Diabetes: Patient Education Survival Skills Class

4-Hour Session
Revised August 2004

Objectives
Describe and contrast 2 principle types of diabetes List the diagnostic criteria for diabetes Describe acute and chronic complications of diabetes Describe how to prevent complications of diabetes Describe diabetes self-management skills

Why Diabetes?
18 million cases in the United States Estimated that 1/3 are unaware of diagnosis Third leading cause of death in the U.S. Leading cause of blindness *Patient education is the cornerstone of diabetes treatment and management* *Complications can be prevented or delayed through intensive treatment*

Diabetes is
A metabolic disease in which the body does not produce or properly use insulin to regulate the level of glucose (sugar) in the blood. In other words, your body cannot use the fuel in the blood for energy..

Quick Review
Glucose: a sugar made in the body after food is digested. It is the bodys main source of energy (fuel for the body) Insulin: a hormone produced by the pancreas that allows glucose to get into the cells to be used for energy (acts like a key)

Normal Glucose Values

Normal Values Fasting Blood Glucose <100mg/dl Hemoglobin AIC 4 - 6 % (shows average glucose over past 60-90 days) Goal < 7% with diabetes

Principle Types of Diabetes

Type 1: autoimmune pancreas does not produce insulin 10% of all diabetes Type 2: pancreas does not produce enough insulin or it meets resistance 90% of all diabetes
Gestational Diabetes: occurs with pregnancy

Type 1 DM
Signs and Symptoms
Usually sudden and severe in onset Increased urination Increased thirst Increased appetite Weight loss Blurred vision Fatigue/weakness Nausea/vomiting Vaginal itching/infections Skin rashes

Type 2 DM
Signs and Symptoms
Onset more insidious Early symptoms may go unnoticed (3-5yrs) Increased urination, thirst, & hunger Blurred vision Fatigue Sores that heal slowly Sexual dysfunction (erectile dysfunction) Infections (vaginal in women)

How Do We Diagnose Diabetes?

Fasting blood glucose level >126 mg/dl Random non-fasting glucose >200 mg/dl Pre-Diabetes: FPG 100-125 mg/dl

Research
Studies show that an increased glucose level in the blood over many years can cause irreversible damage to the eyes, kidneys, heart, blood vessels and the feet.

Medications

Type 1 diabetes: insulin production stops

CELL

Insulin helps sugar (glucose) move into cells, where it is used to produce energy Without insulin, glucose cannot enter the cells
CELL

CELL

Cells quickly waste away from lack of glucose

Type 2 diabetes: insulin production and effectiveness are impaired

CELL

Insulin helps glucose move into cells, where it is used to produce energy If not enough insulin is produced (insulin deficiency), not enough glucose can move into cells When insulin is not used properly (insulin resistance), cells do not respond by taking in glucose Cells slowly waste away from lack of glucose

CELL

CELL

Normally, the body regulates blood glucose levels by removing excess glucose after a meal...

Ingested carbohydrates are metabolized into glucose and absorbed into the blood, causing high blood sugar (hyperglycemia)

The pancreas produces and secretes insulin, which helps move glucose into cells

Muscle, fat, and liver cells take up glucose from the blood

Blood glucose levels return to normal

and releasing stored glucose back into the blood between meals

Gastrointestinal tract is empty; glucose must be supplied by the body for energy

The pancreas produces and secretes glucagon, stimulating the liver to release the glucose stored during meals

The liver releases glucose in response to low blood sugar (hypoglycemia)

Blood glucose levels return to normal

Type 2 diabetes evolves from 2 primary defects: insulin deficiency and insulin resistance
Progression of untreated type 2 diabetes

Glucose is absorbed into the blood, causing hyperglycemia

Muscle, liver, and fat cells develop insulin resistance

Pancreatic dysfunction leads to insulin deficiency Blood glucose levels remain high

Treatment Options
First treatment is controlling diet and getting plenty of exercise Next option is use of oral medications Final option is use of insulin
This is needed in Type 1 diabetes patients because their bodies do not make insulin

Drug therapy is needed in addition when diet and physical activity fail to correct hyperglycemia

Oral hypoglycemic Insulin for type 1 or agents for type 2 type 2 diabetes diabetes

Medication Types
There are several ways in which these medications work
Causes your body to secrete insulin, decreases your bodys resistance to insulin, decreases glucose production in your liver, prevents absorption of sugars in your diet

Classes of drugs
Sulfonylureas and insulin-secreting agents Biguanides Alpha-glucosidase inhibitors Thiazolidinediones

Oral hypoglycemics work in several different ways

Alpha-glucosidase inhibitors decrease gastrointestinal absorption of glucose Sulfonylureas increase insulin secretion

Thiazolidinediones reverse insulin resistance

Biguanides decrease release of glucose by the liver

Sulfonylureas
Brand names
Amaryl DiaBeta Diabinase Glucotrol (XL) Glynase PresTab Micronase

Generic names
glimepride glyburide chlorpropamide glipizide glyburide glyburide

Sulfonylureas
Increase insulin release from your pancreas Help improve muscle sensitivity to insulin Pancreas must be actively making insulin to work Often taken 30 minutes before meals

D-phenylalanine Derivatives
Nateglinide (Starlix) Increase insulin release from pancreas Short acting Take with each meal Do not take if meal skipped

Meglitinides
Repaglinide (Prandin) Helps pancreas secrete more insulin right after meals, thus reducing post-meal blood sugar Works fast and short duration of action Take before meals Do not take if meal skipped

Biguanides
Metformin (Glucophage, Glucophage XR) Decrease glucose production in the liver Increase muscle sensitivity to insulin Decrease insulin need May help with weight loss Improve cholesterol values

Thiazolidinediones
Pioglitazone (Actos) Rosiglitazone (Avandia) Help make your cells more sensitive to insulin

Alpha Glucosidase Inhibitors

Miglitol (Glyset) Acarbose (Precose) Blocks enzymes that digest starches in the stomach and intestines Reduces post-meal sugars Take with the first bite of meal

Medications may have to be combined to keep pace with this progressive disease

Different oral hypoglycemic agents may be taken together

Insulin may be taken along with oral agents

Insulin: Rapid-Acting
Rapid-acting: insulin lispro (Humalog) and insulin aspart (Novolog) Starts working in 5-15 minutes Lowers blood glucose most in 45-90 minutes Finishes working in 3-4 hours

Insulin: Short-acting
Short-acting, regular (R) insulin Starts working in 30 minutes Lowers blood glucose most in 2-5 hours Finishes working in 5-8 hours

Insulin: Intermediate-acting
Intermediate-acting, NPH (N) or Lente (L) insulin Starts working in 1-3 hours Lowers blood glucose most in 6-12 hours Finishes working in 16-24 hours

Insulin: Long-acting
Long-acting, insulin glargine (Lantus) Starts working in 1 hour Lowers blood glucose evenly for 24 hours Finishes working in 24 hours and is taken once per day at bedtime Lantus should not be mixed together in a syringe with any other form of insulin

Insulin Use Considerations

Insulin injection sites
Stomach (works fastest), thigh (works slowest), arm (works at medium speed)

Dont change needle types or site because it may change absorption Keep insulin in refrigerator Reduce pain
Allow bottle to warm before injection (or leave one in use out), allow alcohol to dry, dont reuse needles, dont wipe needle with alcohol

Dispose of needles properly

Summary
Type 2 diabetes is a progressive, but manageable, disease Type 2 diabetes evolves from 2 primary defects:
insulin deficiency insulin resistance

Uncontrolled hyperglycemia leads to serious complications Risk for complications can be reduced by tight glucose control

Summary, cont
Disease progression can be managed through a partnership between physician and patient Treatment options:
increased physical activity and nutritional therapy sulfonylureas other oral agents or insulin (as monotherapy or in combination)

Patient education and self-care are critical

Emotional Aspects

Diabetes and Psychology

Karl O. Moe, PhD, ABPP Clinical Health Psychology

How did you feel when you first heard your diabetes diagnosis?
Fear Relief Worry Desperate Hope Out-of-Control Overwhelmed Frustrated Helpless Hopeless Guilt Alone Resentment Anger Grief

Plan of Action
Information Get care/Get treatment Experiment with control Pay attention to your emotions Plan for changes Make changes

Help Along the Way

Healthcare providers Printed information Support groups Stress management

Questions? Comments? Complaints?

Exercise

Effects of Exercise
Improvement in blood glucose control Improved insulin sensitivity Reduction in body fat Cardiovascular benefits Stress reduction Prevention of Type 2 diabetes

Effects of Exercise on Insulin Requirement: Single Exercise Bout

One hour of exercise requires an additional 15 grams of CHO either before or after activity. Metabolic response to exercise differs according to:
Timing of exercise in relationship to meal and medication Blood glucose level prior to activity Use of other medication Intensity and duration of the exercise Individuals fitness level

Contraindications to Exercise
Active retinal hemorrhage ; retinopathy therapy Presence of illness or infection Blood glucose level > 250 to 300 mg/dl with presence of ketones or Blood glucose level 80-100 mg/dl

Exercise Programming
Aerobic: Large muscle group activities
50-80% HR Max (220-Age x .5-.8) Monitor Rate of Perceived Exertion (RPE) 4-7 days a week 20-60 minutes/session

Strength/Anaerobic
Free weights, weight machines 1-3 times a week

Flexibility: Stretching/Yoga
Maintain/increase range of motion Improve gait/balance and coordination

Helpful Hints
Keep sources of rapidly acting CHO available during exercise Consume plenty of fluids before, during and after exercise Practice good foot care and wear proper exercise shoes and cotton or moisturewicking socks Carry medical identification

Managing Your Diabetes

Managing Your Diabetes

Self-Monitoring of Blood Glucose (SMBG) Sick Day Management Eyes, Feet, and Dental Care Travel Tips Daily To Do list Routine Health Maintenance

Self-Monitoring Blood Glucose (SMBG)

Must have a glucometer Keep a diary and bring to every appointment Maintain enough supplies until next appointment. Know how to obtain more supplies

Sick Day Management

Do not skip medications Test blood sugar 4x day Check ketones if type 1 diabetes Check temperature 2x day Drink plenty of fluids Eat small frequent meals or snacks Keep in contact with provider-know when to call

Eye Care
See your ophthalmologist once a year for a dilated eye exam
Report blurred or double vision Seeing dark spots Narrowed field of vision

Skin Care
Bathing Precautions -Keep dry parts of your skin moist -Mild soap and lukewarm water Protect Skin -Avoid scratches, cuts and other injuries -DO NOT GO BAREFOOT! -Protect you skin from the sun, sunscreen Treat injuries promptly -Wash cuts with soap and water -Notify provider if cuts dont heal or signs of infection.

Foot Care
Clip toenails straight across Keep your feet out of water that is too hot or too cold. No heating pads Do not soak your feet for prolonged periods No OTC remedies for corn/calluses, they may cause burns or ulcers
Wear comfortable shoes that fit Examine feet daily for scratches, wounds, rash, blisters, or any change in sensation or nail color

Dental Care
Keep your teeth clean Dont brush too hard Replace toothbrush every 3-4 months Go to the dentist every 6 months for cleaning and exam Report any signs of redness, pus, patches, or pain

Travel Tips
Carry and wear diabetes identification Have diabetes medical information available:
Prescriptions and Physician information

Follow usual meal, exercise, & medications Insulin storage Easy to carry, easy to eat carb snacks Wear comfortable shoes Take sunblock

Daily to do list
Daily to do list
Check blood glucose with glucometer Take medications as prescribed Follow meal plan Exercise and stress reduction Inspect feet Dental care

Quarterly to do list
Make appointment with health care provider
Take blood glucose diary for review Make list of questions and concerns Blood Pressure check (recommend home BP monitor) Hemoglobin A1C check

Annual Health Maintenance

Annual eye exam by ophthalmologist Dental exam every 6 months Annual Flu vaccine Pneumococcal vaccine Tetanus vaccine every 10 years Primary care manager appointment to: - review cholesterol profile and metabolic profile (checks kidney, liver, proteins, electrolytes, minerals, and microalbumin) -perform focused physical examination

What every patient needs to know!

Written Treatment Plan
When to call provider SMBG (monitor their own blood sugar) Meal plan Sick day management Preventative care Exercise Medications Medic Alert identification

Know Your ABCs

A: A1C B: Blood Pressure C: Cholesterol Profile goal is <7% goal is <130/80 goal is LDL <100 HDL >40 triglycerides <150

Diabetes and Carbohydrate Counting

Individual Meal Planning

Tips for success
Refer to a dietitian Major groups are represented: grains and breads (starches), fruits, vegetables, meats, and dairy products No more than 4-5 hours between meals Meals should be at consistent times Incorporate what you like to eat Do not skip meals All foods fit

Foods contain carbohydrates, fats, and proteins as sources of energy, plus many other important ingredients like water, vitamins, and minerals Carbohydrates (CHO) in food have the most impact on the blood sugar

Although high fat foods can contribute to obesity, heart disease, and higher blood sugars in the long run, they play only a minor role in daily blood sugar control Protein also plays a minor role in blood sugar control- half the protein we eat converts to glucose over a period of several hours but should only make up ~10-20% of our total calories

What are Carbohydrates?

Grains (bread, cereal, rice, pasta) Fruits Vegetables Most milk products (not cheeses) Desserts and candies (refined sugars) -ose foods: sucrose, fructose, maltose

Counting Carbohydrates WHY?

Offers more variety in choices Information on food labels makes meal planning easier You can swap an occasional high sugar food (even though it may contain fewer nutrients) for other carbohydrate-containing foods Better sense of dietary control and better glycemic control

Simple Carbohydrate Counting

Work with a dietitian to plan how many grams of carbohydrates to eat at each meal and snack Choose foods from the carbohydratecontaining food groups to meet your allowance

 One serving from the Bread/Starch/Starchy Vegetable group= 15 grams of CHO One serving from the Fruit group= 15 grams of CHO One serving from the Milk group= 12 grams of CHO (round up to 15 grams for simplicity) One serving from the Non-Starchy Vegetable group= 5 grams of CHO (count as free but 3 svgs= 15 grams CHO) *Meat and Fats do not contain CHO but contain protein and/or fat *Alcohol counts as a fat (moderation defined as 2 drinks/day for men and 1 drink/day for women)

 Because Starch/Bread/Starchy Vegetables, Fruit, and Milk all contain approximately the same amount of CHO they can be exchanged for one another Therefore, if your meal plan calls for 1 Starch, and you would prefer a piece of Fruit, that is fine

Carb Counting Examples

BREAKFAST Cereal, dry Milk, skim Blueberries Yogurt, light, with fruit 1 cups 1 cup cup 1 cup 30 g CHO 12 g CHO 15 g CHO 15 g CHO

Total = 72 g CHO

LUNCH Bread, whole wheat Turkey breast, sliced Cheese, sliced Banana, medium Crackers, wheat Juice, apple

2 slices 30 g CHO 2 oz (protein) 0 g CHO 1 oz (protein) 0 g CHO 1/2 15 g CHO 5 15 g CHO 4 oz 15 g CHO Total = 75 g CHO

PORTION SIZES
VERY IMPORTANT Many people make good food choices but eat eat excessive portion sizes! Use Daily Meal Planning Guide to look up proper portion sizes and use measuring cups/spoons to ensure accuracy

Bread, Cereal, Rice, and Pasta 15 grams carbohydrates

1 slice of bread small bagel, pita, English muffin, or hamburger bun cup cooked cereal or pasta cup peas or corn 1/3 cup rice or beans

Fruits 15 grams carbohydrates

1 medium piece of fruit melon (1 cup cut-up) cup canned (drained) fruit 4 oz fruit juice

Non-Starchy Vegetables 5 grams carbohydrates

1 cup raw vegetables cup cooked vegetables cup tomato juice or tomato sauce

Milk and Yogurt 12 grams carbohydrates

1 cup low-fat or skim milk 1 cup plain yogurt (sugarfree, fat-free)

Meats: Very Lean, Lean, Medium-fat, High-fat

1 oz skinless & non-fried meat, poultry, fish cup canned fish (packed in water) 1 oz fat-free or low-fat cheese 1 egg or 2 egg whites 1 tablespoon peanut butter

Fats: Monounsaturated, Polyunsaturated, and Saturated

1 teaspoon oil, margarine, or mayonnaise 1 tablespoon cream cheese 1/8 avocado 1 slice bacon 1 tablespoon regular salad dressing * Monounsaturated fats= olive, canola, peanut, & avocado oil

FREE FOODS fewer than 20 calories

Celery, cucumber, onions, radishes, salad greens Salsa, hot sauce, garlic, herbs Sugar-free gelatin, jam, or jelly Ketchup, mustard Sugar-free drinks, unsweetened coffee or tea

Label Reading

Complications

COMPLICATIONS
Acute: sudden onset usually reversible

Chronic: gradual onset can be irreversible

Acute Complications
Hypoglycemia (low blood sugar): glucose less than 70 mg/dl Causes:
Too much insulin Skip or delay meals Heavy exercise Errors in medication administration Weight loss Alcohol

Hypoglycemia Symptoms
Weakness Sweating Shakiness Tremors Nervousness HA/Dizziness/Hunger Irritability Tachycardia, palpitations Convulsions, confusion, coma

Treatments for Hypoglycemia

15 grams of carbohydrate
4 ounces of fruit juice (1/2 cup) 4 ounces of soft drink 4 teaspoons of granulated sugar 2 tablespoons of raisins 1 tablespoon of honey or syrup 3 pieces of hard candy 1 cup of skim milk 3 or 4 glucose tablets DO NOT OVER TREAT

Patients need to know

You should feel better 10-15 minutes after treatment Test blood glucose after 15 minutes then 1 hour after episode If no improvement or theres a change in mental status, get transported to an Emergency Room!

Acute Complications
Hyperglycemia (high blood sugar): glucose >200 mg/dl Causes: - forgetting to take medication - not enough medication - eating more than usual - physical illness or emotional stress - less physically active than usual - pregnancy

Hyperglycemia Symptoms
- Increased urination - Increased thirst - Increased hunger - Drowsiness - Fatigue - Hunger - Dry skin

Diabetic Ketoacidosis (DKA)

Complication mainly of Type 1 Diabetes Presence of high glucose over 250 mg/dl, ketones in blood and urine Dehydration, abdominal pain, fluid & electrolyte imbalance Can lead to coma and death if not treated Get transported to an Emergency Room! Tx: insulin, IV fluids, treatment of underlying cause

Hyperosmolar Hyperglycemic State (HHS)

Complication of Type 2 Diabetes 4 Primary Features
Severe high glucose (glucose>600 mg/dl) Dehydration No ketones in urine Confusion, lethargy, may mimic a stroke

May lead to coma and death if not treated Get transported to an Emergency Room! Tx: insulin, IV fluids, treatment of underlying cause

Chronic Complications

Chronic Complications
Diabetes can damage the lining of blood vessels and nerves by causing scarring and stiffness. The vessel linings can trap cholesterol and plaque leading to blockage (atherosclerosis). **The heart must work harder to pump blood through these blocked vessels leading to chronic complications

Cardiovascular Disease
(heart and blood vessels) Accelerated Atherosclerosis (rapid, younger age). hardening of the arteries or Coronary Artery Disease Heart Attacks Heart Failure Strokes

Lower Extremities
Leg ulcers, gangrene, increased risk of infection **Most common cause of amputations Pain in legs and calves (peripheral vascular disease)

Foot Complications
Poor sensation Poor recovery from injury Decreased sweating Dry skin Ulcerations Infection Gangrene

Nerve Complications
Damage to nerves causes numbness, burning, and pain (peripheral neuropathy) Can lead to trouble walking and maintaining balance

Autonomic Neuropathies
(nerves that control bodily functions)

Impotence Gastroparesis (slow emptying of the stomach) Diabetic diarrhea Neurogenic bladder (loss of bladder tone)

Eye Complications
Retinopathy (hemorrhages in the back of the eye and scar formation) Impaired vision Blindness Leading cause of blindness Cataracts

Kidney Disease
Can no longer filter wastes out of the body Protein spills in the urine No warning signs Diabetes is the most common cause of kidney disease requiring dialysis and transplant Can be detected early with blood and urine tests (chemistries and microalbumin) Prevention with medications (ask your provider)

Report These Symptoms!!

Any chest pain, chest tightness, chest fullness or pressure Trouble breathing Increased fatigue Wounds that do not heal Calf pain Changes in vision Headaches Swelling Change in mental status

Questions??