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What’s New in Diabetes Education?. Presented by Lisa Kiblinger, RN, MS, CDE Vicki Karnes, RN Georgia Free Clinic Network Conference May 3, 2010. Objectives. Following the program the learner will be able to: Recognize one new teaching skill Identify weight based insulin doses

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What s new in diabetes education l.jpg

What’s New in Diabetes Education?

Presented by

Lisa Kiblinger, RN, MS, CDE

Vicki Karnes, RN

Georgia Free Clinic Network Conference

May 3, 2010


Objectives l.jpg
Objectives

Following the program the learner

will be able to:

  • Recognize one new teaching skill

  • Identify weight based insulin doses

  • Discuss resources available for

    patients in our community


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Knowledge Deficit

  • There is a knowledge deficit in diabetes

    treatment. It is called clinical inertia.

  • People at risk for diabetes should be

    identified early, treated aggressively

    and monitored regularly.

  • Diabetes out-of-control exists in 90% of

    patients under the care of a practitioner.

  • Diabetes in control reduces risks to near

    normal levels.


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Who Should be Tested and When?

  • Adults without symptoms who are

    overweight or obese and have one or

    more additional risk factors for diabetes.

  • Without Risk Factors: Testing should

    begin at age 45.

  • If results of testing are normal, repeat at

    least every 3 years.


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Identifying Those at Risk

  • Body Mass Index kg/m2

    > 25 * Caucasian, Hispanic, African-

    American

    > 23 Asian American

    > 26 Pacific Islanders

  • Age over 45

    *Note:Weight shown on the American Diabetes Association handouts for the public indicates risk begins at a BMI of 30.


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Risk Factors for Diabetes

  • Family history ↑

  • Gestational diabetes ↑

  • Obesity / abdominal fat distribution ↑

  • Sedentary lifestyle ↑

  • Smoking ↑

  • Low birth weight or high birth weight ↑

  • Depression ↑

  • Antipsychotic medications ↑


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Additional Risk Factors

Dietary Considerations

  • Saturated fats ↑

  • Glycemic load ↑

  • Cereal fiber / whole grain ↓

  • Low fat dairy products ↓

  • High fructose corn syrup ↑

  • Sugar-sweetened beverages ↑

  • Alcohol ↑


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Psychosocial Risk Factors

  • Poverty

  • Education

  • Food insecurity

  • Food environment

  • Neighborhood factors


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New Tool for Diagnosis

2010 ADA Clinic Practice Guideline

Hemoglobin A1c > 6.5 % = Diabetes

Hemoglobin A1c 5.7 to 6.4% = Pre-diabetes

Impaired Glucose Tolerance (IGT) and Impaired Fasting Glucose (IFG) values remain the same.

Note: Health plans may not cover the Hemoglobin A1c blood test. Home

test kits are available for $9 (results in 5 days) or $29 (results in 5 min.)


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Can Diabetes be Prevented?

Exercise 150 minutes/week

Limit Saturated Fat

Increase Fiber

Increase Fruits/Vegetables

Limit Alcohol

Moderate Weight Loss: 7 to 10%


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Motivational Interviewing

  • How do I get my smoking, drinking,

    obese, sedentary, vegetable-phobic

    patient to take better care of himself?

  • O.A.R.S. Strategies

    • Open-ended questions

    • Affirmation

    • Reflective listening

    • Summarize


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Conversation Maps

InteractiveTeaching / Learning Style


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Glucose Control

  • Patient-driven

  • Food choices, portion size, exercise

  • Monitoring Goals:fasting < 130, 2 hrs after meal < 180

  • Teach est. Avg.Glucose:A1c7%=154mg/dL

  • Obst. Sleep Apnea

    screening


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Insulin Types

  • Basal: Lantus, Levemir

    Humulin N, Novolin N

  • Bolus: Novolog, Humalog, Apidra (rapid)

    Novolin R, Humulin R(must wait 30

    min. to eat)

  • Premixed doses:

    70/30, 75/25, 50/50

    (NPH / Regular or Rapid)


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Weight-Based Insulin Dosingin Type 1 Diabetes

  • In most patients the“Total Daily Dose”(TDD)of insulin can be calculated by weight:

    Weight in kg divided by 2 = TDD

  • Insulin Sensitivity Factor = 1700*/TDD

    ISF is the estimated point drop in BG per one unit of insulin.

  • Insulin to Carb (I:C) Ratio = 600*/TDD

    I:C ratio = grams of carb for 1 unit. If I:C is 15, then before 45 gram carb meal, 3 units of insulin is given.

    * When using rapid-acting insulin


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Monitoring Options for Low-income Individuals

Monthly Cost of Test Strips

*Twice daily when adjusting meds or BG higher than 200 mg/dl

Calculations based on $20 cost for 50-strip box


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Learning How Actions Make a Difference: Testing in Pairs

Monitor glucose before and after a specific meal or event. For example, before and 2 hrs after lunch.

Write down the results.

Do this for the same meal/ event for 7 days.

Notice how levels changed.

What can be learned fromthe changes?


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Monitoring FrequencyType 1 Diabetes

  • Basal/Bolus Insulin Regimen

  • Bolus Units based on Carb Count

    or Sliding Scale


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Additional Monitoring Frequency

  • have symptoms of hypoglycemia

  • have infection or on a sick day

  • travelling or are under stress

  • undergoing adjustments in medication, nutrition and/or physical activity

  • entering a new life experience, i.e. going away to school, starting a new job

  • pregnant or planning to become pregnant


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Glucose Monitoring Supplies

  • Roche: ACCU-CHEK meters/test strips now only to Direct Relief USA Clinics (4 in GA?)

  • Abbott Diabetes Care: 400 strips (4 months) for those on insulin, must document use

  • National Association of Free Clinics

  • BG Monitor Company Representative

  • Retail: ReliOn, WaveSense


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National Association of Free Clinics

Available to Member Clinics

Test Strips

  • TrueRead 9.85 per box of 50

  • Bionime 11.00 per box of 50

  • WaveSense Keynote 10.50 per box of 50

    Meters

  • Free meter with every 4 boxes ordered

  • First time order: Meters as needed for $1.00


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Handout: Saving Money on Rx Drugs and Supplies

  • Free Medications

    New GA Partnership for Caring Applic. 3/2010,

    Merck is only PAP that doesn’t require proof of

    financial need. Metformin now free at Publix.

  • Free Supplies: Insulin syringes from BDMedical,Diabetes Id Necklace: www.diabeteswellness.net

  • Discount Medications: CVS only

    program to offer Tramadol for $10 / 90 days


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National Diabetes Education Program

  • More than Partner Organizations

  • Websites

    • National Diabetes Education Program

    • Diabetes at Work

    • Better Diabetes Care (HCPs)

  • Campaigns

    • “Control Your Diabetes for Life”

    • “Small Steps, Big Rewards, Prevent Diabetes”

    • “One Call, One Click”: NDEP Promotion

  • Toolkits

    • “Road to Health” and “Power to Prevent”


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Multicultural Education Materials

  • Consider literacy skills in any language!

  • National Diabetes Education Program

    25 copies free of flyers, brochures

    Available in 15 languages

  • Nutrition Education for New Americans

    Download handouts in 36 languages

  • Drug Companies: Many provide diabetes

    education brochures in Spanish


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Diabetes Education Classes

  • Recognized Programs (ADA, IHS, AADE)

    • Not covered by Medicaid

    • Medicare 20% copay applies to10 hours

      when diagnosed then 2 hours/year.

  • Diabetes Association of Atlanta: Sliding Scale

  • Community Health Centers: West End Med. Center

  • Georgia Medical Care Foundation:

    Classes in the community setting targeting African-

    American and Latino Medicare beneficiaries.


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Other Diabetes Education Programs

  • Emory Latino Diabetes Education Program

  • Conversation Map Group:www.healthyinteractions.com

  • Cooperative Extension Service

    Online Sample Calorie-Count Menus: www.fcs.uga.edu

    Will Provide Agent for Community Classes

    Support Group Meetings

  • Center for Visually Impaired Diabetes Services

  • Church Programs: House of Grace(Decatur)


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MultimediaEducationalResources

  • Television: dLifeon CNBC

    Sunday, 7 pm ET

  • Videos: “Small Steps to Help You

    Manage Your Diabetes”

  • Internet Videos: “Diabetes balance

    and health: my personal roadmap”

    https://members.kaiserpermanente.org


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Find a Diabetes Educator

American Association of Diabetes

Educators website:www.diabeteseducator.org/DiabetesEducation/Find.html


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Review

  • Diabetes can be prevented

  • Patients decide on treatment to be

    followed

  • Insulin can bring down any eAG

  • Tools can help you help your patients

  • Resources are available to you and

    your patients


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Resources

  • Hospital/Orders Resource

    http://diabetes.gha.org/Toolkit/index.asp

  • Insulin

    www.effectivehealthcare.ahrq.gov/repFiles/Insulin_

    Consumer_Web.pdf

  • Diabetes Education http://ndep.nih.gov/publications/index.aspx?keyword=Toolkit

  • Sleep Apnea http://www.edward.org/workfiles/sleep%20center%20Berlin %20Sleep%20Eval.pdf


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Thank You!

We appreciate your

time and attention


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