Re-Education And Carbohydrate Counting Training

Transcription

1 Page 1 of 15 Re-Education And Carbohydrate Counting Training REACCT Guide 1 Introduction You have been recommended to attend the REACCT group and we are delighted that you have chosen to accept this support. This booklet will help you to develop a greater knowledge and understanding of your diabetes. It aims to provide you with the skills to achieve realistic short term and long term management goals, and to help you to estimate the amount of carbohydrate at each meal and inject the correct dose of insulin. The REACCT support is via an informal group that is divided into 2 sessions, 4 to 6 weeks apart. Each session lasts at least 2 hours and is led by a Diabetes Specialist Nurse and a Diabetes Specialist Dietitian. It is important that you attend both sessions to complete the education programme. REACCT sessions are for people with type 1 diabetes who are on a multiple daily insulin injection regime (basal /bolus). The sessions are also a requirement for those being considered for insulin pump therapy. Group members should be motivated to test blood glucose levels before meals, bed time and when necessary 2 hours post meal if working towards carbohydrate counting. The sessions will help to develop the confidence and knowledge to respond appropriately to the blood glucose levels. Reference No. GHPI1113_03_15 Department Diabetes Review due March 2018 Aims and objectives of REACCT To update any previous information that you may have been given and to inform you about the most recent ways of treating diabetes whilst respecting the individual s lifestyle and willingness to change. The aims of REACCT are to: Give you the choice for flexibility in your food options Work towards and achieve consistent target blood glucose levels Review personal HbA1c (glycosylated hemoglobin) level and work towards achieving target level

2 Page 2 of 15 Hear and share peer experiences Calculate the correct dose of insulin in relation to the estimated carbohydrate content of the meal. In this session we will discuss: REACCT insulin regime Blood glucose Insulin Insulin dose adjustment Injection technique, hypoglycaemia Carbohydrates Healthy eating, food labels Typical day 500 rule:ratio of insulin to carbohydrate Contact numbers & acknowledgments. Target blood glucose levels are: 4-7 mmol/l Before meals 8mmol/L Before bed - if below 8mmol/L we recommend you have a snack These levels depend on individual circumstances such as loss of hypo awareness; this may mean targets need to be set higher. HbA1c (glycosylated hemoglobin) The HbA1c test indicates your blood glucose levels for the previous 2 to 3 months. The HbA1c measures the amount of glucose that is being carried by the red blood cells in the body. The way that long-term blood glucose control is reported has changed. This will make it standardised globally. HbA1c gives a guide to the blood glucose level over the previous 8 to 12 weeks. It is expressed in mmol/mol rather than a percentage. The recommended HbA1c for people with diabetes is between 42-53mmol/mol or (6.0 to 7.0%) in old units. At this level long term complications will be reduced / prevented.

3 Page 3 of 15 HbA1c conversion (%) (mmol/mol) What affects blood glucose levels? Food - the Diabetes Dietitian will discuss this with you Insulin Injection sites Mental or physical stress Mobility Activity and exercise Illness Heat/cold Alcohol Medications Hormones. The Diabetes Nurse will discuss the above in more detail. Insulin Note the expiry date of the insulin Do not inject insulin that is out of date It is important to store it at the correct temperature Insulin not in use should be stored in the fridge Do not freeze. Insulin which is in use should be kept at room temperature for 1 month, after which it should be discarded.

4 Page 4 of 15 Types of insulins used Rapid acting Analogue Insulin (bolus) given with meals: NovoRapid Humalog Apidra. Rapid analogue insulin s begin to work 10 to 15 minutes after injecting and last between 2 to 4 hours. These insulins are known as the bolus insulins and are the food/meal related insulins and should be injected immediately before or after the meal. The aim of this process is to mimic the body s normal production of insulin after a meal. You will learn how to calculate the bolus dose of insulin in order to match the food in the carbohydrate counting section. Long acting analogue insulin (basal) lasts for approximately 18 to 24 hours Levemir Lantus. 24 hour insulins Lantus and Levemir insulin work over a 24 hour period and are usually injected once a day. However, Levemir can be injected twice a day. It is important the basal insulin s are administered at the same time every 24 hours. Basal insulin s are not meal related and work as background insulin to control blood glucose levels between meals and overnight.

5 Page 5 of 15 Adjusting Insulin s How to determine the correct basal insulin dose? The aim is for the basal insulin to keep the blood glucose stable overnight, the blood glucose level before bed and before breakfast should be within 1 to 3 mmol/l of each other. Should your blood glucose reduce more than 3 mmol/l overnight, reduce your basal insulin by 2 units and review again after 2 days. Increase basal insulin if your blood glucose is consistently above target across the day. Basal insulin will need to be increased between 2 to 4 units depending on blood glucose levels and the individual. If your blood glucose is above target before bed and within target before breakfast, increase evening meal insulin bolus but decrease basal insulin if the blood glucose level reduces more than 3 mmol/l overnight. If your fasting blood glucose is regularly elevated more than 3mmol/L from bedtime consider if: You are having rebound high blood glucose levels from overnight hypoglycaemia (See next paragraph) You need to increase basal insulin You are experiencing dawn phenomenon (See next paragraph).

6 Page 6 of 15 Overnight hypoglycaemic events If you think you are experiencing overnight hypoglycaemic episodes (blood glucose below 4 mmol/l) check your blood glucose level between 3:00 am and 4:00 am. If you are having hypos and there is no other obvious reason for this (such as alcohol, previous day exercise or extra insulin before bed) you should reduce the basal insulin dose to prevent recurrence. Dawn Phenomenon In some people, hormone levels cause the blood glucose levels to rise quite sharply just before waking in the morning. This is called the Dawn Phenomenon, which may cause problems achieving acceptable blood glucose levels before breakfast. The diabetes team may advise changing the type and timing of your basal insulin injection to correct this. Injection technique Insulin should be injected into the fatty tissue (subcutaneous fat and not lean muscle) beneath the skin at a 90 angle. The recommended injection sites are the abdomen, thighs and buttocks. Injection sites should be varied and rotated to prevent hard fatty lumps (lipodystrophy) as these will affect the absorption of the insulin. If you notice lipodystrophy, change your injection site. You may need to reduce your insulin dose and test your blood glucose more frequently as moving to new sites will allow the insulin to be absorbed more effectively resulting in lower blood glucose levels. The diagram below shows the acceptable injection sites. Injection needle size It is important to inject with the correct size of needle, this will also affect the absorption of the insulin. We recommend 4 to 6 mm needles regardless of individual weight.

7 Page 7 of 15 Hypoglycaemia (Hypos) A hypo is when your blood glucose drops too low (below 4mmol/L). The saying to help you remember this is 4 is the floor. Hypoglycemia can occur when you are treated with insulin or some diabetes tablets due to the following reasons: Physical activity Too much insulin/tablets Too little food/missed/late meals Alcohol Hot weather Loss of weight Sometimes no obvious cause. Signs and symptoms of hypoglycaemia A hypo must be treated promptly and can be mild, moderate or severe. Hypoglycemia warning signs and symptoms vary from person to person. Common symptoms are: Hunger Shaky Tingling lips Sweating Headache/light headedness Vision changes Difficulty with speech Lack of concentration Change in behaviour/mood. Loss of hypoglycaemia warning symptoms: If you have lost your warning symptoms it is advisable not to drive or to operate machinery. It is important to check blood glucose frequently and discuss blood glucose target levels with the diabetes team. Remember always carry a Diabetes identification card or wear a Medic Alert bracelet or necklace.

8 Page 8 of 15 Treatment of hypoglycaemia Always treat a hypoglycaemia immediately. Rapid Acting Carbohydrate: Rapid Acting CHO Amount CHO (g) Lucozade (original) 100mls 18g Coke (Full sugar) 180ml or ½ can 18g Fruit Juice 180mls 18g Glucose tablets 6 18g Glucotabs 5 20g Glucogel 2 tubes 20g Check blood glucose after 10 minutes. If the blood glucose level is still less than 4 mmol/l, repeat fast acting glucose. DO NOT take Chocolate, Milk or Biscuits as first line treatment for a Hypo. These foods do not act quickly enough as the fat content slows down glucose digestion. Follow the fast acting glucose with a snack Half a sandwich Fruit Cereal Biscuits and milk Next meal if due. The REACCT approach to food Starchy foods Sugary foods Fruit and fruit products Milk and milk products Bread Cereals Pasta Rice Potatoes Sweets Chocolate Puddings Desserts Sugar Jams and preserves Fresh fruits Tinned fruits Dried fruits Fruit juices Milk Yoghurts White sauces Ice cream

9 Page 9 of 15 Carbohydrates affect blood glucose levels. The amount of insulin the body needs is determined by how much carbohydrate has been eaten. Question: How can you eat what you what you want? Answer: By counting carbohydrates in your meals and matching the dose of insulin to the amount of carbohydrate (CHO) eaten. Question: Which foods don t need to be counted? Answer: Protein foods - meat, fish, eggs, cheese, poultry (unless coated with breadcrumbs or pastry), green vegetables and salad, fats and oils. Carbohydrate counting aims to provide flexibility and freedom. This way of eating does not mean that we encourage the unhealthy alternatives all of the time. You can eat what you want but remember the healthy eating recommendations. Healthy eating guidelines: Eat less fat, particularly saturated Try to eat some oily fish at least once per week Eat regular meals containing starchy foods throughout the day Aim for 5 portions of fruits, vegetables and salad a day Eat less sugar, sugary foods and drinks Keep alcohol to safe limits Eat less salt Maintain a healthy weight Thirty minutes sustained physical activity on at least 5 days a week. Looking at food labels When you start to look at tinned and packaged foods you should look at the total carbohydrate content of the product, with a view to working out how much carbohydrate 1 portion contains for example a can of Heinz Baked Beans contains.

10 Page 10 of 15 Example of food label Typical Values Per 100g Per Serving/portion (207g) Energy 309kJ/73kcal 640kJ/151kcal Protein 4.9g 10g Carbohydrate 12.9g 26.7g (of which sugars) 5.0g 10.4g Fat 0.2g 0.4g (of which saturates) trace trace Fibre 3.8g 7.9g Sodium 0.3g 0.7g As you can see from the label the total amount of carbohydrate portion for 1 person would be 26.7g (27g). You should start to consider making a list of favourite meals that you have on a regular basis at home, and begin to work out their carbohydrate content in your portion of that meal. Start to make a crib list of preferred meals with a column for the carbohydrate content. This will help you to remember how much carbohydrate you are going to eat each time you have that particular meal (whether you have it at home or eating out). Use the Carbs & Cals book to estimate the carbohydrate content of the meal. Also, look at the snacks and puddings that you like to eat on a regular basis, for example fruit, yoghurt, toast, muffins, crisps and chocolate. Start working out their carbohydrate values. Carbohydrate values have to be added to the carbohydrate content of the main meal. Breakfast may not be as varied as other meals throughout the day so this may be a good starting point for calculating carbohydrate and insulin requirements. Takeaway meals or meals out however are a bit more difficult to estimate. To help you to calculate the carbohydrate content of your meals please see the list below:

11 Page 11 of 15 Scales and special weighing scales Rosemary Conley scales Carb counting books e.g Collins Gem Carb counters Carbs and Cals book by Chris Cheyette and Yello Balolia Food models and packaging Website: Bournemouth Diabetes Centre Phone apps: Diabetes UK Tracker, Carbs and Cals Picture guide Restaurant websites Website: Diabetes Uk.Org A Typical Day Breakfast Porridge with milk 28g 1 med slice granary toast + margarine 20g +1 tsp jam 10g 1 glass (100 mls) fruit juice 10g Total grams of carbohydrate 68g Lunch 6 Bread baguette + margarine 60g Ham 0g Salad 0g 1 Apple 15g Total grams of carbohydrate 87g Evening Meal Chicken breast 0g Green vegetables 0g Pasta (200g cooked) in sauce 60g 1 slice cheesecake 30g Total grams of carbohydrate 90g Grams of Carbohydrate

12 Page 12 of 15 Activity: Using the carbohydrate portion guide provided, calculate the next 2 typical days. Day 1: Breakfast Grams of Carbohydrate Bowl of bran flakes (40g weight) 1/3pt milk Lunch 2 med slices white bread + margarine 1 2 tin baked beans 1 diet yogurt (small) Evening Meal 1 2 pizza (7 thick base) Salad Jacket potato(picture 483) Day 2: Breakfast A bacon sandwich (x 2 thick sliced bread) Lunch Bowl soup (vegetable, medium) 1 Bread roll, medium 1 med banana Evening Meal Beef curry- vindaloo takeaway Rice (picture 14) Naan bread- large, takeaway Grams of Carbohydrate

13 Page 13 of 15 How much insulin do you need with meals? It is important that your basal insulin dose is correct before calculating and using a ratio. Calculating your ratio - The "500 Rule" This is a good starting point that works for many people when calculating the insulin: carbohydrate ratio. Divide 500 by your Total Daily Dose (TDD) of insulin to get a ratio. For example: 8 units + 10 units + 12 units of bolus (quick acting) insulin with meals + 20 units of basal (long acting 24 hour) insulin = 50 units TDD Therefore: 500/50 = 10 This is a 1 to 10 ratio. This means that for every 10g of carbohydrate eaten you would inject 1 unit of insulin. For example 60g carbohydrate requires 6 units of insulin and 100g carbohydrate requires 10 units of insulin.

14 Page 14 of 15 There are half unit increment insulin pens if needed. The insulin to carbohydrate ratio that you start off with may not be the correct ratio. It is a starting point, a basis on which to build the foundation for your true ratio. As everyone is an individual, we suggest that you adjust the ratio to obtain the best glucose levels for you. This can also vary at each mealtime e.g. the breakfast ratio maybe completely different to your evening meal ratio. If you get low blood glucose levels, increase your ratio, for example 1 unit of insulin to 10grams to 1 unit of insulin to 12 grams if you get high blood glucose levels, reduce your ratio, for example 1 unit of insulin to 10 grams to 1 unit of insulin to 8 grams. Adjust ratio with previous meal to affected blood glucose. For example: We recommend injecting your meal bolus after eating as you may not eat the whole meal. It is wise to consider if you are planning exercise as you will probably require less insulin. Exercise and correction doses will be discussed at the second session. Fill in the food diary before attending the next session. You will know if the ratios are correct as the blood test before meals will be within 2mmol/L of the previous blood test or thereabouts. The key to successful carbohydrate counting takes time, effort, patience and blood glucose testing. Good luck and see you at the next session! Contact information Diabetes Specialist Nurse and Diabetes Specialist Dietitian Gloucestershire Royal Hospital Tel: Cheltenham General Hospital Tel: Diabetes Specialist Nurse Diabetes.nurses@glos.nhs.uk Diabetes Specialist Dietitian Diet.diabetes@glos.nhs.uk

15 Page 15 of 15 Further information Driver and Vehicle Licensing Agency Orchard Street Swansea SA99 1TU Website: Diabetes UK 10 Queen Anne Street London W1G 9LH Website: Acknowledgements Carbs and Cals by Chris Cheyette and Yello Balolia The First UK Injection technique recommendations 2 nd Edition 2011 Website: Website: Date of next session: Notes: (Space for you to make your own notes)