What s New in Diabetes Education

1. What�s New in Diabetes Education? Presented by Lisa Kiblinger, RN, MS, CDE Vicki Karnes, RN Georgia Free Clinic Network Conference May 3, 2010

2. 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

3. 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.

4. 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.

5. 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.

6. 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 ?

7. 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 ?

8. Psychosocial Risk Factors Poverty Education Food insecurity Food environment Neighborhood factors

9. 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.)

10. Can Diabetes be Prevented? Exercise 150 minutes/week Limit Saturated Fat Increase Fiber Increase Fruits/Vegetables Limit Alcohol Moderate Weight Loss: 7 to 10%

11. 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

12. Conversation Maps

13. Glucose Control Patient-driven Food choices, portion size, exercise Monitoring Goals: fasting < 130, 2 hrs after meal < 180 Teach est. Avg. Glucose: A1c 7% = 154 mg/dL Obst. Sleep Apnea screening

14. 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)

15. 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

17. Monitoring Options for Low-income Individuals Monthly Cost of Test Strips

18. 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 from the changes?

19. Monitoring FrequencyType 1 Diabetes Basal/Bolus Insulin Regimen Bolus Units based on Carb Count or Sliding Scale

20. 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

21. 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

22. 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

23. 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 BD Medical, Diabetes Id Necklace: www.diabeteswellness.net Discount Medications: CVS only program to offer Tramadol for $10 / 90 days

24. 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�

25. 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

26. 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.

27. 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)

28. Multimedia Educational Resources Television: dLife on 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

29. Find a Diabetes Educator American Association of Diabetes Educators website: www.diabeteseducator.org/DiabetesEducation/Find.html

30. 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

31. 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

32. Thank You! We appreciate your time and attention