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 body’s 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 DMSigns 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 DMSigns 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

Insulin helps sugar (glucose) move into cells, where it is used to produce energy

Without insulin, glucose cannot enter the cells

Cells quickly waste away from lack of glucose CELL

CELL

CELL

INSULIN

INSULIN

INSULIN

Type 2 diabetes: insulin production and effectiveness are impaired

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

CELLINSULIN

INSULIN

INSULIN

CELL

CELL

INSULIN

INSULIN

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

Glucose is absorbed into the blood, causing hyperglycemia

Pancreatic dysfunction leads to insulin deficiencyMuscle, liver, and

fat cells develop insulin resistance

Blood glucose levels remain high

Progression of untreated type 2 diabetes

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

Insulin for type 1 or type 2 diabetes

Oral hypoglycemic agents for type 2 diabetes

Medication Types

• There are several ways in which these medications work– Causes your body to secrete insulin, decreases your

body’s 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 gastro-intestinal 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)

• Don’t 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, don’t reuse needles, don’t wipe needle with alcohol

• Dispose of needles properly

Type 2 diabetes is a progressive, but manageable, disease

Type 2 diabetes evolves from 2 primary defects:

insulin deficiencyinsulin resistance

Uncontrolled hyperglycemia leads to serious complicationsRisk for complications can be reduced by tight

glucose control

Summary

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, ABPPClinical 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 InsulinRequirement: 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

– Individual’s 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 moisture-wicking 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 don’t 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• Don’t 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 ABC’s

• A: A1C goal is <7%

• B: Blood Pressure goal is <130/80

• C: Cholesterol Profile 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 CarbohydratesWHY?

• 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 carbohydrate- containing 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 1 ½ cups 30 g CHO

Milk, skim 1 cup 12 g CHO

Blueberries ¾ cup 15 g CHO

Yogurt, light, 1 cup 15 g CHO

with fruit

Total = 72 g CHO

LUNCH

Bread, whole wheat 2 slices 30 g CHO

Turkey breast, sliced 2 oz (protein) 0 g CHO

Cheese, sliced 1 oz (protein) 0 g CHO

Banana, medium 1/2 15 g CHO

Crackers, wheat 5 15 g CHO

Juice, apple 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 Pasta15 grams carbohydrates

• 1 slice of bread• ½ small bagel, pita,

English muffin, or hamburger bun

• ½ cup cooked cereal or pasta

• ½ cup peas or corn• 1/3 cup rice or beans

Fruits15 grams carbohydrates

• 1 medium piece of fruit

• ¼ melon (1 cup cut-up)

• ½ cup canned (drained) fruit

• 4 oz fruit juice

Non-Starchy Vegetables5 grams carbohydrates

• 1 cup raw vegetables

• ½ cup cooked vegetables

• ½ cup tomato juice or tomato sauce

Milk and Yogurt12 grams carbohydrates

• 1 cup low-fat or skim milk

• 1 cup plain yogurt (sugar-free, fat-free)

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

• 1 oz skinless & non-fried meat, poultry, fish

• ¼ 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 FOODSfewer 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 tabletsDO 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 there’s 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??