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Joyce B. Patterson, MPH, RDN, BC-ADM University of Michigan Adult Diabetes Education Program Objectives Identify risk factors for insulin resistance and describe the progression from prediabetes to type 2 diabetes Describe The Plate Method, Carbohydrate Counting, and portion control and know when to use which approach Briefly review various drug classifications and their mechanisms of action Describe the treatment and prevention of hypoglycemia and identify which patients are most at risk Discuss physical activity recommendations List strategies for preventing Type 2 Diabetes and locate Diabetes Prevent Programs in your area. The ADA Standards Classification/Diagnosis Care Management MNT Pharmacotherapy Complications and Risk Reduction Special populations Diabetes Ed/Support Prevention And more! Available online National Standards for DSME/S Designed to define quality DSME and support and to assist diabetes educators in providing evidence-based education and selfmanagement support. Internal Structure External Input from stakeholders and experts Access Program Coordination Instructional Staff (multidisciplinary approach) Written curriculum reflecting current guidelines Individualization Ongoing Support Patient Progress Quality Improvement, systematic review of process and outcomes Diabetes Care, Volume 37, Supplement 1, January 2014 Risk factors for Pre-DM/T2DM Age CVD or Family History of CVD Overweight/obese Sedentary Lifestyle Poor diet Ethnicity (Asian/Pacific Islander, African American, Native American, Hispanic) Low HDL and/or high trigs History of IGT, PCOS, Metabolic Syndrome, GDM Some medications (antipsychotics, glucocorticoids) Sleep disorders (OSA, night-shift workers) The Plate Method, Carbohydrate Counting, Portion Control, Balanced Meal Planning Explain Carbohydrate Metabolism and Insulin Resistance “Oh, now it makes sense! Nobody ever explained that to me before.” http://youtu.be/m6rHYc0X0jw How many carbs should I eat? About half of total calories from carbs In a 1400 calorie diet, that is about 50-75g Carbs PER meal. (if 3 meals per day) In a 2000 calorie diet it’s more like 60g-100g of CHO 3-4x/day, potentially. Or about 30g CHO 6x/day or 40g CHO 6x/day. 1400 calories x 50% = 700 calories 700/4 calories per gram = 175g per day Carb Counting with insulin therapy http://www.med.umich.edu/pdf/Diabetes-101-Taking-Charge.pdf Carb Counting with insulin therapy Carb Counting with insulin therapy Blood sugar and food After eating carbohydrates alone, peak blood sugar occurs about an hour later. Blood Sugar Fat slows down this curve, causing blood sugar to peak 1.5-4 hours later. Time For T2DM without insulin Teach The Plate Method Recommend portion control and healthy food choices Emphasize balanced meal planning Discuss eating patterns, e.g. The Mediterranean Diet http://www.diabetes.org/food-and-fitness/food/planning-meals/create-your-plate/ Discuss Timing of Meals and Snacks Blood Sugar Snack Mountain Time meals and snacks approximately 3-4 hours apart. breakfas snack lunch snack dinner snack Drug classifications, Mechanisms of Action Explain their medications Algorithm for Progression of DM Treatment Standards of Medical Care in Diabetes – 2016 p. S54 Explain their medications Drug classifications, mechanisms of action, advantages and disadvantages Standards of Medical Care in Diabetes – 2016 pp. S55-56 Insulin Action Times Insulin Regimens Basal only, sometimes combined with oral medications Basal/Bolus Set doses Sliding Scale Carb Ratios Pump Therapy Lots of variation, individualization, and patient/doctor preferences! Insulin pump What does it do? Delivers continuous (basal) insulin via small catheter placed into fatty tissue. Delivers bolus (meal or correction) insulin by a button push. Can be more convenient What doesn’t it do? It does not monitor your blood sugar. It does not “sense” when you have eaten It is NOT an external pancreas. It is not for everyone Risks involved? DKA CGMS: Continuous Glucose Monitors and Vgo insulin delivery device CGMS: What is it? How does it work? How does it help our patients? Vgo Insulin delivery device: It’s new, who should think about it? Breaking News! Automatically adjusts the delivery of your basal insulin Inhaled insulin Afrezza Limited dosing options Not for use in patients with asthma or other respiratory conditions, or smokers or recent exsmokers. Treatment and Prevention Why Hypoglycemia? Remember, it depends on the medication regimen. Too much insulin Exercise/physical activity within last 24 hours up to 48 hours – may need to reduce insulin with increased exercise Inconsistent meal times Skipping meals Skipping carbs at meals Taking oral medications incorrectly Recent dietary changes Alcohol consumption Some symptoms of hypoglycemia Sweaty Shaky Nervous Grouchy Hungry Tired Mouth sensations Tearful Slurred speech Stumbling Headache Unable to complete simple tasks (easy math) Difficulty with recall Giggly How to treat hypoglycemia? Rule of 15: Check BG Consume 15g of simple carbs 3-4 glucose tabs 4oz juice or ½ can regular pop Sugary candies like jellybeans (not Snickers bar, remember the curve!) RE-check BG after 15 minutes, if not >70mg/dL, repeat. Protein stimulates insulin release Do not use protein to treat hypoglycemia or prevent recurrence Follow treatment with balanced meal or snack that includes CHO and healthy fat (e.g. fruit and nuts) Helps to lower blood sugar and improve insulin sensitivity. Physical Activity Guidelines At least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate) Reduce sedentary time, particularly by breaking up extended amounts of time (90 min) spent sitting. Resistance training at least twice per week. Locate a Diabetes Prevention Program in Your Area Strategies to Prevent T2DM 5-10% weight loss At least 150 minutes of physical activity each week Healthy food choices Participation in intensive lifestyle change programs Intensive Lifestyle Change Programs The CDC-led Diabetes Prevention Program was designed for patients with prediabetes Completers reduced their risk for developing T2DM by 58% The 1-year program emphasizes weight loss through healthy eating, physical activity, and stress management 16 weekly sessions followed by bi-weekly and monthly sessions Video: https://www.youtube.com/watch?v=XxFpUYli2Vc CDC Info and Curriculum: http://www.cdc.gov/diabetes/prevention/index.html Medicare and the DPP In 2016, Medicare announced expansion of coverage to include DPP The benefit will be available January 2018. DPP providers must have CDC recognition to participate in the Medicare program Learn more about Medicare and DPP at https://innovation.cms.gov/initiatives/medicarediabetes-prevention-program/ Learn more about developing a DPP program at https://www.cdc.gov/diabetes/prevention/index.html SE Michigan DPP locations http://bit.ly/SEMDPPmap http://bit.ly/SEMDPPlist https://nccd.cdc.gov/DDT_ DPRP/Programs.aspx Search by State and City Other References AACE/ACE Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan –2015 The Art & Science of Diabetes Self-Management Education Desk Reference, 3rd Edition, AADE American Diabetes Association, diabetes.org Thank You! Joyce B. Patterson, MPH, RDN, BC-ADM University of Michigan Diabetes Education Program [email protected]