DTIL is pleased to present a Diabetes Education Series
"Improving Diabetes Care Through Education"
Education is one of the most important issues facing the diabetes healthcare community. Lack of patient and professional education is considered a major risk factor for individuals with any form of Diabetes.
The goal of the DTIL Education Series is to help improve the quality of care and life for individuals with any form
of Diabetes, while helping prevent complications typically associated with sub-optimal control and education.
We hope that you find the information in this series to be useful in assisting you in improving your diabetes care.
Topic # 1.
What Is Diabetes?
Diabetes Mellitus (DM) is a chronic condition characterized by high levels of blood glucose (hyperglycemia).
While there is no cure for diabetes, it can be controlled. The term “Diabetes” describes either a deficiency in
the production of insulin (T1DM) or the inability to use insulin properly (T2DM). Insulin is a hormone produced
in the pancreas that allows glucose to enter the cells of the body where it is converted to energy. Insulin is
also used to synthesize protein and store fats.
T1DM represents approximately 10% of all diabetes cases. T2 DM defines a condition where the body produces
but cannot use insulin properly. T2 DM represents approximately 85% of all diagnosed cases.
How the body uses food: The food you eat turns into glucose (sugar) in your stomach. It than enters the
bloodstream where it is carried to your body’s cells. Insulin, a hormone made in the pancreas, helps the glucose
enter the cells. Once in the cells, the glucose is used for energy.
Types of diabetes and related metabolic conditions: Type 1 or Insulin Dependent DM), Type 2 non-insulin
dependent) and Gestational Diabetes Mellitus (GDM) diabetes during pregnancy (1 % of cases), Impaired Glucose Tolerance, Syndrome X, Metabolic Syndrome and Secondary (SDM) (caused by such factors as infection, cancer, trauma to the pancreas, environmental exposure to certain chemicals). All of the various forms of diabetes have
one thing in common, the ability to properly regulate and/or process a simple sugar known as glucose. In
uncontrolled diabetes, glucose and fats remain in the bloodstream and, with time, can contribute to complications
such as eye, kidney, nerve and cardiovascular disease. The CDC currently estimates that over 25 million Americans have Type 2 DM.
Pre-Diabetes (PD), is a metabolic condition that can go undiagnosed for as many as 8 years prior to diagnosis.
Once properly tested (A1c/albumin in urine) it is diagnosed as T2 DM. During this 8 year period there is often no outward signs with the exception of a rise in A1c levels or presence of protein in the urine (microalbumin) or albumin. The one factor that identifies this condition is an A1c levels between 5.7% and 6.4%. Often these individuals also
have an elevated Body Mass Index (BMI) and/or Enlarged Waist Measurement (EWM). The CDC estimated that over
40 million Americans have PD. CDC estimates that 10% of Americans have PD.
Significance of Diabetes:
Diabetes is the number 1 health burden in the U.S. It is considered an epidemic in the Southern States and in the minority populations. It is the leading cause of Blindness (eye disease), Kidney Disease, non-traumatic lower limb amputations, and third leading cause of death, Nerve disease, sexual dysfunction, stroke and heart attack.
Individuals with Diabetes are 10 times more likely to develop these complications. Complications from diabetes are
also responsible for a significant reduction in the Quality of Life (QOL).
Incidence of Diabetes:
Type 2 DM >25 million individuals in U.S.
Type 1 DM > 1 million individuals in U.S.
Diabetes has increased by 70% over the past 12 years.
Alarming increase in Type 2 DM in school aged children.
Diabetes At-Risk Factors:
● Elevated A1c level
● Presence of albumin in urine
● Elevated fasting/random blood glucose
● Obesity or abnormal BMI (Under or over weight)
● Family history of diabetes
● Sores and/or wounds that heal slowly
● Frequent skin, gum, vaginal or urinary infection’s
● Drowsiness, blurred vision, headaches, dizziness
● Certain ethnic populations (African Americans, Latinos, Asians, American Indians)
● Poor diet
● Dark ring around the neck, underarm or behind knees
● Bed wetting in children
● Smoking or exposure to second hand smoke
● Frequent urination
● High blood pressure
● Extreme thirst, snoring, Impotence
Land-Mark Diabetes Studies:
Several land-mark diabetes studies for both T1 DM and T2 DM have been completed demonstrating the
overwhelming benefits of lowering and maintaining blood glucose levels at or about normal. Complications
typically develop when the blood glucose levels remain elevated and sustained.
The Diabetes Control & Complications Trail (DCCT): demonstrated that “tight control matters” in reducing and/or preventing complications typically associated with Type 1 diabetes. This 8-year study demonstrated that maintaining tight control can reduce complications such as eye, nerve and kidney disease by as much as 76%. The lower the
A1c the less the complications, reversely the higher the A1c the greater the potential for complications.
The United Kingdom Prospective Diabetes Study (UKPDS) also demonstrated that “tight control matters” in
reducing and/or preventing complications typically associated with T2 diabetes. This 20-year study of T2DM
individuals demonstrated that long-term complications can be reduced and/or prevented by implementing more intensive management and using existing treatments more effectively. There was no threshold for the benefits of improved control.
The Core Message from all Diabetes the studies:
The message is clear in all diabetes studies “Control Matters” in reducing and/or preventing the possible
development of long-term complications typically associate with sub-optimal diabetes control.
Diagnosing Diabetes:
The following tests are representative of a comprehensive examination. Other tests may be performed including
urine and blood tests to provide the physician a differential diagnosis.
● Have an annual comprehensive physical and diagnostic examination (regardless of lack of known symptoms or
feeling just fine).
● A foot exam and dilated eye examination (ophthalmologist).
● A1c diagnostic assessment (non-fasting test)
Normal level A1c: 4.2% - 6.0%
5.7% - 6.4% considered Pre-Diabetes
>6.5% considered Diabetes
>7.0% Immediate medical intervention required
● Fasting Blood Glucose > 140 mg/dl 2 hours after glucose load
● Oral Glucose Tolerance Test (OGTT)
● Fasting Blood Glucose >110 mg/dl
● Knowing and acknowledging other warning signs
Note:Certain genetic factors such as Sickle Cell Anemia or other forms of Disturbed Red Blood Cells can affect
the analysis of A1c. An interference free method of A1c analysis is recommended.
A1c Goal: <7.0%. Specific goals should be defined by your physician.
So you have been diagnosed with Pre Diabetes or Diabetes:
Good news, you now know you have a form of diabetes. If you are diagnosed early enough (in the pre-diabetes stage), you can take steps and make life style changes sufficient to halt the progression of the condition.
By implementing a positive intervention strategy (s) you can begin to make changes in life style and help prevent possible diabetes complications. ”Early Diagnosis is the key” Think positive and commit to managing your diabetes
and your emotions. Diabetes can definitively be controlled, and you can lead a normal healthy life.
Intervention steps:
The best way to live with diabetes is to learn as much about the condition as you can including methods for self-management. The internet is a great place to get started.
● Exercise Daily.
● Get educated about diabetes.
● Learn proper diet and nutrition (carbs, proteins and starches).
● Take medications in accordance with medial recommendations.
● Monitor your blood glucose routinely (keep accurate daily self-monitoring blood glucose records).
● Stop smoking or avoid second hand smoke.
● Visit your physician at least every 3 months.
● Perform routine diagnostic tests such as: A1c, urine protein, lipid testing
● Self monitor and record (BG Log) your Blood Glucose. Use a glucose monitor with memory.
● Consult a dietician, learn meal planning, learn and understand the importance of the contribution of
carbohydrates, fats and protein.
● If on insulin or an oral medication that contains insulin, never drive your car or operate equipment without
monitoring your blood glucose.
● Wear a diabetes identification bracelet and/or necklace.
Standards of Care
As part of your rights as an individual with diabetes, you should be familiar with the various diagnostic tests,
physical examinations and recommended guidelines for the care and treatment of your specific type of diabetes. Standards of care also known as guidelines are set in order to help ensure the consistent treatment of individuals
with diabetes across the health care profession. By adhering to the guidelines for the care of people with diabetes,
the health care profession (including the members of AMA) can better help you live healthier while preventing the possible long-term compilations typically associated with diabetes.
The health care professional also has defined guidelines in treating individuals with diabetes. The American Medical Association (AMA) has defined the following summary of minimal standards of care. You should expect to have at
least each of these areas addressed (examined) at each physician visit. EKG’s are also part of these
recommendations.
Minimal Standard of Care
- A1c every (90 days), Check Blood Glucose monitor for data.
- Lipid profile (one or more/year) Triglycerides, Cholesterol, HDL, LDL.
- Urinalysis including albumin and microalbumin (MUA).
- Complete Blood Count (check for anemia (hemoglobin).
- Eye exam (dilated).
- Foot exam (take your shoes and socks off and examine the feet thoroughly (Loss of Sensation sensory testing).
- Flu/pneumonia (annual).
- Blood pressure exam every visit.
- Question status of smoking (stop smoking or exposure to second hand smoke).
- Daily 81 mg Aspirin if tolerated.
- Review of hypoglycemia events (training about how to prevent and/or treat this condition)
- Question your ability to know when you are low.
- Awareness and training on how/when to check for urine or blood ketones.
- Visit your dentist for complete gum and tooth examination.
Goals for Blood Glucose and A1c: Your A1c Goal (Doctor directed) _______%
Goals for Daily Self-Monitoring Blood Glucose
Need adjustment
Before meals glucose 80 – 110 mg/dl < 80mg/dl
Two hours after meals 80 – 140 mg/dl > 150 mg/dl
Bedtime 100 – 130 mg/dl < 100 or > 150
The following table lists some of the standards of care that have been defined for diabetes by the American Medical Association (AMA), the American Diabetes Association, (ADA) and the American College of Endocrinology (ACE).
The following table lists some of the activities and goals that you and your health care team need to accomplish during the year.
The following table lists some of the standards of care that have been defined for diabetes by the American Medical Association (AMA), the American Diabetes Association, (ADA) and the American College of Endocrinology (ACE). The table lists some of the activities and goals that you and your health care team need to accomplish during the year.
Guidelines and Recommendations
Members of Your Health Care Team:
You, your Doctor, Dentist, Registered Dietitian, Certified Diabetes Educator and Pharmacist as well as any
referred health care professionals.
Maintain a list of Medications:
You should maintain a list of all medications and how they are administered including dosage times and specific dosages as prescribed by your health care team, this includes all over the counter medications. Using a smart
phone, you might consider taking photos of each label. You should keep the list of your medications in your wallet
or electronic device at all times. Also remember to make changers to the list each time your medications are changed.
Topic 2.
Hypoglycemia
Hypoglycemia: Hypoglycemia (Low Blood Glucose) is a serious and possibly life threatening condition where the
blood glucose (BG) level in the body falls below normal (70 mg/dl). The condition when detected should be treated immediately and steps to avoid this condition should be implemented. This condition can occur in all types of
diabetes (Type 1,Type 2 and GDM) or in individuals suffering from pre-diabetes or undiagnosed metabolic conditions. In some cases, individuals may not be aware of any of the classic signs of hypoglycemia, this is called “Hypoglycemia Unawareness”. This is a particularly dangerous condition that should be discussed with your health care professional
to help you prevent or manage this condition.
TIPS
Steps to take if you have been diagnosed with hypoglycemia unawareness:
· Know the warning signs of hypoglycemia, and keep a source of sugar at your side.
· Monitor your blood glucose frequently, and wear a medical ID bracelet.
· Do not miss meals or snacks
· Consume sufficient carbohydrates to prevent hypoglycemia
· Learn to balance (match) insulin and/or diabetes medication to carbohydrate intake.
· Never drive and/or operate machinery unless you have monitored your blood glucose level.
· Maintain a blood glucose target level of 150 mg/dl on a regular basis to allow for drops in blood glucose levels.
“Warning Signs of Low Blood Glucose”
There are many warning signs of low blood glucose if you are able to recognize them. Your own signs may be
different from what someone else feels. Learn your early warning signs. Share your signs with others around
you so they can help you become aware of a possible problem. Signs may include but not be limited to:
Angry Irritable Sick to stomach Anxious Light-headed
Sleepy Clammy Nervous Stubborn Clumsy
Numb Sweaty Confused Pale Tense
Hungry Sad Tired Impatient Shaky
Weak Blurry vision Dry mouth Headache Rapid pulse
Pounding
heart
When any of these signs occur, you need to treat low blood glucose right away. If not treated, low blood glucose
can cause you to pass out. In addition, low blood glucose can cause seizures, coma and even death.
Write down your warning signs that you experience and share them with others so they can recognize them as
well.
Sometimes, you may not be able to treat your own hypoglycemia. It may be due to the fact that you did not
recognize your own signs. You low level of glucose may cause you to be confused and unable to help yourself.
Never-the-less, teach someone in advance how to provide assistance to you in your moment of need.
Keep foods, snacks or glucose tablets or gel (sugar sources) near you at all times. Place a small box of juice where it can be seen or easily located. You should wear a Medical ID bracelet informing others that you have diabetes and/or hypoglycemia unawareness. Have others be prepared to call 911 if necessary. After you have recovered, you should record the incidence and convey it to your medical team. Together, you and the physician should isolate the cause of the hypoglycemia. It may indicate that you need to adjust your insulin or oral medication. Never enter an elevator without your sugar sources.
Treating your low blood glucose condition:
1. Sit down and monitor your blood glucose (BG) if you can. If it is below the target range set by you physician go
to step 2.
2. Eat or drink something with about 15 grams or more of carbohydrate, or use a glucose tablet or gel.
3. Wait 10 minutes and recheck your BG level. If your BG level is still below target, repeat step 2, and/or have
someone call 911. Continue to monitor every 10 minutes. Try not to over treat hypoglycemia causing a dramatic
rise in BG (such as going from 40 -400 mg/dl).
4. If your BG level is within target range, stop ingesting foods and fluids and/or sugar source. You may still
experience feelings of hypoglycemia for a while. By monitoring your BG levels every 10 minutes for the first hour,
you can reassure yourself that BG levels are rising to desired levels.
A list of possible foods or possible recovery strategies is listed on the following page.
Possible causes of hypoglycemia:
- You ate too little food to compensate your current medication dosage. In general, you should not overeat simply to compensate your medication (insulin and/ or oral agents). If you routinely have low blood glucose, you should consider an adjustment to your medication (discuss with your physician).
- You many have not eaten enough carbohydrates.
- You may have delayed or skipped a meal or snack.
You may have exercised more than usual. Exercise will lower BG as much as several hours later.
You may have taken too much insulin and/or oral agent (diabetes pills).
You may be ill.
Drank alcohol on an empty stomach. Alcohol consumption typically lowers BG.
Possible foods and/or sugar sources that can be used during in an episode of hypoglycemia: The list is not order of priority. You will need to choose the sugar/carbohydrate source that best works for you. As a practice drill, you may want to monitor your BG levels when you are now having a low and experiment with various methods to determine how much they raised your BG level 10 – 15 minutes later.
· ½ cup (2 oz) of fruit juice. · 1 cup (8 oz of whole milk · 2 tablespoons of raisins (40-50)
· 6 1/2 –inch sugar cubes · Glucose tablets or gel · 1/3 can (4 oz) of non-diet soft drink
· 3 graham crackers · 6 saltines crackers · 1 tablespoon of honey or syrup
· Glucose tablet (part or all) · Glucose paste
Prevention & First Aid for
Acute Hypoglycemia (Low Blood Sugar)
Frequent blood glucose monitoring is highly recommended in Type 1 and Type 2 diabetes on oral agents that contain insulin.
WARNING: Individuals with Type 1 diabetes or individuals with Type 2 diabetes taking oral medications containing glucose lowering compounds should: ALWAYS MONITOR THEIR BLOOD GLUCOSE LEVEL PRIOR TO OPERATING OR ENTERING AN AREA WHERE MACHENIARY IS IN USE. It is highly recommended to monitor blood glucose levels prior to operating a motor vehicle. In many states, individuals with diabetes may be arrested
since the police officer may rule the individual as intoxicated (DWI). All individuals with diabetes should wear an ID bracelet indicating that they have Diabetes.
“FIRST AID FOR HYPOGLYCEMIA”
Step 1. Call for help “911 if unconscious”, ensure an open airway. Ask the nurse or safety personnel to bring a
blood glucose meter with strips and lancet to the subject. If unconscious or unable to swallow or identify themselves move the subject to a safe upright location close by. If unconscious, rub sugar or glucose
paste inside the victims’ lips or gums.
Step 2. If conscious, do not move; do not suggest that they walk or stand. The victim should not attempt to walk
until their blood glucose levels are confirmed by a blood glucose meter to be above 80 mg/dl.
Step 3. If conscious, provide the victim with glucose tablet (s), glucose gel, orange juice, regular soft drink/fruit
juice (non-diet), pack (s) of sugar, whole milk, honey or syrup. Reassure the victim that you will stay with
them until help arrives. Continue to encourage the victim to take in any of the above items. Often the victim may be difficult or resistant to assistance.
Step 4. Monitor the blood glucose as soon as possible; continue to monitor the blood glucose every 15 minutes to ensure that the blood glucose level is returning to normal 70 -110 mg/dl. Once the blood glucose is above
70 mg/dl, offer a carbohydrate snack such as cookies, graham crackers, or cheese crackers to ensure that
the blood glucose level stays at or above the normal level.
If a child has a low blood sugar episode at school, instruct the teacher to have someone assist the child to the
School Nurse. The nurse should determine when it is safe to return the child to class or to call 911.
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