Gems from AADE and ADA 2008

1. Gems from AADE and ADA 2008 Affiliate Conference Call 9/24/08

2. An Unmet Need: Enhancing Diabetes Care in Skilled Nursing Facilities Elaine D. Sullivan, MS, RN, CDE Karen McAvoy, MSN, RN, CDE

3. Differences Sub-acute vs. LTC Residents • Sub-acute residents • Tight BG control to promote healing and prevent long term complications • Demonstrate independence in diabetes survival skills before discharge • Frail LTC residents • Avoid hypoglycemia • Prevent hospitalization for acute and chronic complications

4. Why Do People With Diabetes in SNF End Up In The Hospital? • Severe hypoglycemia can cause: • Falls • Heart attacks and strokes • Infection and/or dehydration can cause severe hyperglycemia (HHNS) • Amputations due to neglected foot injuries • All the reasons other people go to the hospital • Higher risk for cardiac events, stroke and infection

5. The Joslin Program to Improve SNF Care • Staff and physician orientation and ongoing education • Verification of staff competence • On site Diabetes Care Coordinator • Joslin patient education and materials • Joslin guidelines and protocols • Data collection and analysis • Endocrinologist/nurse practitioner consultation

6. Case Example—Short Stay Patient • V.B. - 73 yo white female with type 2 dm x 10 years • Never received any diabetes education • Not taking care of her diabetes at home • Admitted to the facility for pulmonary edema • 1 ½ month stay, received OT and PT services and diabetes education • Admission A1c 9.4% (4/14/08); 1 low at bedtime • On Levemir 13 units and Novolog 12 ac • Levemir adjusted slightly, Novolog 14 with breakfast and 9 with lunch and dinner • 5/22/08 • Fructosamine 312 umol/L(Non-diabetes normal range 190-270 umolL) • FBS range 96 – 154 mg/dl before discharge • Post- discharge A1C 7.5% (7/14/08) • LaGreca’s Self Care Inventory on admission 61; 1 month post discharge 75

7. Physical Activity, Exercise, and Obesity: Clearing the Hurdles to Success AADE 35th Annual Meeting Washington, D.C. August 9,2008 Karen Kemmis, PT, DPT, MS, CDE kemmisk@upstate.edu Donna Wolf, PhD, ACSMES wolfd@upmc.edu

8. Objectives • Discuss the benefits of physical activity, state the components of an exercise prescription, and describe the current evidence-based guidelines for physical activity/exercise for individuals with diabetes. • List common barriers to physical activity and identify strategies to overcome these barriers for those who are overweight or obese. • Create a successful physical activity/exercise plan for the person with obesity to prevent or treat diabetes.

9. Improved glycemic control Increased fat free (muscle) mass Reduction in visceral adipose tissue and sub-Q adipose tissue Increased insulin response Decreased plasma triglycerides Thomas DE et al Cochrane Collaboration 2006 Stronger muscles, bones, joints Increased endurance Improved CV parameters Psychological benefits Weight loss/maintenance Improved ease of ADLs Decreased mortality Summary of benefits of physical activity

10. Walking (running) Stationary bike Outdoor bike Exercise video/DVD (walking, dancing, sitting) Elliptical Glider Recumbent stepper Water exercise Swimming Exercise programs/ classes Fitness clubs Resistance training Physical therapy Pain: Options for exercise

11. AADE Position Statement • “Diabetes educators play a vitally important role in overcoming barriers to regular exercise participation. • …be prepared to apply counseling strategies that will enhance adoption and long-term maintenance of a physical activity habit. • …include assisting in a plan to introduce exercise in a safe and progressive manner, emphasizing proper selection of goals and rates of progression.” • Hayes C et al The Diabetes Educator 2008

12. Prevention of Diabetes Through School-Based Nutrition Interventions By: Sheri Hotchkiss, RD, LD, CDE, Ericka Pine, RD, LD

13. Healthy Moves Program • Goal is to improve food choices and increase activity in school-aged children. • Requested by middle school teacher as part of health curriculum. • Includes an interactive nutrition lesson, cooking demonstration and physical activity.

14. Healthy Moves Sessions • Exercise = Fun! • Jump Start With Breakfast • Whole-ly Great Grains! • Green-Light, Red-Light – Healthy Snacking Made Easy! • Sugar, Sugar Everywhere! • Fast Fat Facts • Fruit and Veggies: Meet Our Family – “Uncle Fight-O-Chemical and Antie Oxidant” • The Calcium Scramble Game: Make It or Break It!

16. Standardized newsletters Incentive program that works ? Of adding a web component Grant Changes for future programs

17. Other Highlights from AADE…

18. Humor: Facilitating the Laugh-Learn Connection with Your Patients with Diabetes Theresa Garnero, APRN, BC-ADM, MSN, CDE • Benefits of using humor in your practice • Laughing lower glucose levels • Reduces stress and pain • Improves immune function • Allows for expression of anger • Minimizes professional burnout • Turns a “ha ha” moment into an “aha” moment

19. Humor: Facilitating the Laugh-Learn Connection with Your Patients with Diabetes • Possible negative “side effects” of humor • Can be hurtful • Some people can get offended • Can distract from the message • Can promote anger • Practice Pearls • Assess – test the waters, assess readiness for humor • Ask if humor is helpful • Watch the eyes and listen to the tone of the laugh • Too much laughing may indicate high stress • Apologize if offense is taken • Less is more! • If you use cartoons in your presentations, you must get permission from the author

20. Dietary Supplements for Diabetes: The Intriguing Intricacies Laura Shane-McWharter, PharmD • Diabetes patients 1.6x more likely to use complementary/alternative medicine • 20-30% of people with DM take supplements; 28% use herbal products • Cinnamon: • increases insulin sensitivity • may lower BG and lipids, but not A1C • ½ -1 tsp powdered cinnamon per day • should be water-extracted

21. Dietary Supplements for Diabetes: The Intriguing Intricacies • Chia (salvia) • As seen on Oprah! • Seeds are used; very high in fiber and alpha linolenic acid • May decrease postprandial BG and blood pressure • But may increase TG levels and risk for prostate CA • Salacia • Roots and stems used • Inhibits alpha-glucosidase in brush border • More potent than Precose • Can lower postprandial BG • Dose: 240-1000 mg per day

22. Motivational InterviewingSummary Two speakers- Elaine Massaro, MS, RN, CDE Micheal Goldstein, MD

23. MI- Definition • (Previous) A skillful clinical style for eliciting pts own motivation, and guiding them towards effective use of Self-Management strategies • (New)“A skillful clinical style for eliciting from pts their own motivation for making changes in the interest of their health” • Micheal Goldstein, MD Institute for HC Communication- New Haven, CT / (Rollnick, Miller, Butler “Motiv interviewing in HC”—2 008)

24. The key- Core Skills * Core skills for Motivational Interviewing -Build a relationship -Explore the person’s needs, expectations, values -Share Information -Use Collaboration when goal setting -Engage in shared Action Planning -Build Skills for problem solving * Follow up on progress/ achievements (new health partnerships: www.newhealthpartnershhips.org)

25. Key Elements • Expressing empathy, Roll with resistance; develop discrepency; support self efficacy • Use a “guided” communication style: asking; informing; listening; use equal amounts of all three. (Rollnick,2008) • Use “open ended” questions; affirmations; reflective listening; summaries Remember: The Pt has the Freedom of choice…. The Professional offers advice…. when asked….

26. What other tidbits did you bring back from AADE, ADA or other national meetings???