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1 STANFORD PATIENT EDUCATION RESEARCH CENTER: CHANGES TO THE DSMP LEADER MANUAL (2012 version to the 2015 version) Stanford has corrected the DSMP manuals with the new ADA guidelines. Call- out icons and other changes will not appear in this revision. The current version of the manual is labeled "June 2015 version". Per Stanford, the Spanish DSMP manuals will most likely be available within the next month You may continue to use your old manuals by writing in the detailed changes below: Session 1 - Activity 4 Monitoring Item # 1, bullet 4 suggested that leader write A1C on board; now it is required. The first is a test called A1C (Leaders: Write this one the board or flipchart paper) and is done at your doctor s office. Item # 4, bullet 2, sub- bullets 2&4 acceptable blood sugar levels are now mg/dl; whereas before it was mg/dl. Also, too low blood sugar level is changed to below 80mg/dl. A change from 70 mg/dl. o o Before meals blood glucose should be between 80 and 130 mg/dl Blood sugar below 80 mg/dl is too low Chart 5; item #2 &3 the above changes are now reflected on the corresponding chart. BLOOD SUGAR LEVELS Too High Acceptable Too Low Above 180 mg/dl mg/dl before meals Below 180 mg/dl 2 hours after meals Below 80 mg/dl

2 Session 2- Activity 2 Formula for a Healthy Eating Plan Chart #7 - bullet 3 verbal wording (not written on the chart) was slightly changed Eat breakfast everyday (is important because it helps fuel the body after a long night of resting and fasting; it gives us the energy to start the day s activities. If you are trying to lose weight, eating breakfast will help with this.) Item #3, bullets 6, 7, 8, 11, 15 language about fats was added; language about carbohydrates was revised. SAY / PARAPHRASE: Before we talk more about healthy eating, we need to talk a little about proteins, fats and carbohydrates and foods containing these. Proteins build and repair muscles and other tissues and also give us energy. We get most of our proteins from foods like meat, fish, dairy products and some vegetables and some grains. Our bodies also produce some proteins. It is best to choose protein foods that are also low in fat. Fats are necessary for energy and to digest some vitamins. However, some fats can cause problems while others can keep you healthy. The quality of fat you eat is as important as the amount you eat. A good place to start is avoiding or significantly reducing fats that are solid at room temperature. We will talk more about this later. Fats have a little more than twice the calories as protein or carbohydrate. Therefore, eating fatty foods can put on pound really fast. The other problem is some fats can lead to heart problems. This is especially important because heart disease is the number one killer of people with diabetes. We will talk more about fats next week. Carbohydrates are our main source of energy and they also keep our brain functioning. They are especially important for people with diabetes because having too many carbohydrates will lead to high blood sugar.

3 No matter what you have heard, carbohydrates are not bad for you but monitoring how much of them we eat is critical for people with diabetes. It is true that there are the good and the not so good carbohydrates. Item # 7, bullets 2, 4, 5 language about carbohydrates was revised. Here are some simple facts about carbohydrates: Carbohydrates are found in cereals, grains, sweets, fruits, vegetables, starchy foods like rice and potatoes, sweets and even some hidden carbohydrates such as those in dairy products like milk, and yogurt. Of all foods, carbohydrates have the greatest effect on your blood sugar because almost all carbohydrates break down into glucose. Carbohydrates should not be avoided, but may need to be limited to help you reach or maintain your blood glucose target. Whether a carbohydrate is sugary or starchy is important but NOT MOST important. What is MOST important is the total amount of carbohydrates that you eat in a meal. Some carbohydrates are better for your overall health than others because they also provide vitamins, minerals and fiber. These are your whole grain products, vegetables and fruits. Some vegetables are lower in carbohydrates than others, and we will point this out in a moment. If you eat 3 meals and 2 snacks a day limit carbohydrates to about grams per meal and 25 grams per snack. Now, let s open our books to page 186 and learn more about determining how many grams of protein and carbohydrates we are eating. Session 2 - Activity 3 Preventing Low Blood Sugar (Hypoglycemia) Item # 5, bullets 4&5 language was slightly revised to remove the words you do not need to repeat things already mentioned.

4 Add any of the following if they were not mentioned. Mention that these are the most common signs or symptoms of low blood sugar and usually come on suddenly: o shaky, dizzy or weak o nervous, anxious or feeling confused o heart pounding or beating faster o hunger o cold sweats, feeling clammy Chart #14, # 6 - language in #6 on the chart was revised. Chart changes should read as follows: 6. If your symptoms are better and your blood sugar level is back to near normal and your next meal is more than 1 hour away, eat a snack (e.g. ½ sandwich, low fat cheese, crackers, cup of milk, a tortilla with cheese, etc.) If your next meal is less than 1 hour away, eat a meal to prevent another low blood sugar episode. Session 3 - Activity 2 Preventing or Delaying Complications Item # 5, item 9 in the table Hepatitis B shot was added to the chart as #9. The Flu shot is now #10 on the table. 9 Hepatitis B Shot Recommended- ask your doctor Session 3 - Activity 3 Planning Low Fat Meals Item # 2, bullet 2 & 3 language about saturated fat was revised.

5 Eating too much saturated (bad) fat increases the amount of fat and cholesterol in your blood and, therefore, the chances for developing heart problems. Reducing the amount of saturated (bad) fat you eat reduces your risk for heart attack or stroke. Item # 5 the brainstorm question was revised. Brainstorm: What are some ways we can reduce the amount of bad fat we eat? Session 4 - Activity 3 Reading Nutrition Labels Item # 2, bullet 6 a new bullet about sodium was added Sodium is also important; however, because the exact amount of sodium recommended for people with diabetes is highly individual we recommend you talk to your doctor or diabetes educator about your sodium intake Item # 10, bullet 1 begins a set of instructions that the leader gives participants. This should now become #11 and so on. (this becomes the new #10 SAY/PARAPHRASE ) SAY / PARAPHRASE: If you are watching your cholesterol, fat, and sodium any food with more than 20% per portion should be considered high.

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