions, food preferences, food availability and family/cultural eating patterns. To help individuals achieve effective behavior change, the diabetes educator needs to: Provide the patient with knowledge and skill training. Help identify barriers and facilitate problem solving and coping skills.

2. HEALTHY EATING - MEDICAL NUTRITION THERAPY Diabetes medical nutrition therapy (MNT) is the term used for the specific nutrition services provided to treat diabetes and promote healthy eating habits.

It is also used to treat pre-diabetes and is individualized per patients metabolic needs, preferences, and willingness to make life-style changes. The ADA does not endorse any specific diet there is no such thing as an ADA diet! Small changes make a BIG difference. Meal planning is central to managing diabetes. There are tools available to assist with meal planning which will be highlighted. In fact, everyone would benefit from healthy eating, just in decreasing CV risk alone.

MEAL PLANNING/TOOLS TO ASSIST Exchange system: a certain number of food choices to spend at each meal or snack. Any food in one group can be exchanged for another in the same group. Carbohydrate counting: A method for keeping track of the amount of carb in each meal. One carb choice has 15 grams of carb. (refer to handouts on carb counting) Advanced carb counting will be discussed later with insulin use. Refer to handout #11, 5 pages Glycemic Index: Rates foods on how they affect BG levels, how quickly various foods raise blood sugar levels. Low GI<55 Intermediate GI=56-69 High GI=70 or greater Refer to handout #12 Glycemic Index) CARBOHYDRATE COUNTING All carbs are converted to glucose during digestion. 45-60 grams per meal is usually adequate carbs for a healthy diet, depending on if male or female and persons size. 15 grams carb per snack 15 grams carb will raise BG up about 30-45 mg/dl in 15 minutes. Total amount of carb consumed is a strong predictor of glycemic response. Both type and amount of carb in food influences BG levels. Very low carb diets (<130 g/day) are not recommended. Teach patients how to read a food label. Educate on serving size and total carbohydrate grams per serving CARBOHYDRATE COUNTING - ADVANCED Basic carb counting Patient needs to have math skills, resources to calculate complex foods, and ability to identify and manage patterns. BG monitoring is critical. Insulin to Carbohydrate ratios: patient mastery of:

Self-adjustment of insulin Record keeping and analysis Algorithms based on grams of CHO are effective DCCT study: those who used insulin to carb ratios had lower A1c

INSULIN TO CARB RATIO METHOD A: Add all carb consumed at meals Add all insulin doses used at meals Divide total carb grams by total daily insulin dose METHOD B: 500 Rule Divide 500 by total daily dose of insulin (TDD) Insulin sensitivity factor or correction factor may also be ordered by the healthcare provider Add x units of insulin for each x change in BG i.e. add 1 unit of insulin for each 10 mg/dL over BG of 120 or add 2 units for each 50 over BG of 120 May also be in the form of a sliding scale FIBER AND SOY Fiber is the part of plant foods that cant be digested or absorbed by the body it is a carbohydrate and included in the total carb grams on a label. The ADA recommends 25-30 grams of fiber/day. Fiber helps slow the digestion of digestible carbs. Refer to handout #13 Fiber. Soy protein has a favorable effect on blood lipids. Sterols are natural components found in soybeans. Sterols and stanols interfere with the bodys ability to absorb cholesterol. Research suggests that soy improves insulin sensitivity and glycemic control. MEAL PLANNING Refer to Handouts for Healthy meals, Balanced diet, Exchange lists, Plate method, etc. #14, 9 pages Meal planning questions to ask your patients: What are the times that you eat your meals? Do you eat fish? What type of milk do you drink? How many eggs a week do you eat? What beverages do you drink? Do you eat fruits and vegetables? How many/day? 3. BEING ACTIVE/EXERCISE Benefits of exercise: Improved insulin sensitivity.

Reduction in body fat and weight; even a modest weight loss (510% of body weight) reduces insulin resistance Reduction in incidence of cardiac disease. Reduction in triglycerides and LDL. Increase in HDL. Improved control of hypertension. Improved self-esteem. Reduced psychological stress. MD approval, start slow, daily activity, safety. Instead of what cant you do? Ask what can you do? Frequency: 3-5 days/ wk. Intensity: low-moderate (most type 2s) Duration- minimum 20 minutes; for weight loss, 60 minutes Exercise can affect BG levels for 72 hours. ADA Statement: moderate weight training programs that utilize light weights and high repetitions can be used for maintaining body strength in all patients with DM. ACSM Guidelines-Frequency: at least 2 days/week, minimum of 810 exercises involving the major muscle groups, minimum of 1 set of 10-15 repetitions.

EXERCISE SAFETY Avoid injecting insulin into body areas likely to be involved in exercise, such as thigh or deltoid area. To prevent low BG, best time for an exercise session is 1-2 hours after a meal if on insulin or oral agents that promote insulin secretion. Test BG before/after exercise to indicate individual response. If BG <120 mg/dl, eat a snack. Eat a snack if >90 minutes since last meal. Carry a fast acting carb while exercising. BG can increase with exercise if BG is over 250 mg/dl. Exercise with someone who knows about hypoglycemia. Wear Diabetes Identification. Wear appropriate footwear that will not cause pressure or blisters SUMMARY: HEALTHY EATING/BEING ACTIVE Encourage patients to have an action plan with goals What are 3 changes you will make this week? Write these down. Choose an accountability partner. Use resources to assist you; remember, each persons nutrition and exercise plan should be individualized and incorporate all tools available that will accomplish this. All ADA Cookbooks are acceptable and very helpful. Joslin and Journey for Control web sites are good for diabetes information.

4. MEDICATIONS Taking medications is one of the self-care behaviors that are important to develop, evaluate and enhance. The educator plays an important role in this. Educators need the ability to recognize potential barriers that interfere with an individuals appropriate taking of medications. Assist patients in identifying and addressing these barriers. The educator must be familiar with ALL of the patients medications, including over the counter meds and supplements. Familiarity with all diabetes meds, including proper use of insulin, is essential The educator can assist the health care provider to adjust the medications after careful assessment of significant history/pattern of BGs. Keeping a log is of paramount importance so these changes can be made without too much time passing. Many med changes may be made to achieve glycemic control. Refer to handouts: Diabetes Pills, Types of Insulin, and Injectable Diabetes Medicine; Not Insulin. Injection sites #16; 4 pages Advanced carbohydrate counting, #17, 2 articles; 6 pages with food lists. 5. PROBLEM SOLVING - ACUTE AND CHRONIC COMPLICATIONS ACUTE COMPLICATIONS: Hyperglycemia: BG>180; BG >200 is toxic Hypoglycemia: BG<70: treat immediately DKA: diabetic ketoacidosis: emergency Hyperosmolar non-ketotic syndrome HHS or HHNKS: emergency Refer to these handouts/articles for more In depth instruction: # 18 Acute/chronic Complications, DKA, Depression, DCCT, and foot care, 8 pgs. CHRONIC COMPLICATIONS Microvascular -small blood vessels Eye Kidney Autonomic and peripheral nerves Macrovascular - large blood vessels Heart Brain Skin Peripheral Vascular Disease Peripheral Arterial Disease Models of Behavior Change: Adherence/Compliance Empowerment:

99% of diabetes care is self-care Patients are experts about their lives Consequences accrue to patients Patients are primary decision-makers Identify problems/issues/thoughts/feelings/attitudes Identify goals and plan to achieve them; evaluate results Develop a plan with long-term and short-term goals Ask: What do you want? What can you do? What needs to happen to change a situation?

6. REDUCING RISKS Identify high risk situations Dont give up Rehearsal for what to do in situations Slipping away from control: why? Balance: need to have or to regain Evaluate/Revise Plan: How did it work? What did you learn? What would you do differently? Still a goal? Define problems/facilitate problem-solving Seek help/social support/maintain contact 7. HEALTHY COPING Coping strategies: Individual preferences and History of coping techniques. Stress Management: Problem solving Inevitable: Life stress, diabetes related stress, etc. Reframe thoughts/attitudes Specific techniques Seek help Emotional response - diabetes evokes strong feelings We all respond differently Motivators for self-care Diabetes burnout - patient feels overwhelmed Depression- Common, not often recognized, can be severe. Do depression screen for patients suspected to be depressed Refer to mental health professional if symptoms present. Other disorders may be present that effect diabetes clinical anxiety disorder, eating disorders and other psychiatric diagnoses such as bipolar or personality disorders. Eating disorders in teenagers in particular. Refer to handout article on depression listed in complications. CONCLUSION

As educators, we can do much to assist patients to properly self-manage their disease. Utilize the information in this packet and you will experience good results. Lifetime Care CDEs will continue to assist all diabetes team members to learn and be updated on whats new with diabetes; please utilize us as resources. Patient log forms can be of great assistance Refer to 2 BG logs, My Test Goal Numbers and a 7 day food record; handout # 19; 4 handouts

RESOURCES Web sites