Diabetes Self Management Education Course by hcj

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									Diabetes Self Management
    Education Course


             Amy Bouthillette
     Clinical Dietitian, Certified Diabetes Educator

                Carrie Palmer
  Adult Nurse Practitioner, Certified Diabetes Educator
What Is Diabetes?
            Learning Points
• Know the difference between Type 1 and
  Type 2 diabetes
• Know the job of glucose
• Know the job of insulin
• List some health factors related to getting
  Type 2 diabetes
          Type 1 Diabetes
• Body does not make insulin
• Usually develops in children or young
  adults
• Normal Weight
• Must take insulin daily to live
            Type 2 Diabetes
• Cells do not use insulin properly
• Not enough insulin being produced
• Generally develops in adulthood
  – Becoming more common in children due to
    obesity
• Common in persons who are overweight
• Many different ways to treat, including diet
  and exercise, pills, or insulin
Type 2 Diabetes, Key Concepts

•   Obesity
•   Insulin Resistance
•   Elevated Insulin Levels
•   Reduced ability to make insulin
          Insulin Resistance
• Common in persons who are overweight
• Insulin not as effective, and does not allow
  glucose into cells efficiently, causing blood
  sugar levels to rise
• There is enough insulin activity to prevent
  diabetic coma
      What Is Diabetes:
      How Insulin Works

                   Insulin




Insulin Receptor
          How Insulin Works
• Insulin is a hormone made in your
  pancrease
• It works like a key to unlock cells so that
  blood sugar (glucose) can enter
• Glucose is then used by the body as fuel
                What Is Diabetes:
                How Insulin Works
                                            Insulin Fills
                                            Receptor Sites
         cell        insulin
                                    cell

Receptor Site                                      insulin
                glucose

                                    Insulin Passageways

           glucose
                               glucose
   What Is Diabetes: Insulin
Resistance Due to Excess Weight
                     glucose
                                   insulin
insulin


   glucose    cell
                               glucose




              glucose
  What Is Diabetes: Normal
Blood Glucose & Insulin Levels
        Normal Blood Glucose & Insulin
                   Levels

        150
                                        Blood
mg/dL




        100                             Glucose Level
         50                             Plasma
                                        Insulin Level
          0
          Early am Early pm Overnight
  Monitoring
    Your
  Diabetes:
Important Tests
  and Goals
          Learning Points
• Know why it is important to check
  glucoses
• Be able to describe a range for normal
  glucoses before food
• Be able to describe what A1c test
  measures and what the goal is for A1c
• Know when you need to test your glucose
  more often
     Monitoring Your Diabetes:
     Target Blood Glucose Levels
                 Without    With Diabetes With Diabetes
                 Diabetes     (normal)       (target)

Before meals     70-115         110         80-130
                 mg/dL         mg/dL         mg/dL

Before bedtime   70-120         120        100-150
                 mg/dL         mg/dL         mg/dL

Hemoglobin A1c     6%           7%           7%
               Know Your Number
                14         360
                                        Monitoring Your
Poor Control
                13         330          Diabetes: What
                12         300         does an A1c mean
                11         270

                10         240         An A1c measures how much
 Not Good
                                       sugar has been sticking to red
                 9         210
                                       blood cells over a 3 month period
                 8         180         of time.
Pretty Good

                 7         150

Good Control     6         120
                                       An A1c is a measure of long-term
                                       diabetes control.
                 5          90

               A1c       Blood Sugar
                                       Goal is A1c <7
    Monitoring Your Diabetes:
          What is an A1c
The higher your blood sugar, the more sugar that sticks to your red
cells and the higher your A1c

 Normal Blood Glucose                                 Red blood cell
                       Glucose
                       particles
Red
blood
cell
                                   Above-Normal Blood Glucose
    Monitoring Your Diabetes:
         Testing your A1c

• Your doctor will check your A1cevery 3
  to 6 months
• Your doctor may check your A1c more
  often if:
  – You have blood sugars above goal
  – Your last A1c was high
  – You have had symptoms of low blood sugar
    Monitoring Your Diabetes:
   Controlled blood sugars and A1c

• Blood sugars and an A1c at or below goal
  (7% or less) can protect your:
  – Heart, brain, blood vessels
  – Eyes
  – Kidneys
  – Nerves
  – Feet
Monitoring
  Your
Diabetes:

Testing Your
 Sugars at
   Home
      Testing Sugars- How often?
• Depends what kinds of medicine you take:
  – Most patients taking pills test once a day
  – Patients taking insulin may need to test between 1
    and 4 times a day
     • Determined by the type of insulin and its action

• Test more often if:
  – You have had low blood sugars (BG<70)
  – Sugars have been unusually high (over 200)
  – You are sick
  – You are starting a new exercise program
  Monitoring Your Diabetes:
Sample Diabetes Record- Fasting
   Monitoring Your Diabetes:
Sample Diabetes Record- Alternating
                Monitoring Your Diabetes:
              Sample Diabetes Record- Detailed
          Breakfast                 Lunch            Supper          Bedtime            Other              Comments:
        Dose   Blood            Dose   Blood     Dose    Blood    Dose    Blood     Dose   Blood     Physical Activity, Stress,
              Glucose                 Glucose           Glucose         Glucose           Glucose              etc.
Sun     18L 220                                  10L                    100
        6R                                       4R
Mon     18L      80                  120         12L    170             140               30
        4R                                       4R
Tues    18L      240                 180         12L    240             110               70
        4R                                       4R
Wed     18L      90                              10L    120             80                90
        4R                                       4R
Thur    18L      100                             10L    180
        4R                                       4R
Fri     18L      120                 150         10L    160             120
        4R                                       4R
Sat     18L      90                  70          10L    180             240
        4R                                       4R


Number of             7                    4              6                   6                 3
measurements

Total of blood        940                  520            1050                790              190
glucose values

Average of                134             130             175                 132              64
blood glucose
values
Monitoring Your Diabetes:
Your meter provides important
        information
   Other Points to Remember
• Make sure you know how to correctly use
  your meter
• Don’t share meters
• Always bring meter to doctor’s visits
What Affects
Your Blood
  Sugar?


   What is
hypoglycemia &
hyperglycemia?
           Learning Points
• Know signs of high blood sugar
  (hyperglycemia)

• Know the signs of low blood sugar
  (hypoglycemia)

• Know what to do when sugars are too high
  or too low
       Your Blood Sugar:
Hyperglycemia or High Blood Sugar
 • Symptoms
   – Extreme thirst
   – Frequent urination
   – Dry skin
   – Hunger
   – Blurred vision
   – Drowsiness
   – Decreased healing
        Your Blood Sugar:
 Hyperglycemia or High Blood Sugar
• Causes
  –   Too much food
  –   Too little insulin or diabetes medicine
  –   Illness
  –   Stress
• Onset
  – Gradual
  – If extremely high or you have type 1 diabetes it
    may progress to diabetic coma
  – Damage to your eyes, kidneys, and nerves
    happens over time
       Your Blood Sugar:
Hyperglycemia or High Blood Sugar
• What can you do when you have
  symptoms?
  – Test blood glucose more often
  – Don’t wait, call your doctor if your blood
    sugar is over 200mg/dL for several tests or
    for 2 days
    Your Blood Sugar:
Symptoms of Hypoglycemia
• Shaking     •   Hunger
• Fast        •   Impaired vision
  heartbeat
              •   Weakness/fatigue
• Sweating
              •   Headache
• Dizziness
              •   Irritability
• Anxiety
      Your Blood Sugar:
Hypoglycemia or Low Blood Sugar
• Causes
  – Too little food
  – Too much insulin or diabetes medicine
  – Extra activity or exercise
• Onset
  – Sudden
    • May progress to unconsciousness,
      confusion, or insulin shock
              Your Blood Sugar:
          Treatment of Hypoglycemia
  4 Steps to treating your blood sugar:
     1. Quick sugar, 10 to 15 grams carbohydrate
     2. Recheck blood glucose in 15 to 20 minutes and
        repeat treatment if necessary
     3. If your glucose is normal, eat a protein meal or snack
     4. If you have symptoms, but BG is over 70, have snack


*Treat all sugars under 70 mg/dl (with or without symptoms)

*If you have symptoms, but no meter, treat and try to be
prepared and have meter with you the next time.
   Hypoglycemia or Low Sugar:
      Step 1- 10 to 15 Grams of Carbs
             Pick One of these
                     1/4 to 1/3 cup                5 to 8 Life
                     raisins                       Savers®


4 oz. orange juice
                                      8 oz. milk

   2 to 3
   Glucose
   Tablets                                            ½ can of
                                                      regular soda
                 3 to 5 peppermint candies
Hypoglycemia or Low Sugar:
 Step 2- Recheck Blood Sugar
Hypoglycemia or Low Sugar:
  Step 3- Eat a protein snack
           Pick One



  ½ meat sandwich
                                peanut butter
                                sandwich or
                                  crackers
            crackers & cheese
      Hypoglycemia or Low Sugar:
         Foods to avoid for lows

                    Potato          Doughnuts
                    Chips

Chocolate

            Pizza
                                    Cookies
                             Nuts


Ice Cream
                    Cake
  Monitoring
     Your
   Diabetes:
  Your blood
   pressure,
cholesterol, and
key medications
               Your Heart:
Controlling diabetes is more than just sugar


• The number one killer of Americans is heart
  disease:
   – Heart attacks
   – Strokes
• If you have diabetes, your have 4X the risk of
  a heart attack
• You must control your blood pressure,
  cholesterol, and take key medications
                 Your Heart:
                Blood Pressure
• What used to be considered a “normal” blood
  pressure may in fact be abnormal
   – Goals change
• If your blood pressure is significantly elevated, it
  may be more important for your doctor to improve
  than your sugar
• Goal
   – If you have diabetes your pressure should be lower
     than someone who does not have diabetes
   – Systolic less than 130 mmHg (top number)
   – Diastolic less than 80 mmHg (bottom number)
                      Your Heart:
                        Cholesterol
• What used to be considered a “normal” cholesterol may in
  fact be abnormal
   – Goals change
• Goal
   – If you have diabetes your cholesterol should be lower than
     someone who does not have diabetes
   – Total cholesterol under 200 mg/dl
   – LDL (bad cholesterol) less than 100 mg/dl
   – HDL (good cholesterol) over 40 mg/dl
   – Triglycerides (blood fat) less than 150 mg/dl
• You need a cholesterol medicine if you are not at goal,
  you have had heart surgery or a heart attack/stroke, or
  your total cholesterol is over 135 mg/dl and you are older
  than 35
             Your Heart:
             Key Medicines
• Most patients over 35 years old who
  have diabetes could benefit from key
  medications:
  – Cholesterol medications- Statins
  – Blood pressure medications- ACE-I or
    ARB
  – Blood thinners- A daily baby aspirin
Monitoring
   Your
Diabetes:
 Summary
                           Take Care of Your Diabetes
 Date: _________________

                 Know Your Number                          You Should…
                                                 Have an A1c test every 3-6 months
                   14           360
                                                 Check your blood sugars as directed
                   13           330
Poor Control                                Have your blood pressure checked at each visit
                   12           300           Have your cholesterol checked every year
                                                      Check your feet every day
                   11           270
                                                    See an eye doctor every year
                   10           240                   Have a flu shot each year
 Not Good
                                                       Have a pneumonia shot
                    9           210


                    8           180               Talk with Your Doctor About…
Pretty Good
                                                            Eating healthy
                    7           150
                                                            Staying active
Good Control        6           120                      Giving up smoking
                                                     Taking an aspirin every day
                    5            90
                                                       Taking an ACE inhibitor
                 A1c          Blood Sugar
                                                   Taking a cholesterol medication
                                                                                       February 2005
                                                  ___________________________
      Cholesterol and Blood Pressure              ___________________________
       Test               Goal         My Value   ___________________________
LDL                   Less than 100               ___________________________
HDL                 Greater than 40               ___________________________
Total Cholesterol     Less than 200
                                                  ___________________________
Triglycerides         Less than 150
                                                  ___________________________
Blood Pressure          Less than
                                                  ___________________________
                         130/80
                                                  ___________________________
                                                  ___________________________
              Goal Blood Sugars
                                                  ___________________________
                                                  ___________________________
                                                  ___________________________
Fasting (No food for 8 hours)         80 - 120    ___________________________
                                                  ___________________________
        If you have any questions, please contact your doctor or the Diabetes Care Team
                        toll-free at 1-866-633-8002 or at (919) 843-0391.
Long Term Considerations
      with Diabetes
     Preventative Efforts
       Complications
           Learning Points
• List some complications of uncontrolled
  diabetes
• Describe some preventive screenings for
  your eyes, feet
• Know how often you should check your
  feet
• Describe some behaviors to prevent
  developing complications from diabetes
    Preventing Complications
• Diabetes can cause other problems if not
  well controlled
• Be sure to monitor:
     Feet
     Eyes
     Heart
     Kidneys
     Screenings Your Doctor Can Do

•   Check cholesterol every year
•   Dental exam and cleaning twice a year
•   Foot check every visit with your doctor
•   Thorough foot exam every year
•   Urine check for kidney damage
    (microalbumin) every year
          Behaviors to Prevent
             Complications
• Pneumonia
  vaccination at least
  once
• Flu shot every year
• Dilated eye exam by
  an ophthalmologist
  every year
      Personal Habits You Can Do
•   Check your blood sugar
•   Maintain a healthy weight
•   Stop smoking
•   Exercise
•   Eat a healthy diet
•   Check your feet every day
•   Brush and Floss your teeth every day
                Foot Care
• Keep your blood sugars in good control
• Check your feet every day
  – Look for cuts, blisters, red spots, swelling
  – Use a mirror to check the bottoms of your feet
    or ask someone to help
• Wash your feet every day in warm (not
  hot) water
  – Dry well, especially between the toes
                 Foot Care
• Keep your feet soft and smooth
  – Use thin coat of lotion on the tops and
    bottoms of feet
  – Do not use lotion between your toes
• Trim toenails weekly if you can reach them
  – Trim straight across
  – File edges with an emery board
               Foot Care
• Protect your feet from hot and cold by
  avoiding contact with hot water or surfaces
  and wearing socks to keep feet warm
• Elevate feet when you are sitting and
  avoid crossing legs
• Stop smoking to improve blood flow to
  your feet
                   Foot Care
• Wear Shoes and
  Socks at All times
  – Never walk barefoot
  – Wear comfortable
    shoes that protect feet
  – Feel inside of your
    shoes before putting
    them on to make sure
    lining is smooth and
    no objects are inside
      When to see the Podiatrist
• If you cannot reach or see well enough to
  cut your own nails
• If your toenails are too thick for you to cut
• If you have thick callouses
• If you have now or have ever had a foot
  ulcer
• If you have numbness in your feet
     Long Term Complications

Cardiovascular disease

Retinopathy (eye damage)

Nephropathy (kidney damage)

Neuropathy (nerve damage)
     Cardiovascular Disease
• Diseases of the heart and large blood vessels

• 65% of people with diabetes die from heart
  attack or stroke

• People with diabetes often have heart attacks
  earlier in life

• 1 out of 3 people with diabetes have peripheral
  arterial disease, which reduces blood flow to
  your feet
  ABC’s to Protect Your Heart and
           Blood Vessels

• A is for A1c: less than 7%
• B is for Blood Pressure: 130/80 or less
• C is for Cholesterol:
  – LDL (bad) cholesterol less than 100
  – HDL (good) cholesterol greater than 40 in
    men and 50 in women
  – Triglycerides less than 150
What YOU can do to Protect Your Heart


•   Take your medicines!
•   Take an aspirin every day
•   Exercise
•   Eat a healthy diet
•   Quit Smoking
•   Reduce stress
   Retinopathy (eye damage)
• Leading cause of blindness in US is
  diabetes
• Risk is increased each year you have
  diabetes
• Can be prevented by excellent control of
  blood sugar
• Can be prevented with routine eye exams
  and early detection
• Can be treated with laser surgery by an
  ophthalmologist
 Nephropathy (kidney damage)
• Leading cause of kidney failure and need for
  dialysis in US

• First sign is protein spilling into urine, tested with
  urine Microalbumin.

• Advanced kidney damage later evident on
  bloodwork

• Kidney damage or worsening kidney damage
  can be prevented by excellent blood sugar and
  blood pressure control, and by certain blood
  pressure medications
  Neuropathy (nerve damage)
• Diabetes is the leading cause of leg
  amputation in the US
• Numbness, tingling, burning, or other
  painful sensations in hands and feet
• Slowed digestion of food in stomach
  causing nausea, vomiting, or diarrhea
• Carpal tunnel syndrome causing pain in
  hands and wrists
• Other nerve problems-sexual dysfunction
  Neuropathy (nerve damage)
• Increased risk with each year of diabetes,
  high blood sugar, and smoking
• Can lead to foot ulcers and foot
  deformities
• Prevent and improve symptoms with
  excellent blood sugars
• Must practice good foot care
• Some medications can improve painful
  symptoms, but not numbness.
       Hour 2
Medicines for Diabetes
• Diabetes pills
• Insulins
• New diabetes medicines
           Learning Points

Know why it is important to take your
 medicines as prescribed

Know the medications you are on for
 diabetes

Know the possible side effects of your meds
Diabetes Pills:
    Oral
 Medications
         Diabetes Pills:
          Sulfonylureas

• These tell the pancreas to make
  more insulin
         Diabetes Pills:
      Names of Sulfonyureas
     Brand Name        Generic Name
Diabeta           glyburide
Micronase
Glynase

Glucotrol         glipizide
Glucotrol XL
Amaryl            glimepiride
          Diabetes Pills:
Things to know about sulfonylureas
• Main thing to watch out for is having too
  many low blood sugars. If this
  happens, your doctor will give you a
  lower dose.
• Take the same way everyday
• Glucotrol XL cannot be crushed or cut in
  half; might see its empty shell in toilet
          Diabetes Pills:
            Metformin
• Tells the liver to stop sending out
  sugar
         Diabetes Pills:
           Metformin
• Comes as generic metformin or brand
  name Glucophage
• Also comes in a long-acting form
            Diabetes Pills:
    Things to know about metformin
• Can help people lose some weight
• Main side effects are upset stomach and diarrhea
   – These usually get better after about 1 week
   – Taking with food can help

• Does not cause blood sugar to go too low
• Cannot be used in kidney disease or certain kinds of heart
  failure. Talk with doctor if you have these.
• Contact doctor if you notice new fatigue, nausea, muscle
  pain/weakness, or fast breathing because these could be
  signs of a serious side effect
              Diabetes Pills:
                Glitazones

• These help insulin in your body work better
         Diabetes Pills:
       Names of Glitazones
• Avandia and Actos
• Only come as brand name pills
         Diabetes Pills:
 Things to know about glitazones
• The more common side effects of these are
  weight gain and swelling
• People with heart failure should discuss this
  with their doctor before taking
• Occasional blood work to test the liver is
  recommended, although liver problems on
  this medicine are very rare
• These pills usually take 6 to 12 weeks before
  you can see their full benefit on blood sugar
• These are expensive
           Diabetes Pills:
            Meglitinides
• These tell the pancreas to make more
  insulin
• These are taken with meals, so you skip
  a dose if you skip a meal
          Diabetes Pills:
        Names of Meglitinides
• Prandin® and Starlix®
• Only come as brand name pills
              Diabetes Pills:
               Meglitinides
• Things to know
  – Main side effect to watch out for is low sugars
     • Might have a lower chance of having lows
       compared with sulfonylureas
  – These are expensive
         Diabetes Pills:
   Alpha-glucosidase inhibitors
• These pills slow down the absorption of
  carbohydrates (carbs) from the gut after
  you eat
           Diabetes Pills:
 Names of Alpha-glucosidase inhibitors
• Precose®
• Glyset™
• Only come as brand name pills
               Diabetes Pills:
Things to know about alpha-glucosidase inhibitors

 • Biggest problem with these pills is that they
   can cause a lot of stomach upset and gas
   (70%)

 • This gets better over time, but for some
   people it stays a problem with these pills

 • Have to take it with every meal, since it works
   on food directly. Skip taking if you skip a
   meal
Combination Diabetes Pills Available

• Glucovance®
  – Metformin + glyburide
• Metaglip®
  – Metformin + glipizide
• Avandamet®
  – Avandia® + metformin
• Avandaryl®
  – Avandia® + Amaryl®
  All
 About
Insulin
                        Insulin
• Used in patients with type 1 and type 2 diabetes
• Used to replace the insulin your body is no
  longer able to make
   – You need insulin to move glucose into cells after
     eating. This lowers blood sugar and provides fuel to
     your body.
• Available in different formulations
   – Short-acting insulin to take with meals
   – Long-acting insulin to provide baseline insulin
   – Insulin mixes
             Types of Insulin
•   “Meal” Insulin
•   Long-Acting Insulin
•   Insulin Mixes
•   Come in vials or pens
Why are there different types of
           insulin?
             “Meal” Insulins
• Humulin R®, Novolin R®
  – “Regular” insulin
  – Clear
  – Short-acting
  – Inject these 30 minutes before meals
  – For some people, these last a couple of hours
    too long, so that blood sugar is too low after
    effect of meal wears off
             “Meal” Insulins
• Novolog®, Humalog®, Apidra®
  – Clear
  – Rapid-Acting
  – Inject these 15 minutes before meals
  – Can inject right before meal or immediately
    after finishing meal
  – These last for a shorter time in body, so they
    wears off faster and are less likely to cause
    low blood sugar between meals
   Intermediate-acting insulins
• Novolin N®, Humulin N®
  – Cloudy
  – Lasts about 12-18 hours
  – Inject these at consistent times, as
    prescribed
  – Usually taken twice a day
        Long-acting Insulins
• Lantus®
  – Clear
  – Longer acting, usually taken once a day at
    same times
• Levemir®
  – Clear
  – Long acting, taken once or twice a day
           Insulin “Mixes”
• Humulin 70/30, Novolin 70/30
  – Mixtures of 70% NPH and 30% regular
    insulin
• Humalog Mix 75/25
  – Mixture of 75% longer-acting and 25% fast-
    acting insulin
• Novolog Mix 70/30
  – Mixture of 70% longer-acting and 30% fast-
    acting insulin
            Insulin “Mixes”
• Cloudy
• Usually taken twice a day with meals.
• Longer-acting part tends to work better
  when taken later at night (8-10pm) than
  when taken with supper
• Difficult to obtain good control with mixes
  due to low blood sugar risks
• Depend on very consistent meal patterns!
                     Insulin
• Side Effects:
  – Hypoglycemia = low blood
    sugar
  – If you experience these
    symptoms, you need a
    quick source of sugar:
    juice, hard candy or
    glucose tablets
                     Insulin
• Side Effects (continued):
  – Soreness or redness at injection site
     • You can minimize this by rotating the injection site
       each time you administer insulin
  – Feeling nervous or agitated
  – Increased thirst or appetite
     • Your dose may need to be changed to help with
       these symptoms
     Insulin – Drawing up doses
1.   Wash your hands
2.   Inspect insulin for particles before using – replace if
     necessary
3.   If using a cloudy insulin (like Humulin N, Novolin N, or
     a “mixed” insulin) – gently roll vial between hands
4.   Check how many units you need to inject. Then pull
     back the syringe plunger to draw that amount of air
     into the syringe
5.   Push the needle into the top of the insulin bottle. Push
     the plunger to put air into the bottle. Keep the needle in
     the bottle
6.   Holding the needle in the bottle, turn the bottle upside-
     down. Then pull out the plunger to measure the units
     of insulin you need.
7.   Take the needle out of the bottle
        Insulin - Administration
• Pick injection site:
   – Anywhere on belly at least 2
     inches away from belly button
   – Outer thighs
   – Backs of arms
• Pinch skin, hold needle like a
  pencil, and inject at a 45 to 90
  degree angle
• Rotate injection sites-next
  injection should be at least 2
  inches from where last injection
  was given
Insulin - Administration
          Insulin – Storage
• Refrigerate all insulin vials while not in-
  use
• May keep individual insulin vial at room
  temperature once in-use
  – Just avoid exposing vials to high
    temperatures (over 85 degrees F) for
    extended periods
• Never freeze insulin – do not use after it
  has been frozen
           Insulin – Storage
• Whether kept in refrigerator or at room
  temperature, most insulin vials should be
  discarded 4 weeks after first dose was drawn
  from it
  – Exception: Levemir is good until 42 days after first
    use
• Insulin pens – vary widely in expiration dating
  once in-use– always check with pharmacist for
  your individual product
    New Medicines
• Byetta
• Symlin
• Januvia
     New Medicines - Byetta®
• Injections: 5- and 10-mcg
  prefilled pens
• Can be used in people
  who are not on insulin but
  are taking diabetes pills
• Given twice a day with
  meals
• Cannot be mixed with any
  insulins
   New Medicines - Byetta®

• Generally only small decreases in blood
  sugar
  – A1c goes down about ½ %
• Lowers blood sugars that are high within a
  few hours after meals
• Side effect of nausea
  – May cause some people to lose some weight
   New Medicines - Symlin®
• Injection: comes in vial or pen
• Can be used in people on insulin, in
  both type 1 and type 2 diabetes
• Given 3 times a day with meals
    New Medicines - Symlin®
• Generally only small decreases in blood
  sugar
   – A1c goes down about ½ %
• Your doctor will cut down doses of your
  insulins, since there can be a risk of dropping
  your blood sugar too low
• Lowers blood sugars that are high within a
  few hours after meals
• Side effect of nausea
   – May cause some people to lose some weight
   New Medicines – Januvia®
• Oral tablets
• Usually given once a day and can be
  taken with or without food
• Used for patients with Type 2 Diabetes
• Can be used in patients also taking
  metformin or a glitazone
    New Medicines – Januvia®
• Works in 2 ways:
  – Tells your body to make more insulin
  – Tells your body to make less sugar
• Generally only small decreases in blood sugar
  – A1c goes down ½ %
• You may need a lower dose if you have kidney
  disease
• Side effects: headache, respiratory infections
  and low sugars
Physical Activity
           Learning Points
• Describe how exercise affects blood
  glucose levels
• Describe how regular exercise affects the
  body
• Know how much exercise a person should
  get each week
        Physical Activity:
     How Does Exercise Help?

• Improves cholesterol and other
  lipids
• If hypertensive, helps to control
  high blood pressure
• Improves cardiovascular
  function
• Diminishes potential for weight
  gain
     Physical Activity:
  How Does Exercise Help?
• Improves insulin sensitivity
• Increases sense of well-being
• Increases flexibility and
  muscle strength
Physical Activity: Before You
 Begin an Exercise Program...
• Consult your doctor
• Adjust insulin and
  carbohydrate, if necessary
• Check your blood sugar before
  and after exercising
• Carry fast-acting sugar
• Wear ID
• Use stomach area for shots
        Physical Activity:
      Things to Keep in Mind
• Exercise should be
  appropriate for your lifestyle
  and general condition
• Wear proper shoes & inspect
  your feet daily
• Use protective equipment as
  necessary
          Physical Activity:
           Getting Started
• Start your exercise program
  slowly
• Be sure it is enjoyable
• At first, exercise may be limited to
  5-10 minute periods on 3-4 days
  a week
• When you are ready, gradually
  increase the length of time you
  exercise and the number of days
  of exercise each week
           Physical Activity:
           Types of Exercise
• Aerobic exercise (with oxygen)
  – Includes endurance exercise
     • Walking, riding bikes, swimming
  – Improves heart fitness
• Anaerobic exercise (without oxygen)
  – Lasts for short durations
     • Resistance training (lifting weights)
     • Flexibility training (stretching)
  – Improves muscle strength
   Exercise Recommendations for
             Diabetes
Aerobic activity
• At least 150 minutes per week (moderate)
• And/Or 90 minutes per week (vigorous)
• Spread over at least 3 days, not skipping more than 2
  days in a row

Strength or resistance training
• 3x a week
• Work up to 3 sets of 8-10 repetitions

To keep lost weight off (over 30 pounds)- maintain 60
  minutes a day of moderate to vigorous activity
         Physical Activity:
  Planning Your Exercise Program

• What exercise programs or activities are safe
  & practical for you to do regularly?
• Where will you do these activities?
• What time of day will you do your program?
• How often will you exercise?
• How long will you exercise each time?
        Physical Activity: Let Your Goal
          Determine How You Exercise
   Your Goal                Frequency                Intensity                Duration
   Lower risk of            2-3                      40% MHR*                 15-30 min.
   heart disease            time/week
   & illness
   Get fit     4 times/week 70-90%                                            15-30 min.
                            MHR*
   Lose weight 5 times/week 45-60%                                            45-60 min.
                            MHR*
   Be able to talk, but not sing
   *To calculate Maximum Heart Rate: MHR = 220-age

From Pumping Insulin, 3rd edition by J. Walsh & R. Roberts Torrey Pines Press. 2000.
         Physical Activity:
           Precautions
• Avoid exercising in extreme heat or
  cold

• Maintain adequate hydration
  before, during, and after exercise

• Self-monitor blood glucose

• When during exercise is your risk
  for hypoglycemia the greatest?
  Planning Your Exercise Program

• Include a mix of stretching, aerobic, and
  weight-bearing activities
• Know your target heart rate
• Plan activities in your calendar
• Track your exercise progress in a notebook
• Plan a reward for sticking to your program
Eating Basics- Hour 3
           Learning Points
• Know which foods contain carbohydrates
• Describe appropriate portion sizes
• List some items to look for on the food
  label
• Describe a healthy snack or meal
          Overview of Topics
•   Food and Blood Glucose
•   Meal Planning
•   Carbohydrate Counting
•   Food Labels
•   Heart Healthy Eating
•   Goal Setting
•   Food Log/Diary
    Food Types and Examples
• “Fat” Foods: butter, oils, fatback,
  mayonnaise, cream, margarine

• “Protein” Foods: chicken, fish, meat, eggs

• “Carbohydrate” Foods: bread, rice,
  crackers, cereal, fruit
 Food & Blood Glucose: Percent
   Nutrients Changed to Blood
             Glucose
  Up to
  100%      Carbohydrate

                           Blood
  50%       Protein
                           Glucose

             Fat
Less than
  10%
Food & Blood Glucose: How Fast
Nutrients Changed to Blood Glucose
                       1.2


                        1
Percentage of Change




                       0.8

                                                                                 CHO
                       0.6                                                       Protein
                                                                                 Fat

                       0.4


                       0.2


                        0
                             0   0.25   0.875   1.5   2.25   3      5   8   12
                                           Rate of Change (hours)
Meal Planning
 Why Do I Need to Plan Meals?

• Helps maintain normal blood glucose
• Helps maintain normal cholesterol (blood
  fats)
• Provide right amount of calories
• Prevent, delay, or treat diabetes-related
  complications
• Improve health through optimal nutrition
      Meal Planning :
Plate Method - Lunch/Dinner
                   Carbs
     Fruit                    Milk


         Meat/
         Protein     Starch



             Vegetables
      Carbohydrate Counting
• Try to eat the same amount
  at each meal
• Swap one “exchange” or
  another in list
• 1 exchange = 15g
  carbohydrate
• Match carb intake to insulin
• Use the food label to figure
  out grams or other
  carbohydrate counting book
       Examples of Exchanges
•   1 cup milk
•   6 saltine crackers
•   1/3 cup rice
•   ½ cup of canned fruit
•   ½ cup pinto beans
•   1 slice bread
•   1 small apple
•   5 pieces hard candy
     How Many Exchanges?
• Many people can start with 3 exchanges
  per meal
• Snacks can be 1 or 2 exchanges
• Individualized for each person
• Check glucoses 2 hours after eating
• (150-180= carbohydrate intake is ok)
Food Labels: Nutritional Facts
    Serving size: 4 graham crackers
    Servings per container: 32

    Amount Per Serving
    Calories: 80 Calories from fat: 18

                       Percent of Daily Value*
    Total Fat 2g                          5%
     Saturated Fat 1g                     5%
    Cholesterol 0mg                       0%
    Sodium 66mg                           3%
    Total Carbohydrate 14g                5%
     Dietary Fiber 1g                     4%
     Sugars 4g
    Protein 2g
     Looking at Labels Exercise
•   Look at your food product
•   How many calories? Carbs? Sodium?
•   How many servings in the package?
•   If you ate the whole package, how many
    servings did you eat? How many carbs?
          Heart Healthy Eating
• Eat Less Unhealthy
  Fat (cholesterol,
  saturated, trans fat)
• Replace with Healthy
  fats (oils, margarine)
• More Fiber
• Less Salt or Sodium
         Types of Fat in Blood

                          Fat

    Triglycerides           Cholesterol
less than 150 mg/dL        less than 200

                    LDL                   HDL
                    (bad)                (good)
            less than 100 mg/dL    men: over 45 mg/dL
                                  women: over 55 mg/dL
              Types of Fat in Diet
 Unhealthy Fats              Healthy Fats
Limit total intake       Use these in place of
                         the unhealthy fats
Cholesterol              Unsaturated Fats:

Saturated Fat                   Monounsaturated

Trans fat                       Polyunsaturated
                                Omegas 3s
    Eating for a Healthy Heart:
    Sources of Cholesterol & Fat
Trans Fat Cholesterol             Saturated Fat             Unsaturated Fat
              (limit these)         (limit these)
Fried Foods   Meat            Meat                  Safflower oil
                                                                           Poly-
Donuts        Cheese          Cheese                Sunflower oil
              Egg yolk        Egg yolk              Corn oil            unsaturated
Chips         Whole milk      Whole milk            Soybean oil         (ok in small
              2% milk         2% milk               Sesame oil           amounts)
Packaged
              Ice cream       Ice cream             Walnuts
cookies,      Butter          Butter                Sesame seeds
crackers,     Organ meats     Cream cheese          Olive oil
cakes                         Sour cream            Canola oil      Monounsaturated
Margarine                     Palm oil              Peanut oil       (choose more
                              Coconut oil           Olives
Small                                                                   often)
                              Cocoa butter          Avocados
amounts in                    Hydrogenated          Almonds
animal                          vegetable oil       Peanuts
products                      Poultry with skin     Cashews
                                                    Pecans
      Eating for a Healthy Heart



•   Eat More Fiber
•   Two types, two jobs
•   Soluble fiber- helps to lower cholesterol
•   Insoluble fiber-helps prevent constipation
   Sources of Fiber: Soluble
• Soluble Fiber (helps lower blood fats)
  –   Raw vegetables   – Pinto beans
  –   Fresh fruits     – Black-eyed peas
  –   Barley           – Whole-grain products
  –   Dried peas          • oat, oat bran, and rice
                            bran cereals
  –   Brown rice          • soy pasta
  –   Okra                • oat bran, rye, and
  –   Kidney beans          pumpernickel breads
                          • oat and rye crackers
  –   Lentils
  Sources of Fiber: Insoluble

• Insoluble Fiber (helps prevent
  constipation)
  – Some raw vegetables
  – Wheat bran products:
    •   cereal (100% bran, Allbran, Fiber One)
    •   Pasta (whole wheat)
    •   Bread (whole wheat, white wheat)
    •   crackers
        Grocery Shopping Tips
• Read all Food Labels
• Stick to the outside aisles
  of the store
• Focus on lean meats,
  fruits and vegetables, low
  fat dairy and whole grain
  products
• Always shop with a
  grocery list
• Don’t shop while hungry
   Will it be more expensive?
• Reduce food costs:
  – Canned/frozen or seasonal fruits and veggies
  – More meatless meals
  – Purchasing less junk foods, sodas, “extras”
  – Preparing more meals at home
  – Special “diabetic foods” are not necessary
  – Shop store sales and use coupons
  – Avoid food waste & spoilage, use up leftovers

             Tips on Cutting Cost
           Breakfast Ideas
• Breakfast One:      • Breakfast Two:
  – toasted low fat     – oatmeal-1c.after
    cheese sandwich       cooking-(1/2c. Dry)
  – 8 oz. skim milk     – tangerine (1 small)
                        – boiled egg (1)
         More Breakfast Ideas
• Breakfast Three:            • Breakfast Four:
  – apple, 1 small              –   Cheerios ( 1 cup)
  – low fat cottage cheese,     –   ½ cup 1% milk
    ½ cup                       –   Wheat toast- 1 slice
  – english muffin- 1 whole     –   1 Tbsp. peanut butter
  – margarine, 1-2 tsp.
                Snack Ideas
• Snack One:                 • Snack Two:
  – peanut butter (1-2 T.)     – turkey roll-up (1-2 oz.)
  – graham crackers            – 4 or 5 olives
  (3 squares, 2 1/2”           – popcorn (3 c., reduced
    square)                      fat microwave)
  unsweetened tea              – diet soft drink
           More Snack Ideas
• Snack Three:                 • Snack Four:
  – 8 oz. artificially           – hummus (1/3 c.)
    sweetened yogurt             – carrots (1/2 c.)
  – handful of nuts (1/4 c.)     – herbal tea
  – Water with lemon
              Food Log
• Write down what you eat
• Write the date, time, amounts of food,
  mood, blood sugars, medicine
• Try for a week
• Look for patterns
• Bring to your nutrition appointment
• Recommend all patients meet with RD at
  least once
                Example Food Log
What           Amount       Time     Mood   BG Before BG 2 hrs.
                                                      After
Cereal         ¾ cup        7:30AM          122       100
Skim milk      ½ cup
Boiled egg     1
Toast          1
Margarine      1
               teaspoon


Apple        1 small        10:45           90
                            AM
Peanut       1 tablespoon
butter
Notes: went for a walk at 9:00AM
Stress
 and
Coping
            Learning Points
• Know how stress or depression can affect
  blood glucose
• Be able to identify/anticipate stressful
  situations
• Be able to provide a solution for a stressful
  situation or change in routine
         Stress and Coping

• Social pressure from friends, family,
  church, work
• What are some examples of situations
  where you are pressured to not take care
  of your diabetes?
      What Stress Can Do
• Too much stress can keep you from taking
  good care of yourself and your diabetes
• Make other problems worse (blood sugars,
  blood pressure)
• Lead to poor choices, poor planning
• Keeps you in the “stress cycle”
Putting the Pieces Together:
       Social Situation

       You are attending a family birthday dinner at
your sister’s house. Your sister, who takes pride in
her cooking, has prepared a special meal with several
courses. Most of the foods are combination dishes
with sauces and gravies. After dinner, your sister
personally hands you the dessert tray, insisting that
you take some. She says, “I know several people with
diabetes, and they eat anything.”
 Putting the Pieces Together:
        Social Situation

1. What are some ways to handle this situation?


2. What are some ways you can plan ahead for these
special events?


3. What are other strategies for dealing with this type
of situation?
 Putting the Pieces Together:
        Social Situation
You feel good about the way you have been following
your diabetes care plan. You want to keep doing
well, but the holidays are coming. You know that
both your schedule and usual meal plan will be
different.


1. What are strategies you can use
so that you stay on track?
Putting the Pieces Together:
       Social Situation

You usually take your evening insulin at about
5:30pm, eat dinner at 6:00pm, and have a snack
before bedtime at about 10:00 pm. Today you
have been invited to a holiday dinner at a
friend’s home at 8:00 pm.


*How might you handle this
change in your
schedule?
Putting the Pieces Together:
    Family Situation (con’t)

1. What problems might happen when you get home?




2. What are some ways to handle this situation?
     Putting the Pieces Together:
            Family Situation

         You are a 50-year old woman with newly diagnosed type 2
 diabetes. You’ve decided to follow a meal plan because you want to
lose one pound a week. You take insulin, but your doctor says if you
   can lose weight, there’s a chance you may not need to stay on it.
    Since you’ve always cooked all the meals for the family, your
husband & sons expect you to keep doing so. Your sons have already
 told you they do not want to eat “rabbit food.” Your husband has
 kept on eating his snack foods in front of you. He makes a point of
          telling you that you shouldn’t have “even a taste.”
Changing Behavior
Setting Goals
           Learning Point s
• Be able to identify a personal goal for your
  diabetes care

• Name key steps to help reach your goal
            Goal Setting
• S.M.A.R.T. Goals
• Specific (what exactly are you going to
  do?)
• Measurable
• Achievable
• Realistic
• Time-line
              Goal Setting
I want to eat more vegetables.

SMART Goal:
I will eat more vegetables at lunch.
I will eat 1 extra serving a day.
I will pack carrot sticks in my lunch.
    Stress and Coping: Ten
Commandments for Managing Stress
 • Thou shalt organize thyself
    – take better control of how you spend time & energy
      to better handle stress

 • Thou shalt control thy environment
    – get rid of stress or get help by
      controlling who & what you’re around
    Stress and Coping: Ten
Commandments for Managing Stress
 • Thou shalt love thyself
    – give yourself positive feedback
    – you’re a unique person doing the best you can
 • Thou shalt reward thyself
    – put leisure activities into your life
    – doing this will give you something to look forward
      to
      Stress and Coping: Ten
  Commandments for Managing Stress
• Thou shalt exercise
   – exercise at least 3 days per week for 15-30 minutes
   – health & productivity depend on your body’s ability to bring
     oxygen & food into its cells
• Thou shalt relax
   – get away from stress by focusing on
   – breathing & positive thoughts
   – ways to relax include dreaming, prayer & meditation,
     progressive relaxation, listening to music, & talking with
     friends & loved ones
    Stress and Coping: Ten
Commandments for Managing Stress
• Thou shalt rest as regularly as possible
   – take breaks and sleep 7-8 hours a night
   – there is only so much your mind can absorb at once
• Thou shalt be aware of thyself
   – watch for stress signs like insomnia, headaches,
     anxiety, upset stomach, & cold/flu
    Stress and Coping: Ten
Commandments for Managing Stress
• Thou shalt feed, thy body healthy food
   – eat a balanced diet so your body is well fueled
   – avoid foods high in calories, fat, & sugar
   – avoid using drugs or alcohol to deal with stress
• Thou shalt Enjoy thyself!
   – happier people tend to live longer &
   have fewer health problems
   – look for the humor in life when times
   are tough
                        Resources
Books:
Diabetes Burnout
Caring for the Diabetic Soul
Diabetic Meals for $7 a day or Less
Diabetic Cooking for One

Websites:
www.diabetes.org
www.ncdiabetes.org
www.americanheart.org
www.mypyramid.gov

Organizations:
American Diabetes Association (1-800-DIABETES)

North Carolina Diabetes Association (1-877-362-2678)
     Diabetes and Pregnancy
            Planning
• Higher rates of miscarriage and birth
  defects with high blood sugars in mom
• If not planning pregnancy, must use
  method of birth control
• If planning pregnancy, get sugar under
  control first
• Get weight under control with diet and
  exercise
     Diabetes and Pregnancy
            Planning

• Before getting pregnant
  – Get blood pressure checked
  – Get eyes checked
  – Exam of heart and blood vessels by your
    doctor
  – Have kidneys and thyroid checked by blood
    work
       Gestational Diabetes
• High blood sugar during pregnancy in
  otherwise non-diabetic person
• Can cause large birthweight babies
• Must tightly control sugar during
  pregnancy
• Goes away after pregnancy, but likely
  occur in future pregnancies; many women
  go on to develop type 2 diabetes

								
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