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1 Hello, and welcome to today s education session, Next Steps Toward Better Control. Its part of an online education program from Sanofi US that brings the expertise of Certified Diabetes Educators to diabetes education. While managing diabetes can be a challenge, you re taking an important step by joining us for today s session. I will be your host today; I am a Certified Diabetes Educator, or CDE. CDEs are skilled and trained healthcare professionals certified by the National Certification Board for Diabetes Educators. Always remember to consult with your healthcare provider regarding your diabetes treatment. The objective of this session is to help you learn how to better manage your blood sugar. An important feature of this online education session is its interactive component, which allows you to give, receive, and discuss information, rather than just receive it. At times during today s presentation, I ll ask you to answer some questions, which you will be able to answer using your computer. If you have additional questions, I will be happy to answer them at the end of the presentation using a private chat function. After the session, you ll receive an e- mail with a link that will allow you to view this presentation again 2

2 Today, we ll talk about what diabetes is, the importance of checking A1C and blood sugar levels, why A1C and overall blood sugar management is important as well as review the signs of high and low blood sugar and the benefits and risks of adding insulin. And, as I mentioned, I will also answer your questions following this presentation. 3

3 Let s take a look at how the body balances blood sugar in a person who does not have diabetes. After a person eats, the body breaks down food from carbohydrates and other nutrients, which are absorbed into the bloodstream. The carbohydrates in food turn into sugar, shown here by the letter S. However, it s not good for the body if too much sugar stays in the bloodstream. It needs to be turned into energy by going into cells, shown here by the blue circle. Your body needs energy to survive. For example, when you breathe or when your heart beats, your body is using energy. For the sugar to get into cells, it must first get through the closed and locked doors of the cell walls, known as cell membranes. That s why an organ in the body called the pancreas makes insulin, which is a natural hormone in the body. When sugar builds up in the bloodstream, the pancreas releases insulin, shown here by the green keys. It then travels through the bloodstream to cells and unlocks the doors into the cell walls, shown here by the door on the left side. By unlocking and opening the doors, sugar can get in, shown here by the open doors in the middle and right side of the blue cell. As sugar enters the cells, it is turned into energy, and blood sugar levels in the body go down. 4

4 In people with type 1 diabetes, the pancreas stops making insulin. Without these insulin keys, the doors to the body s cells stay locked and closed, and sugar can t get in. Because it can t get into the cells, sugar stays in the blood. This makes blood sugar levels go up. People who have type 1 diabetes need to inject insulin every day to replace the insulin the body doesn t make anymore. This way, they have the keys they need to unlock the doors of the cell walls, so that sugar can get inside to be used for energy. 5

5 If you have type 2 diabetes, your body may have one or 2 problems balancing blood sugar. This picture shows the first way your body may have trouble turning sugar into energy. Although your pancreas is still making insulin, it s not making enough. In other words, your body has missing insulin keys, shown here by the green keys in the bloodstream. Because you don t have enough insulin keys, some of the cell doors stay closed and locked, which causes some of the sugar to stay in the blood and build up to cause high blood sugar. Another way the body may have trouble balancing blood sugar is when the body is still making insulin keys, but they no longer match the locks on the doors to the cell. When the keys don t work in the locks, the doors stay closed and sugar can t get into cells to be turned into energy, so it builds up in the blood to cause high blood sugar. Type 2 diabetes may get harder to manage over time, because the pancreas usually makes less and less insulin as time goes on. This is why people with type 2 diabetes, after diet and exercise and oral antidiabetic medications, may need to add insulin injections to their treatment plan to make up for the limited insulin keys made by their pancreas. 6

6 If you have type 2 diabetes, your insulin levels may have started dropping years before you were diagnosed. Beta cells in your pancreas produce insulin. However, beta cell function declines, on average, about 5% per year in people with type 2 diabetes. Because of the progressive decline in beta-cell function and the progression of the disease, patients with type 2 diabetes may eventually require insulin therapy to achieve or maintain blood glucose control. In fact, at diagnosis, more than 50% of beta cell function may have been lost. 1. Holman RR. Assessing the potential for α-glucosidase inhibitors in prediabetic states. Diabetes Res Clin Pract. 1998;40(suppl):S21-S DeFronzo RA. Banting lecture. From the triumvirate to the ominous octet: a new paradigm for the treatment of type 2 diabetes mellitus. Diabetes. 2009;58(4): American Diabetes Association. Standards of medical care in diabetes Diabetes Care. 2013;36(suppl 1):S11-S66. 7

7 Type 2 diabetes may get harder to manage over time, which means that your treatment plan may also need to change. Healthy eating, exercise, and diabetes medications are 3 key ways to help keep your diabetes in check; finding the right balance among them can help you to better manage your diabetes. At the end of today s program, I will let you know about another on-line session that you can attend that focuses just on healthy eating and exercise. 8

8 Checking your blood sugar levels as directed by your Health Care Provider is an important part of diabetes management. Most people can check their blood sugar levels at home. Talk with your Health Care Provider to find out how often you should check your blood sugar levels. Write the results in a blood sugar log, and look for extreme numbers. Take your log and notes to your visits with your Health Care Provider, and call him or her right away if there are any unusual changes in your levels. 9

9 Keep track of blood sugar levels by writing the results in a blood sugar log, and watch for readings outside of your recommended target range. Make sure to include the time of day you checked your blood sugar and, if it was around mealtime, what you ate. If your readings are higher than what your Health Care Provider recommends, you may need to reduce the amount or change the type of food you re eating, increase your physical activity, or ask your Health Care Provider about adjusting your treatment plan. Review your blood sugar log often to see how food, activity, and stress affect your blood glucose readings. If you keep seeing the same patterns for instance, if your levels are too high or too low it might be time to find a plan that works better for you. Work with your Health Care Provider to understand what these patterns mean and how they may affect your treatment plan. 10

10 In addition to blood sugar checks, another way to see if your blood sugar is under control is by checking A1C. An A1C test is needed to give you and your healthcare team a picture of your average blood sugar control over the past 2 to 3 months. Your A1C reading is a reflection of your average blood sugar levels and is impacted by premeal blood sugar levels, which are also known as fasting blood sugar levels, as well as your blood sugar levels after you eat. It s important that your Health Care Provider performs this test at least 2 to 4 times per year, depending on how well your blood sugar is controlled. But remember, the A1C is just one way to measure blood sugar control. 11

11 The American Diabetes Association or ADA recommends an A1C goal of less than 7%, which works for most people with diabetes; however, your Health Care Provider may have a different goal for you, so be sure to discuss this with him or her. 12

12 Let s take a closer look at the relationship between blood sugar and A1C. As you can see, your A1C level may get lower as your blood sugar becomes better controlled. For example, an A1C of 6% is equal to an average plasma glucose, or sugar, of 126 mg/dl, which is within the ADA target range for fasting plasma glucose of 70 to 130 mg/dl. 13

13 Another reason A1C is important in people with type 2 diabetes is the relationship between A1C and the risk of developing diabetes-related complications, such as heart attack or death caused by the blockage of blood vessels, and complications with the eyes, kidneys, or nerves. Data from an analysis of a medical study showed that each 1% reduction in A1C was linked with a significant reduction in the risk of diabetes- related complications. For example, a 1% reduction in A1C resulted in a 37% reduction in complications with the eyes, kidneys, or nerves. 14

14 Since A1C reduction may help reduce the risk of complications, it s important for your healthcare provider to take action if blood sugar goals are not met. Every three months your healthcare provider will check your A1C until it is 7% or the individual goal that he or she has set for you. Once your A1C is stabilized, they will continue checking your A1C at least every 6 months afterwards to make sure you are staying at goal. Your healthcare provider should continue to encourage you to maintain those healthy lifestyle changes and remind you to take all of your medication exactly as prescribed. And you can expect your healthcare provider to take action if your A1C remains above your individual goal. 15

15 One of the most important things you can do to manage your diabetes is to keep your blood sugar levels within your target range. The guidelines shown here are from the American Diabetes Association, or ADA, and are the recommended treatment targets for most adults with diabetes. These guidelines suggest a fasting, or premeal, plasma glucose, or sugar, of 70 to 130 mg/dl and plasma glucose, or sugar, 1 to 2 hours after starting a meal also known as post- meal plasma glucose of less than 180 mg/dl. Be sure to ask your Health Care Provider what blood sugar targets are right for you. 16

16 It s important to know the symptoms of high blood sugar. Possible symptoms include increased hunger, blurred vision, fatigue, weight loss, dry, itchy skin, frequent infections, frequent urination, slowhealing cuts or sores, and tingling or numbness in the feet or hands. But you may have high blood sugar without any symptoms, so checking your blood sugar is important. 17

17 Too much food, usually those that are high in carbohydrates, can cause high blood sugar in people with diabetes. Common sources of carbohydrates are breads and grains, starchy vegetables like potatoes and corn, milk, and fruit, as well as table sugar, sweetened beverages, and dessert-type sweets or foods. Food is not the only cause of high blood sugar. Other things that can cause blood sugar levels to rise above target ranges include too little physical activity; too little diabetes medication; other medications, such as steroids; and stress or illness. 18

18 If your blood sugar is above your target range, you ll want to work with your Health Care Provider to adjust your meal plan and/or physical activity routine. Talk with your Health Care Provider about adjusting your medications. Also, find out what your Health Care Provider considers to be very high blood sugar for you, so that you ll know at what point to take emergency action. 19

19 Now let s talk about low blood sugar. Possible symptoms of low blood sugar include anxiety, blurred vision, confusion, dizziness, fatigue, heart palpitations, hunger, nervousness, nightmares, shakiness, and sweating. But you may have low blood sugar without any symptoms, so checking your blood sugar is important! 20

20 For people with diabetes, low blood sugar may be the result of too little food, too much physical activity, too much diabetes medication, other medications, and alcohol. When you experience low blood sugar, it s important to understand what may have caused it so that you can better manage that situation in the future. 21

21 If you have low blood sugar, you should eat 15 grams of fast-acting carbohydrate, contained in glucose tablets or such foods as hard candies (not chocolate and not sugar-free), or 4 ounces, or half a cup, of juice or regular (not diet) soda. Then wait 15 minutes and check your blood sugar again. Repeat until your blood sugar is within range, and follow up with regular snacks and meals to keep blood sugar levels up. To make this easier to remember, think of it as the rule of

22 Now that we ve discussed high and low blood sugars, let s take a look at how type 2 diabetes advances, and then we ll discuss the different types of medications used to manage blood sugar. Type 2 diabetes develops over time, and it doesn t stay the same over time. That s why treatment plans may also change as the condition advances. Impaired glucose tolerance and insulin resistance usually develop for several years, before advancing to diabetes. It may take several more years for diabetes to be diagnosed. It s important to note that this diagram shows what typically might happen in people with type 2 diabetes over time. This won t always happen, and early treatment and careful management may prevent or delay the onset of the complications shown in this diagram. Traditionally, a slow-paced, stepwise approach has been used in type 2 diabetes care, starting with diet and exercise upon diagnosis. By the time a person is started on diabetes pills, he or she may have already developed complications in the small blood vessels, such as damage to the eyes, kidneys, and nerves. Insulin therapy is too often started when diabetes is more advanced. Usually, people have had the condition for 10 to 15 years before adding insulin to their treatment plan. However, if your body is no longer making enough insulin, it may be better to start insulin therapy earlier rather than later. Insulin is not a last resort. In fact, the ADA identifies it as the most 23

23 effective way to control blood sugar when diet, exercise, and other non-insulin therapies are no longer enough. Now let s take a closer look at the different treatment options. But first, a poll question. 23

24 True or False? Insulin can help with better control of diabetes. If you believe this statement is true, please select True now. If you believe this statement is false, please select False. The correct answer is True. As we ve discussed, diabetes may get harder to manage over time, which means your treatment plan may need to change. In fact, adding insulin may help to better control blood sugar, even if you re still active and otherwise healthy. 24

25 People without diabetes typically secrete insulin in 2 different ways. The first is called basal insulin, which is steadily produced 24 hours a day. Basal insulin prevents the production of too much blood sugar during the night, and it maintains a nearly constant level of insulin throughout the day. The second is called prandial, or mealtime, insulin, which is produced in response to eating food. Prandial insulin limits increases in blood sugar that happen after a meal. 25

26 There are different types of replacement insulin that you can take by injection. Prandial insulins include rapid-acting and regular or shortacting insulins. Rapid-acting insulin starts to work in about 5 minutes after injection and continues to work for 2 to 4 hours. Regular or short-acting insulin begins to work within 30 minutes after injection and continues working for up to 6 hours. Basal insulins include intermediate- and long- acting insulins. Intermediate-acting insulins usually begin to work in 2 to 4 hours after injection and continues to work for about 12 to 18 hours. And long-acting insulins begin to work in 2 to 4 hours after injection and can work for up to 24 hours. Premix insulin is a mixture of 2 insulins in predetermined proportions. It combines an intermediate-acting and a rapid- or short-acting insulin in 1 dose. 26

27 Important safety information about insulin: All medications have side effects. The most common side effect of insulin is low blood sugar. Some people may experience symptoms such as shaking, sweating, fast heartbeat and blurred vision, while some experience no symptoms at all. That s why it s important to check your blood sugar often. 27

28 There are several devices that can be used to deliver insulin. When using a vial, or bottle, the user fills a syringe with insulin from the vial and, through a needle, injects the contents of the syringe under the skin. Another option is an insulin pen. The pen has a view window that lets you see and set your insulin dose. It is either prefilled with insulin or contains a cartridge of insulin, and features a push-button injection system. And remember: Many people using a pen or syringe are surprised at how small the needle really is. Your Health Care Provider may also prescribe a pump as your insulin delivery method. The pump is a device that pumps insulin continuously through plastic tubing attached to a needle under the skin. Consult your Health Care Provider about proper injection technique for the device you re using. 28

29 Here is some additional information about insulin that you may not know: Many insulins do not require refrigeration, always check the storage conditions for all your medications Some insulins come in pens Insulin pens are generally easy to use but if you have vision (or other) problems, have someone help you Traveling with insulin is manageable check with your healthcare professional about how to dose when crossing time zones Insulin can be injected with a very small, thin needle. 29

30 Now it s time for another poll question; this one allows you to type your answer in the Q & A box at the bottom of your screen. Remember, no one except you and I can see what you are typing. What are the benefits of going on insulin? I ll let you take a few minutes to type in your answers. Everyone may identify different benefits of starting insulin, but one of the most important benefits of going on insulin is that insulin is the most effective way to help control blood sugar when diet, exercise, and oral anti-diabetes medicines are no longer enough. 30

31 So what are your next steps for better control? Be sure to talk to your healthcare provider today about how to achieve your goals. Since you and your Health Care Provider will have so much to share with each other, it s important that you have an open line of communication. Being open and honest with him or her is very important when it comes to managing your diabetes, so make sure to ask any questions that you might have. Asking questions will show your Health Care Provider that you are taking an active role in managing your blood sugar. 31

32 Before I get to your individual questions, I do want to share with you some information about additional on-line education sessions that you can sign up for to learn how to get better blood sugar control. You can sign up for these free sessions just as you did for today s session, by going to In The Highs and Lows of Blood Sugar you can get more information about blood sugar control. In Making Healthy Choices you ll learn about healthy meal planning, carbohydrate counting, exercise, and more. And in Guide to Routine Diabetes Tests and Meds you ll find out more about regular in-office diabetes tests and diabetes medications. Always remember that ongoing education is an important part of managing your diabetes. You can sign up for these and other CDE HELP Team sessions by using the convenient website link that will be displayed on-screen after this session. I will now go over the answers to your individual questions that you sent into the Q & A box. 32

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