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Diabetes Update

Diabetes Update. Marcia Johnson BSN RN CDE marcia.johnson@spectrumhealth.org (616) 391-9288. Overview of Today. Physiology / pathophysiology Self-management areas and treatment goals Physical activity guidelines Nutritional management Pharmacological therapies Acute complications

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Diabetes Update

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  1. Diabetes Update Marcia Johnson BSN RN CDE marcia.johnson@spectrumhealth.org (616) 391-9288

  2. Overview of Today • Physiology / pathophysiology • Self-management areas and treatment goals • Physical activity guidelines • Nutritional management • Pharmacological therapies • Acute complications • Chronic complications • Special populations • Case management and self-management support

  3. Objective #1 • Contrast physiology of normal fuel metabolism with pathophysiology of pre-diabetes, type 1, type 2 and gestational diabetes.

  4. Hey Sugar Sugar!

  5. insulin Fuel Metabolism: Fed State • Carbs digest into blood glucose • Glucose travels to cells • Insulin is released • Insulin allows glucose into cells • Insulin inhibits breakdown of glycogen

  6. Liver Glucose (sugar) Storage Fuel Metabolism: Postabsorptive State Liver releases glucose (glycogenolysis) and makes glucose (gluconeogenesis) S S S S

  7. Activity: different types of DM

  8. Diabetes Risks– the Epidemic • If born since 2000 in the US: • 1 in 3 will develop diabetes in their lifetime if white • 1 in 2 if Hispanic or black

  9. Testing for Type 2 DM in Children • Should be tested if over overweight, age 10 or more AND has 2 of these: • A family history of Type 2 diabetes in first and second-degree relatives (e.g. parents, siblings, or grandparents) • High risk race/ethnic group (American Indian, African-American, Hispanic, or Asian/Pacific Islander) • Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome).

  10. Testing in Asymptomatic Adults If overweight (BMI ≥25) AND other risk factors (or begin at age 45 w/o risk factors): • Physical inactivity • First-degree relative with DM • High risk race/ethnicity • Hx GDM or baby > 9 lb • Hypertension • HDL <35 • Polycystic ovarian syndrome (PCOS) • Prior A1c ≥5.7, IGT or IFG • Insulin resistance syndromes • History of CVD

  11. How are Diabetes & Pre-diabetes Diagnosed? Fasting 2 Hr A1c Normal 70-99 mg/dL under 140 <5.7% Pre-Diabetes 100-125 mg/dL 140-199 5.7-6.4% Diabetes 126 or more 200 or more 6.5% or more Or random BG over 200 with symptoms

  12. Gestational DM Screening at 24-28 Wks ACOG Criteria ADA-Proposed Criteria At 1st prenatal visit, if high risk for DM: screen for undiagnosed type 2 DM with FBS or A1c

  13. Obesity IFG* Diabetes Uncontrolled Hyperglycemia 350 Post-meal Glucose 300 250 Fasting Glucose Glucose (mg/dL) 200 150 100 50 250 Insulin Resistance 200 Relative Function (%) 150 100 Insulin Level 50 -Cell Failure 0 -10 -5 0 5 10 15 20 25 30 Years of Diabetes *IFG=impaired fasting glucose. Natural History of Type 2 Diabetes

  14. Objective #2 • Identify categories of diabetes self-management and glycemic treatment goals.

  15. AADE7™ Self-Care Behavior Categories • Healthy Eating • Being Active • Monitoring • Taking Medication • Problem Solving • Healthy Coping • Reducing Risks

  16. Behavior: Monitoring

  17. A1c

  18. Glucose Meters • Possible technique errors: • Coding • Sites: fingers vs. other • Contaminants on finger • Squeezing finger too hard • Storage of supplies, expiration dates

  19. Barriers to Monitoring • Cost, reimbursement, DME vs pharmacy • Discomfort • Nuisance • Don’t know what the numbers mean • No one uses the info • Why write the #’s down? They’re in the memory • High numbers = I’m bad

  20. Strategies to Enhance BG Monitoring • Make it meaningful: self-experiment • Use the Noah’s Ark Principle (pairs, pre/post meal) • Actually review the pt’s results • Congratulate the effort, not the #’s • Challenge self-worth interpretations (not good/bad #’s, just info and it’s all valuable) • Provide guidance in interpretation and promoting action

  21. Continuous Glucose Monitors (CGM) • Professional vs. Patient • iPro • Dexcom • Pump-enabled

  22. Objective #3 • Summarize American Diabetes Asso/American College of Sports Medicine guidelines on physical activity for prevention of type 2 diabetes and for those with type 2 diabetes.

  23. Behavior: Being Active • Physical Activity vs. Exercise • Use of word “exercise” with patients

  24. How can being active help? • Helps to Lower: Weight Blood sugar, blood pressure Risk of heart disease and stroke Risk of some cancers Stress Strengthens bones and muscles • Sleep better • Live longer And More!

  25. Types of activity • Aerobic • Weight training / resistance • Benefits of combination of aerobic and resistance training • Mild activities (tai chi, yoga) • Flexibility

  26. How much aerobic activity is needed? • ADA/Am. College of Sports Medicine: • At least 150 minutes/wk over at least 3 days • (may need more for weight loss) • No more than 2 days in a row w/o aerobic activity • Can break it up, but do at least 10 min. • Moderate to vigorous

  27. Weight Training or Resistance Exercise • Weights • Resistance bands • Machines at fitness centers • Do 2-3 days per week • Do not do 2 days in a row • Learn the “moves”

  28. Adding Extra Steps

  29. Safety Thoughts General safety: Liquids Pace Cell phone Feet: Proper shoes Check feet after • Low blood sugar

  30. Barriers to Physical Activity • Time • Boredom • Fatigue • Pain • Weather • Cost • History of failure • And more!

  31. Summary of Part 1 • Physiology and pathophysiology of DM • Categories of self-care and glycemic treatment goals • Physical activity guidelines

  32. Break Time (go walk!!)

  33. Objective #4 • Explain nutritional management of diabetes, including carbohydrate, protein and fat intake.

  34. Behavior: Healthy Eating • Improves: • Blood sugar • Blood lipids / cholesterol and triglycerides • Weight • Blood pressure

  35. Truth or Myth???

  36. McD’s caramel sundae has same amount of carbs as a Panera whole grain bagel

  37. People with diabetes should have no sugar

  38. People with diabetes need to eat snacks

  39. A cup of rice and a Big Mac have the same amount of carbs

  40. What are Foods Made of? • Carbohydrate • Protein • Fat • What turns into blood sugar?

  41. Healthy Eating Guidelines • Moderation (portion control) • Have 3 meals. Do not skip meals • Space meals 4-5 hours apart • Beverages • Variety • Good for the whole family

  42. Methods of Meal Planning: Plate Method

  43. Methods of Meal Planning: Exchanges

  44. Methods of Meal Planning: Carb Counting • Carb Choices or Carb Grams • 1 carb choice = 15 grams • General Guideline: • Women: 3-4 carb choices (45-60 grams) per meal • Men: 4-5 carb choices (60-75 grams) per meal • Snacks: 1-2 carb choices (15-30 grams)

  45. Carb Foods • Grains, beans, and starchy vegetables • Fruit and fruit juice • Milk and yogurt • Sweets

  46. Carb Foods: Serving size for 1 carb choice • Grains, beans and starchy vegetables • 1 oz. bread product (1 slice bread, ½ English muffin) • 6 inch tortilla • 1/3 cup pasta or rice • ½ cup dried beans, corn, peas, mashed potato, cooked cereal • ¾-1 oz. pretzels, crackers

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