Classification/ Types of Diabetes:

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1 DIABETES EDUCATION FOR ADULTS IN THE OUTPATIENT SETTING: BEYOND THE BASICS OF CARBOHYDRATE COUNTING Alison Kaplanes MS,RD,LDN,CDE Joslin Clinic at the BID Needham, MA (Sodexo) Private Practice Waltham, MA Corporate Nutrition Consultant OBJECTIVES: To understand the most current diagnostic criteria for diabetes as well as current terminology related to diabetes. Put into practice the most current medical nutrition therapy (MNT) guidelines for adults with type 1 and type 2 diabetes. State the AADE7 self care behaviors used in diabetes education. Understand the various types of medications available to treat diabetes, including modalities (vials, pens, pumps) 2 HOW MANY PEOPLE HAVE DIABETES? United States, all ages (CDC 2010 data): Total: 25.8million people (8.3% of the population) have diabetes Diagnosed: 18.8million Undiagnosed: 7 million Pre-diabetes: 79 million American 20 years & older. RDs need to stay current with diabetes management 3 Classification/ Types of Diabetes: Pre diabetes or At Risk of Diabetes Type 1 diabetes (5-10%) Usually autoimmune More commonly diagnosed in children/ young adults Type 2 diabetes (90-95%) Insulin Resistance & insulin secretory defect Most common in adults but on the rise in children & adolescents Gestational diabetes(~ 5% of all pregnancies ) Goes away but ~10% later diagnosed with type 2 diabetes Secondary Surgically or medically caused ADA Criteria for the diagnosis of diabetes 2010 ADA Criteria for Increased Risk for diabetes (prediabetes) 5 An A1C of 6.5% * OR Random plasma glucose 200mg/dL plus symptoms of DM (polys, unintentional weight loss) OR An Fasting plasma glucose (FPG) 126mg/dL * OR 2 hour PP 200mg/dL * (75-gram oral glucose tolerance test) * Repeat on separate day 6 An A1C: 5.7%- 6.4% OR Fasting plasma glucose: mg/dL Impaired Fasting Glucose OR 75-gram oral glucose tolerance test: 2 hour PP: mg/dL Impaired Glucose Tolerance 1

2 Progression to type 2 diabetes SOMEONE WITHOUT DIABETES Insulin resistance BLOODSTREAM CELL Hyperinsulinemia Compensated insulin resistance Normal glucose tolerance Abnormal glucose tolerance β-cell failure 7 Type 2 diabetes Insulin resistance Hepatic glucose output Insulin secretion Adapted from Kruszynska Y, Olefsky JM. J Invest Med. 1996;44: JOSLIN S CENTER FOR INNOVATION IN DIABETES EDUCATION TYPE 1 DIABETES TYPE 2 DIABETES BLOODSTREAM CELL BLOODSTREAM CELL JOSLIN S CENTER FOR INNOVATION IN DIABETES EDUCATION JOSLIN S CENTER FOR INNOVATION IN DIABETES EDUCATION PREVENTION OF TYPE 2 DIABETES Diabetes Prevention Program (DPP) Results were published in New England Journal of Medicine, 2002 DPP: 27 center study to determine if type 2 diabetes could be delayed or prevented 3,234 overweight participants with prediabetes 11 Diabetes Prevention Program (DPP) 1 st Group: Lifestyle Intervention Intensive training in diet, physical activity & behavior modification Goal: 7% weight loss, 150+ minutes of PA per week 2 nd Group: Metformin (850mg BID) Received some information about diet and exercise 3 rd Group: Placebo pills Received some information about diet and exercise 4 th Group: Treated with Rezulin (discontinued due to liver damage) 12 2

3 DPP RESULTS: Lifestyle Intervention Group: Reduced risk of developing diabetes by 58% by losing 7% of their weight and exercising 150 minutes per week. ** 60 years and older: reduced risk of diabetes by 71%! Metformin Group: reduced their risk of developing diabetes by 31%. RDs can play a major role in prevention! 13 Pre-diabetes or At risk for diabetes Educate your patients. Weight Loss: 7% of body weight Regular exercise: at least 150 minutes per week of moderate activity (walking) Heart healthy nutrition, including fiber rich foods (DRI: 14g/1000kcal or 20-35g/day) Regular follow up important for success 14 Potential complications of diabetes Initial treatment for all patients with diabetes: 15 Acute: Low Blood Glucose Hypoglycemia High Blood Glucose Hyperglycemia Chronic: Microvascular Eye Disease Retinopathy Kidney Disease Nephropathy Nerve Disease Neuropathy Macrovascular Heart and vessel disease Joslin s Center for Innovation in Diabetes Education 16 Medical Nutrition Therapy (MNT) Physical activity Blood glucose monitoring DM self management education * Recommendations & treatment should be individualized * Joslin Guidelines for Pharmacological Management of Type 2 DM Comments/ fears of newly diagnosed: Medical Nutrition Therapy (MNT) for adults with diabetes Do I have diabetes? I m afraid of long needles. My uncle/ mother/ cousin lost his leg from diabetes. 17 Etiology of type 1 and type 2 diabetes are different, but MNT goals are similar. Sources: 1. Joslin 2. American Diabetes Association 3. Academy of Nutrition Dietetics 18 I switched to sugar-free ice cream. I ve cut out all bread & pasta. I can t afford to shop at a health food store. I have to eat different from my family now. My doctor told me to avoid fruit. 3

4 GOALS OF MNT for type 1 and type 2 diabetes: RD NUTRITION ASSESSMENT: Academy of Nutrition & Dietetics Evidence based Nutrition Practice Guidelines Achieve & maintain: Normal blood sugars Lipid profile that reduces risk for CVD Blood pressure in ideal range Prevent or slow rate of chronic complications Optimal calories & nutrition for good health Maintain the pleasure of eating, by only limiting food choices when indicated by scientific evidence. (ADA) Food intake (focus on carbohydrates) Anthropometrics: weight management Medications Metabolic control: blood sugar, lipids & blood pressure Physical activity RD NUTRITION INTERVENTION: Academy of Nutrition & Dietetics Evidence based Nutrition Practice Guidelines RD NUTRITION INTERVENTION: Academy of Nutrition & Dietetics Evidence based Nutrition Practice Guidelines 21 TAILOR EDUCATION TO PATIENT S Level of understanding Willingness/ readiness to change Personal needs Ability to make changes Personal and cultural food preferences 22 VARIETY OF INTERVENTION OPTIONS: Calorie reduction for weight loss Carbohydrate counting- basic or advanced Plate method Simple meal plans Exchanges Insulin to carbohydrate ratios Healthy food choices Physical activity Behavioral strategies Don t teach diabetic diet, rather CARBOHYDATES: the focus Heart Healthy eating plan that is consistent in carbohydrates. Whether on MNT alone, glucose lowering medications or fixed insulin doses: meal & snack carbs should be consistent day to day

5 25 CARBOHYDRATES: ~ % of total calories from carbohydrate * Minimum of 130grams of carbohydrate per day Education Focus: 100% break down into sugar in the bodyregardless of source Quality of carb choices for optimal nutrition Consistency: amount of carbs at meals & snacks Match insulin to carbohydrates consumed 15 GRAMS CARBOHYDRATE Starch 1 slice bread 1/3 cup pasta 3/4 cup dry cereal 4-6 crackers 1/3 cup rice Fruit 1 small piece 4oz juice Milk/ yogurt 8oz low-fat 6oz yogurt Desserts / Other 2 small cookies 1 Tbsp sugar jam, honey 1/2 cup frozen yogurt 26 The TOTAL AMOUNT OF CARBOHDRATE consumed at meals, regardless of whether the source is sucrose or starch is the primary determinant of postprandial blood sugars. USE CARBOHYDRATE INFORMATION FROM LABELS Locate serving size Determine grams of carbohydrate per serving Grams of sugar and fiber are part of total carb. Insert label containin g at least 15 grams carb, but not 15, 30,or 45 JADA 2010; 110: Starter Meal Plan- consistent carbs Advanced Carbohydrate counting CARB GRAMS PER MEAL CARB GRAMS PER SNACK Women grams 0-15grams Used for intensive management Multiple daily injections of insulin (basal plus bolus mealtime insulin) Insulin Pump 29 Men & Active Women Active Men grams 0-30grams grams 0-30grams For patients who are willing/ able to intensify their carb counting skills & treatment Provides FLEXIBILTY in how much carbohydrate can be consumed. 30 5

6 Advanced Carb counting: Using insulin to carbohydrate ratio Advanced Carb counting: Using insulin to carbohydrate ratio Insulin to Carb ratio: Number of grams of carbohydrate that is covered by 1 unit of short or rapid acting insulin Calculate Total Daily Dose of Insulin (TDD) / TDD= Insulin: Carb ratio Example: 13 units Lantus + 17 units rapid insulin daily (TDD= 30units) = 15 Insulin:Carb 1unit: 15grams 32 Example: Insulin: Carb= 1 unit: 15grams Breakfast: 1 cup cooked oatmeal: 30grams 1 tablespoon honey: 15 grams ¾ cup blueberries: 15grams Hardboiled egg: 0 grams carb Total carbs in this meal: 60grams 60 15= 4 units Patient would take 4 units of rapid insulin (Novolog/ Humalog/ Apidra) to cover this meal Gradually Build Carb Skills 33 Fine-tuning/glycemic index Carbohydrate-to-insulin ratio Count carb grams / label reading Count carb servings (1 serving = 15 g) Portion sizes weights/measures Identify which foods are carbohydrates Physical Activity Healthy eating principles heart healthy 34 In teaching patients their diets, I lay emphasis first on carbohydrate values, and teach to only a few, the values for protein and fat. E. P. Joslin, MD PROTEIN IS PROTEIN NEEDED AS PART OF A SNACK? % of total calories (DRI) if normal renal function Education Focus: Minimal effect on blood sugar levels, if adequate insulin on board. Protein still has calories! Teach portion control Choose lean proteins 36 No! Research does not support the need for protein with snacks to decrease the risk of hypoglycemia 6

7 FAT: ALCOHOL Considerations 37 Saturated fat: <7% of total calories (teach grams to limit per day) Trans fat: Minimal to none Education Focus: Minimal effect on blood sugar levels Teach healthy vs. unhealthy fats Portion control with healthy fats for weight management High fat meals can slow digestion & the rise in blood sugars (may need to adjust meal time insulin dose/ timing). No need to routinely discourage alcohol If adults chooses to drink One alcohol equivalent for women, two for men (per day) Drink with food to reduce risk of hypoglycemia Recognize risks: Hypoglycemia Added calories /carbohydrates Excess / abuse 38 Diabetes self management education (DSME): American Association of Diabetes Educators Self care behaviors (AADE- 7) 39 Defined as The ongoing process of facilitating the knowledge, skill and ability necessary for diabetes self-care Empower patients through education to improve clinical outcomes & quality of life. 40 The AADE believes that behavior change can be most effectively achieved by using the AADE-7 framework AADE website 2/6/ Healthy Eating 2. Being Active 3. Monitoring 4. Taking medication 5. Problem solving 6. Reducing risk 7. Healthy Coping BEING ACTIVE: PHYSICAL ACTIVITY RECOMMENDATIONS: MONITORING: WHY SELF MONITOR BLOOD GLUCOSE (SMBG)? 41 BENEFITS OF REGULAR PA: Type 2 diabetes : both aerobic and resistance training improve glycemia; improves insulin sensitivity Type 1 and type 2: Decreased risk of CVD Improved wellbeing Weight management RECOMMENDATIONS: 150 minutes of aerobic activity per week + resistance/ strength exercises 3x per week. Teach safety guidelines for patients at risk of hypoglycemia Address barriers: physical, psychological, time limitations 42 RD can use results to evaluate effectiveness of MNT. Gather information / blood sugar patterns Teaches patient how food, exercise, stress, medication affect BS levels. Helps with need for medication (type and or dose) adjustments. Patients with DM may also monitor: blood pressure, urine ketones & weight. 7

8 Blood Sugar Goals (ADA/ Joslin): BLOOD GLUCOSE RECORD Fasting & premeal glucose: mg/dL Bedtime 2- hour post prandial glucose: < 180mg/dL Bedtime glucose: mg/dL Hemoglobin A1C: <7% *exercise *exercise GLYCOSYLATED HEMOGLOBIN / A1C Normal <5.7% Target A1C Less than 7% High A1C Above 7% 46 HEMOGLOBIN A1C: MEAN PLASMA GLUCOSE A1C (%) Mg/dL Patient's blood sugar record Recent A1C= 7.8 % (average BS ~ 170) Patient's blood sugar record Recent A1C= 6.7 % (average BS ~ 140) Bedtime Bedtime

9 49 CONTINUOUS GLUCOSE MONITORING SYSTEM (CGMS) Sensor inserted into skin Measures glucose in interstitial fluid every 5-10 minutes Pt still has to check BS BENFITS OF USING CGMS: Provides over 250 blood per day to track patterns Shows what direction the blood sugars are going & rate Alerts for glucose highs & lows. 50 Type 1 Diabetes MEDICATION: Options for the treatment of diabetes Insulin Type 2 Diabetes Insulin Oral medication Non-insulin Injectable: Symlin Non- insulin Injectable: Byetta Bydureon Victoza Symlin Oral medication options- Type 2 diabetes Class BRAND NAME Primary mechanism of action Biguanides Insulin secretagogues Alpha glucosadase inhibitors TZDs Bile acid sequestrant Centrally Acting 51 Glucophage, Glucophage XR, Glumetza Amaryl, Glucotrol, Glyburide Prandin, Starlix Precose Glycet Actos Avandia- limited use Welchol Cyclocet Decreases amount of glucose released from the liver Helps pancreas release more insulin Slows the absorption of carbohydrates in the stomach and intestines Reduces insulin resistance (muscle) Type 2 diabetes: Dipeptidyl Peptidase IV Inhibitor (DPP-4 Inhibitors) Introduced to market: 2006 Oral Medication (Januvia, Onglyza, Trajenta) Weight neutral No hypoglycemia Mechanism of Action: Stimulates pancreas to produce insulin (glucose dependent). Stimulates liver to release glucose if BS are low and reduces hepatic glucose production when BS high 52 Non Insulin Injectables: Incretin memetics & synthetic analogs Matching Pathophysiology with Treatment 53 Introduced to market: 2005 Taken by Injection : Byetta- BID Victoza- 1x/day Bydureon: NEW!! once a week injection Symlin (type 1 & 2) taken with meals. Possible weight loss No hypoglycemia Mechanism of Action: Stimulates glucose dependent insulin secretion Suppresses sugar production from liver Slows gastric emptying May decrease appetite/ weight loss Matfin G. Diabetes mellitus and the metabolic syndrome. In: Pathophysiology. G Matfin, Rd Joslin Diabetes Center 9

10 INSULIN Insulin pump Taken as an injection (vial & syringe or insulin pen) or insulin pump. User enters: 55 Supplements or replaces the body s own insulin Needs to be viewed as a positive step, not a failure Being used much earlier in disease process than in years past 56 Continuous flow of rapid acting insulin 1.Blood sugar 2.Grams of carbohydrates eaten Insulin options : Basal- Bolus Insulin for patients on multiple daily injections 57 Image: MNT for patients taking insulin Integrate insulin with eating and exercise habits Problem solving: Treat hypoglycemia using 15:15 Rule Low blood sugar <70mg/dL (<50mg/dL= SEVERE low) Synchronize food with insulin Conventional Therapy Eat consistently, adjust insulin Intensive Therapy Integrate insulin into lifestyle Adjust insulin to compensate for lifestyle 1.Eat or drink 15 grams of fast acting carbohydrate* 3-4 glucose tablets 1 tablespoon sugar or honey 4oz juice 2 T raisins 6 oz. regular soda 2.Re-test blood sugar after minutes 3.Follow with a meal or snack. 60 * Pt to consume 30grams of carbohydrate if severe low. 10

11 Reducing Risk: 6 Tests patients should know about Diabetes Apps: TEST/ EXAM TARGET How often? A1C < 7% (for most) 2-4x per year Blood Pressure < 130/80 At least yearly Diabetes App reviews: 61 LDL cholesterol Microalbuminuria (measure of protein in urine/ kidney function) Dilated eye exam Foot exam <100 (may be lower for some) Less than 30 At least yearly Annual Every visit to MD office Daily foot checks 62 Blood sugar & carbohydrate tracking Medication compliance Track weight, physical activity Blood pressure Diabetes Resources: To sum it up 63 Academy of Nutrition & Dietetics EAL American Diabetes Association: Diabetes Care- Clinical Practice Recommendations (online) Joslin Clinical Guidelines (online) 64 Treatment for diabetes is constantly evolving- RDs need to stay current MNT is an essential part of prevention & treatment of diabetes. No one approach to diabetes MNTneed to individualize. RDs can empower patients with diabetes through education, including self management skills. THANK YOU! ALISON KAPLANES, MS, RD, LDN, CDE INFO@ALISONRD.COM 65 11