Diabetes: Patient Education Survival Skills Class

1. Diabetes: Patient Education Survival Skills Class 4-Hour Session Revised August 2004 Power Point Presentation: �Diabetes: Patient Education Survival Skills Program� 4 Hour Session � �Diabetes: Patient Education Survival Skills Program� is a 4 hour power point presentation (103 slides) designed for patients and family members. Patient participation is encouraged. Breaks are recommended (15 minutes) every 45 minutes and included in the total time of 4 hours. This program differs from the 2 � hour powerpoint presentation by providing the survival skill topics in greater detail. � This presentation was initially written by the diabetes education team at the National Naval Medical Center. The program has been updated and modified by Susan Marullo, NP, CDE August 2004. Thorough knowledge of diabetes is recommended by the instructor given the depth of the materials covered. The dietary section would optimally be taught by a dietitian, but a nurse knowledgeable in dietary therapy may substitute if a dietitian is not available. These slides may be individualized further at commands using this tool to accommodate their time schedule, audience, focus, and new forth coming research. � Ideally, the patient should have already been taught survival skills to include glucose self monitoring prior to this class. Written information on diabetes should be given to the patient to supplement the information received during class. Provide resource information as well to assist the patient in continued education and support. � Learning Objectives include: Describe the basic pathophysiology of diabetes Differentiate between the 2 principle types of diabetes Describe the acute and chronic complications of diabetes Discuss prevention measures to avoid complications of diabetes List and describe the treatment modalities (nutrition, medication, exercise) Describe the following self-management skills: SMBG, sick day management, traveling, daily and routine health maintenance, and stress reduction. State your HbA1C goal and importance of self-management skills to obtain/maintain this in optimal range. Power Point Presentation: �Diabetes: Patient Education Survival Skills Program� 4 Hour Session � �Diabetes: Patient Education Survival Skills Program� is a 4 hour power point presentation (103 slides) designed for patients and family members. Patient participation is encouraged. Breaks are recommended (15 minutes) every 45 minutes and included in the total time of 4 hours. This program differs from the 2 � hour powerpoint presentation by providing the survival skill topics in greater detail. � This presentation was initially written by the diabetes education team at the National Naval Medical Center. The program has been updated and modified by Susan Marullo, NP, CDE August 2004. Thorough knowledge of diabetes is recommended by the instructor given the depth of the materials covered. The dietary section would optimally be taught by a dietitian, but a nurse knowledgeable in dietary therapy may substitute if a dietitian is not available. These slides may be individualized further at commands using this tool to accommodate their time schedule, audience, focus, and new forth coming research. � Ideally, the patient should have already been taught survival skills to include glucose self monitoring prior to this class. Written information on diabetes should be given to the patient to supplement the information received during class. Provide resource information as well to assist the patient in continued education and support. � Learning Objectives include: Describe the basic pathophysiology of diabetes Differentiate between the 2 principle types of diabetes Describe the acute and chronic complications of diabetes Discuss prevention measures to avoid complications of diabetes List and describe the treatment modalities (nutrition, medication, exercise) Describe the following self-management skills: SMBG, sick day management, traveling, daily and routine health maintenance, and stress reduction. State your HbA1C goal and importance of self-management skills to obtain/maintain this in optimal range.

2. 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

3. 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*

4. 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�..

5. 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�)

6. 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

7. 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

8. 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

9. 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)

10. 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

11. 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.

12. Medications

13. 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

14. 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

15. 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)

16. �and releasing stored glucose back into the blood between meals Gastrointestinal tract is empty; glucose must be supplied by the body for energy

17. Type 2 diabetes evolves from 2 primary defects: insulin deficiency and insulin resistance Glucose is absorbed into the blood, causing hyperglycemia

18. 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

19. Drug therapy is needed in addition when diet and physical activity fail to correct hyperglycemia Insulin for type 1 or type 2 diabetes

20. 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

21. Oral hypoglycemics work in several different ways Alpha-glucosidase inhibitors decrease gastro-intestinal absorption of glucose

22. Sulfonylureas Brand names Amaryl DiaBeta Diabinase Glucotrol (XL) Glynase PresTab Micronase Generic names glimepride glyburide chlorpropamide glipizide glyburide glyburide

23. 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

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

25. 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

26. 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

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

28. 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

29. Medications may have to be combined to keep pace with this progressive disease Different oral hypoglycemic agents may be taken together

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. Emotional Aspects

38. Diabetes and Psychology Karl O. Moe, PhD, ABPP Clinical Health Psychology

39. 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

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

41. Help Along the Way Healthcare providers Printed information Support groups Stress management

43. Exercise

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

45. 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

46. 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

47. 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

48. 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

49. Managing Your Diabetes

50. 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

51. 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

52. 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

53. 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

54. 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.

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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

61. 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

62. 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

63. Diabetes and Carbohydrate Counting

65. 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

66. 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

67. 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

68. 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

69. 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

70. 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)

71. 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

72. Carb Counting Examples BREAKFAST Cereal, dry 1 � cups 30 g CHO Milk, skim 1 cup 12 g CHO Blueberries � cup 15 g CHO Yogurt, light, 1 cup 15 g CHO with fruit Total = 72 g CHO

73. 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

74. 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

80. 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

81. 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

83. Complications

84. COMPLICATIONS Acute: sudden onset usually reversible Chronic: gradual onset can be irreversible

85. 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

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

87. 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

88. 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!

89. 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

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

91. 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

92. 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

93. Chronic Complications

94. 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

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

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

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

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

99. Autonomic Neuropathies(nerves that control bodily functions) Impotence Gastroparesis (slow emptying of the stomach) Diabetic diarrhea Neurogenic bladder (loss of bladder tone)

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

101. 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)

102. 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

103. Questions??