•1
Palm Beach Diabetes and
Endocrine Specialists
Workshop 1
•2
Feelings you may be
experiencing…
Shock
Grief
Denial
Anger
Frustration
Fear
Resistance
Disappointment
Anxiety
Embarrassment
Depression
Guilt
Irritability
•3
Feelings are Normal
• Feelings arise from thoughts about loss:
loss of freedom
loss of control
loss of who you were before diagnosis
• Problems arise when strong feelings get in the
way of taking care of yourself
CHOOSE ACCEPTANCE
•4
We have choices in life…
So choose to modify your:
• Attitude:
• Thinking:
• Behaviors:
“I want to”
“Yes I can!”
Eating
Activity
Stress
•5
Why Bother?
1.
2.
3.
4.
5.
6.
7.
To feel better
Improve relationships
To relieve the anxiety of loved ones
To relieve your own anxiety
To have a sense of control
To set an example for family and friends
To have a better quality of life
WHAT IS YOUR MOTIVATION?
•6
Behavior Modification
Create new habits in different areas of your life:
1. Eating
2. Exercising
3. Stress Management
•7
Diabetes Is…
Common
nearly 26
million people in
the US
Chronic
Controllable
A lifelong condition
Good management
depends on YOU!
•8
What is Diabetes?
• Diabetes results when:
• The body cannot use food properly and glucose
(sugar) builds up in the blood
• Diabetes happens when:
- The body cannot make insulin
- Insulin does not work properly (Insulin Resistance)
•9
What is Insulin?
• Insulin is a hormone made by a gland called the
pancreas
• After we eat, food is broken down into glucose (sugar)
• When blood sugar levels rise, insulin is released from
the pancreas
• Insulin allows sugar to enter cells where it is used for
energy
• Glucose is to your body like gasoline is to your car
•10
How Insulin Works
1. Food enters
stomach
4. Pancreas
releases insulin 5. Insulin unlocks
receptors
6. Glucose
enters cell
3. Glucose enters
bloodstream
2. Food is converted
into glucose
•11
Pancreas
Cell
Insulin
Receptor
Glucose
•12
Diagnosis
Fasting Plasma Glucose Test
Less than 100mg/dL
Normal
100 – 125 mg/dL
Pre-diabetes
126mg/dL or greater
Diabetes
Oral Glucose Tolerance Test
Less than 140 mg/dL
Normal
140 – 199 mg/dL
Pre-diabetes
200mg/dL or greater
Diabetes
or a random blood sugar of 200 or more with symptoms
•13
Types of Diabetes
• Pre- Diabetes
• Type 1
• Late Onset Type 1
• Type 2
• Gestational
• Secondary Causes
•14
Pre-Diabetes
•
•
•
•
Nearly 79 million Americans have pre diabetes
Many will develop diabetes within 10 years
An “early warning sign” or “wake-up call”
Blood sugar is higher than normal but not high
enough to be diabetes
• Main problem is “insulin resistance”
(insulin is less effective at lowering blood
sugar)
•15
Pre-Diabetes
Risk Factors
• Excess weight, especially around the
waist
• High Blood Pressure
• Abnormal cholesterol levels
• Not enough exercise
• Family history Type 2 diabetes
• Age
•16
Pre-Diabetes
Pre-diabetes can be delayed or possibly reversed by
weight loss and physical activity
Weight Loss and
Increased
Physical Activity
Possible Medication
Healthier
Food Choices
18
•17
Type 1 Diabetes
▫
▫
▫
▫
Formerly called “Juvenile Diabetes”
Autoimmune destruction of pancreatic beta cells
No insulin produced so insulin injections required
Represents 5 – 10 % of people with diabetes
Risk Factors:
▫ Genetics – 3 - 7% risk if parent has Type 1
10% risk if sibling has Type 1
▫ Age – usually before age 30 (can occur at any age)
Symptoms:
▫ Rapid onset
▫ Include weight loss, frequent urination, extreme
hunger and thirst, weakness, vomiting
•18
Late Onset Type 1
• Autoimmune disease
• Beta cell destruction happens slowly
over many years
• Patients diagnosed over the age of
30yrs.
• Usually not overweight
• Physical inactivity not a factor
• Insulin resistance not usually a factor
•19
Type 2 Diabetes
• Formerly called “Adult Onset Diabetes”
• 90-95% of diabetic population
• Body produces insulin, but it doesn’t work
properly (insulin resistance)
• More insulin has to be made to help lower
blood glucose
• Eventually insulin production diminished and
“pancreatic exhaustion” results
•20
Type 2 Diabetes
• Risk factors:
▫ Age (>45 years)
▫ Genetics – family history of diabetes
▫ Race (African Americans, Hispanics, Native North
Americans, Asians, Pacific Islanders)
▫ Physical inactivity and being overweight
• Symptoms:
▫ Tiredness, blurred vision, dry skin
▫ Increased hunger, thirst and urination
▫ Increased infection
▫ Sexual problems
• Treatment:
▫ Diet, exercise, and pills and/or insulin injections
Type 2 Diabetes Epidemic
45
40
35
30
25
# of People
with Diabetes
(per 1,000)
20
15
As obesity rates have
climbed due to changes in
diet and decreased
physical activity, so has
the incidence of Type 2
diabetes
10
5
19
40
19
50
19
60
19
70
19
80
19
90
20
00
20
10
0
•21
•22
Gestational Diabetes
• Occurs in about 7% of all pregnancies
• Risk increases if older and/or overweight
• Mother has 40–60% risk of Type 2 later in life
•If blood glucose is not controlled, may have:
•Complications with fetus
•Complications with delivery
•Increased chance of baby developing diabetes later in life
•23
Secondary Diabetes
Diabetes due to secondary causes such as:
•Toxins (poisons)
•Certain medications (steroids, chemo, HIV)
•Certain Diseases (pancreatic cancer, polycystic ovarian syndrome, cushing’s syndrome,
cystic fibrosis, chronic pancreatitis)
•24
Diabetes Medications
• Currently, there are ten
classes of diabetes
medications
• Each class of drugs
works in a unique way
• Oral agents (“pills”)
do not work in people
with Type I Diabetes
Meglitinides
Prandin (repaglinide)
Starlix (nateglinide)
•Increase insulin release in
response to food
•Rapid onset – take right before
meals
•May cause hypogycemia when
taken without food
•25
Sulfonylureas
•26
•Amaryl ……..(glimepride)
•Micronase…...(glyburide)
•Diabeta
•Glynase
•Glucotrol…….(glipizide)
•Glucotrol XL
•Help the pancreas to produce more
insulin
•Take 30 minutes before meals
•May cause low blood sugar &
weight gain
•27
Insulin Sensitizer (TZD’s)
Actos
(pioglitazone)
•Increases insulin sensitivity, so
insulin works more effectively
•May promote water retention and
weight gain
•28
Biguanides
Glucophage
Glucophage XL
(metformin)
(fortamet)
(Glumetza)
•Decrease glucose production and
release by the liver
•Hold for 48 hours after dye procedure
•Possible side effect is diarrhea, nausea
or heartburn
•Does not cause hypoglycemia or
weight gain
•29
DPP-IV Inhibitors
Januvia (sitagliptin)
Tradjenta (linaglitin)
•A class of drugs that stimulates the secretion of insulin
•Helps keep blood sugars from going too high after
meals
•Take once daily without regards to food
•Does not promote weight gain or hypoglycemia
SGLT2 Inhibitors
•30
Invokana (canagliflozin)
Farxiga (dapagliflozin)
Jardiance (empagliflozin)
• Blocks re-absorption of glucose by the kidney and
increases glucose excretions in the urine.
• May help to reduce A1c levels and promote weight
loss
• Taken once per day before the first meal of the day
• Side effects:
▫
▫
▫
▫
Frequent urination
Yeast Infections
Dehydration
Kidney Damage
•31
Incretin Mimetic
Byetta (exenetide)
Victoza (liraglutanide (rDNA) origin)
These medications mimic GLP-1 in the body which helps
lower glucose levels and decreases glucagon levels.
An injectible drug (NOT insulin) – either given 2 shots a
day-given 1 hour before meals or once per day
•It increases insulin secretion, delays gastric emptying,
and promotes a feeling of fullness (helps you eat less)
•Helps lower high blood sugars after meals
•May lower A1C by 1% and help with weight loss
•Main side effect is nausea
•32
Incretin Mimetic
Bydureon (exenetide)
Tanzeum (albiglutide)
Trulicity (dulaglutide)
• An injectable drug administered once per week
with our without food
• Main side effect is nausea or redness at injection
site
▫ Helps lower high blood sugars after meals
▫ Suppresses appetite
▫ May lower A1C by 1% and help with weight loss
•33
Amylin Analogs
Symlin (pramlintide)
•
An injectible drug that helps the body regulate
how quickly food is turned into glucose
•
People with diabetes make little or no amylin,
so taking Symlin helps bring levels back to
normal
Produces up to a 0.6% lowering of A1c
Reduces post meal high blood sugar
Decreases appetite and increases feeling of
fullness
•
•
•
•34
Onglyza
• Onglyza (Saxagliptin) is a dipeptidyl peptidase-4
inhibitor
• Once daily
• Helps the body increase insulin levels after
meals.
• Helps the body handle the amount of sugar
released by the liver overnight and between
meals.
• Taken once per day with or without food.
•35
Combination Medications
(2 different medicines in 1 pill)
Combinations pills:
Glucovance = metformin + glyburide
Metaglip = metformin + glipizide
Janumet = Januvia + metformin
Avandaryl = rosiglitazone + glimepiride
Duetact = glimepiride + pioglitazone
Actos plus Met = Actos + Metformin
Kombiglyze = Onglyza + Metformin
•36
Insulin
Methods of Administration
Injection
Pump
V-Go Device
•37
Types of Insulin
Insulin Name
Type
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
Rapid
Regular (Humulin R)
(Novolin R)
Short
NPH (Humulin N)
(Novolin N)
Intermediate
Glargine (Lantus)
Detemir (Levemir)
Glargine (Toujeo)
Long Acting
•38
Rapid-Acting Insulins
Lispro (Humalog), aspart (Novalog), and glulisine (Apidra)
Insulin
Activity
Hours
Starts lowering blood glucose within
10 – 15 minutes after injection
0
2
4
6
8
10
12 14 16 18 20 22 24
Should be taken immediately before eating
Short-Acting Insulins
Regular insulin (Humulin R and Novolin R)
Most effective at
2 – hours after injection
Insulin
Activity
Hours
Should be taken 30 – 60 minutes before eating
•39
Intermediate-Acting Insulins
NPH (Humulin N, Novolin N)
Greatest effect
at 6 – 10 hours
Insulin
Activity
0
2
4
6
8
10
12
14
16 18
20 22 24
Hours
Usually taken before breakfast, and dinner or
bedtime
Usually used with rapid or short-acting insulin
•40
•41
Long-Acting Insulin
Levemir
Insulin
Activity
0
2
4
6
8
10 12 14 16 18 20 22 24
Hours
Insulin glargine (Lantus)
Insulin
Activity
0
2
4
6
8
10 12 14 16 18 20 22 24
Hours
•42
Insulin Administration
• Abdomen has the most uniform absorption
• Back of the arms absorb insulin more slowly
than abdomen
• Thighs/buttocks absorb insulin the slowest of
all
• Don’t inject into:
belly button, bruises,
scars or bones
• Rotate injection sites
•43
Care of Insulin
• Check insulin appearance before use
if cloudy, it should remain cloudy
if clear, it should remain clear
• Don’t use insulin after
expiration date
• Store insulin properly
•“If in doubt, throw it out”
•44
Storage of Insulin
• Unopened vials & pens – keep refrigerated
• Open vials - may keep at room temp for 30 days
• Open Insulin pens - store at room temp for 28
days depending on the type of insulin
• Pre-filled syringes - keep refrigerated and use
within 21 – 30 days
Be consistent with insulin storage since
temperature affects absorption rate
•45
Traveling with Insulin
• If you are flying, have your healthcare
professional write a letter stating that you have
diabetes and need to use syringes and insulin.
Make sure your supplies are clearly labeled.
This will help you get through security without
delay.
• Changing time zones can impact your regular
insulin schedule. Your healthcare professional
can help you figure out how to adjust your
dosage before you travel.
•46
Traveling with Insulin
• Bring 2 to 3 times the amount of insulin,
medications and supplies you need with you. This
way, if anything is lost or damaged, you’ll have
plenty of extras. Medications must be kept in your
carry on luggage.
• When you travel, maintaining your regular
schedule for insulin injections and blood sugar
checks can be challenging. Discuss your plans with
your healthcare professional before you go.
•47
Blood Sugar Goals
American Diabetes Association (ADA)
• Before meal: 70-130mg/dl
• 2 hours after a meal: less than 180mg/dl
American College of Endocrinologists (ACE)
• Before meals: 70 - 110 mg/dl
• 2 hours after a meal: less than 140 mg/dl
•48
Blood Glucose Monitoring
• Wash hands
• “Milk” from the palm of your
hand toward the finger tip
• Prick the SIDE of your finger
(less painful)
• Touch test strip to blood droplet
• Record your reading
•49
Monitoring: How Often?
Depends on:
•
•
•
•
•
Type of Diabetes
Blood sugar control
Last change in medication
Health
Activity level
•50
Monitoring
General Guidelines
• Insulin users, check blood sugar before each
injection
• Everyone else: check before and 2 hours after eating
at least one meal a day, alternating the meals
• If you get an unusually low or high number, RETEST
• Log results and review them often
• Bring log book to all diabetes appointments
•51
Blood Sugar Log
Breakfast
lunch
Date Pre
Post Pre
Mon 97
213
Tue
Dinner
Post Pre
Bedtime
Post
88
Business meeting/Buffet
134 88
Wed 60
100
Fri
220
104 197
80
Sun
60
Workout after lunch
128 147
Thur 108 197
Sat
Comments
90
90
100
Dentist app.
150
200
•52
Why Monitor?
• Puts you in the driver seat!
• Provides information about
your blood sugar trends
• Gives you feedback on how medicine, food and
exercise affect your blood sugars
• Let’s you take action to help get your blood sugar
back into target range
•53
Monitor Care and Storage
•Do not store meter or strips in
hot, cold or damp places
•Keep meter clean and strips dry
•Dispose of used lancets and
strips in sharps container
Questions? Call the manufacturer’s toll free customer
support line or ask your Health Care Team
Needle/Lancet Disposal
• Dispose of used supplies in
sharps container
• Dispose of container at drop
site (Health Department)
•54
•55
Sick Days
Set up a sick-day plan
before illness occurs
Ask your doctor about flu and pneumonia
vaccinations
•56
Sick Day Guidelines
• Blood sugars increase with illness
• Continue to take your medications
as prescribed
• Test blood sugar every 2 - 4 hours
• Test urine ketones if blood sugar is
>250 mg/dl (Type 1)
• Keep a log of your test results
Sick Day Management
Increased risk of dehydration
due to:
• Decreased fluid intake
• Evaporation losses from fever
• Loss from vomiting and diarrhea
Goal: Drink 8 ounces of caffeine
Free, sugar free fluids every hour
you’re awake
•57
•58
Recommended Fluids
• Caffeine-free diet soda
• Sugar-free Kool-Aid
• Crystal Light
• Water
• Bouillon or consume
• Canned clear soups
▫ (Must be low sodium!)
•59
Sick Day Management
If you are unable to eat solid
foods:
• If blood sugar is higher than 250 continue to
drink calorie-free liquids
• If blood sugars is 180 – 250 eat or drink 15
grams of carbohydrate per meal
• If blood sugar is less than 180 consume
tolerated foods equivalent to the normal
amount of planned carbohydrate for that meal
•60
When To Call The Doctor
• Persistent vomiting or diarrhea
• Temperature >101
• Positive urine ketones (Type I)
• Blood sugars more than 250
on 2 – 3 consecutive
occasions
Symptoms of Hypoglycemia
(blood sugar less than 70)
LOW
•
•
•
•
•
•
•
•
Weakness/Tiredness
Shaking/Sweating
Hunger
Headache
Confusion
Anxiety
Pale color
May have no symptoms
•61
Causes of Low Blood Sugar
• Too Much medication
 need dose decreased
 incorrect dose taken
• Skipped meal/too little eaten
• More exercise than usual
•62
Treating Hypoglycemia
15:15 Rule
• Check your blood sugar,
If below 70:
• Take 15 grams of fast acting
carbohydrate
• Wait 15 minutes and retest
• Repeat if sugar not increased
• If your blood sugar is still low
after 3 checks, call 911
•63
Fast-Acting
Carbohydrate Sources
(15
grams carbohydrate each)
 ½ cup (4 oz) fruit juice
 1 cup (8 oz) milk (skim or 1%)
 ½ cup (4 oz) regular soda
 3 – 4 glucose tablets
 1 tablespoon syrup or honey
 3 – 4 hard candies
 (smarties, peppermints, skittles, etc.)
 Small box of raisins
•64
•65
Driving Safety and Diabetes
• Check blood sugar before driving
• If less than 70mg/dl,
treat using the 15:15 rule
• If blood sugar is 70 – 99mg/dl, eat a small snack
containing carbohydrate to ensure blood sugar stays
within the target range while driving
• For long car trips, plan ahead to make sure meals or
snacks are not missed or delayed
• Driving a car requires mental alertness and quick
reflexes -Do not drive with low blood sugar!
•66
Driving Safety and Diabetes
• Don’t forget to take your blood sugar meter and
supplies with you
• Keep a fast acting source of carbohydrate (such as
glucose tablets) in your car at all times
• If you feel symptoms of low blood sugar while
driving, pull over when possible, test your blood
sugar, and treat if low
• Do not resume driving until your blood sugar has
increased above 100mg/dl
•67
Symptoms of Hyperglycemia
HIGH
• Extreme thirst
• Frequent
urination
• Dry skin
• Hunger
• Drowsiness
• Nausea
• Blurred vision
Causes of Hyperglycemia
(High Blood Sugar)
Not enough
medication
Too much
carbohydrate
Illness or
stress
•68
•69
Causes of Hyperglycemia
The Dawn Phenomena
•
“blood sugar rises with the sun”
• Glucose (called “glycogen”) is stored in the liver
• It is released into the bloodstream in the predawn hours as the body gears up for the day
•70
Acute Complications of
Hyperglycemia
Diabetic Ketoacidosis (DKA)
• Usually occurs in Type 1 DM
• Blood glucose level between 300-800
mg/dl
• Ketones produced from fat breakdown
• Increased hunger and thirst, fruity
breath, labored breathing, nausea
and/or vomiting, stomach pain
• Medical emergency
•71
Acute Complications of
Hyperglycemia
Hyperglycemic Hyperosmolar
Nonketotic Syndrome (HHNKS)
• Usually occurs in TYPE II DM
• Blood glucose between 600-1200 mg/dl
• Severe dehydration, possible
hospitalization
• Little or no ketones produced
•72
What can you do to lower
blood sugar levels?
•
•
•
•
Eat less carbohydrate
Exercise after a meal
Add a protein source with meals
Ask your physician about a
medication or dosage change
• Talk to your diabetes educator
•73
Why Care About High Blood
Sugar?
•74
Long-Term Complications
of Hyperglycemia
Cardiovascular
Disease:
Retinopathy
Kidney disease
Nerve damage
Stroke
Heart attack
Peripheral Artery
Disease:
Loss of circulation
in arms and legs
Amputation
•75
Hemoglobin A1c
• Sugar sticks to red blood cells while circulating
throughout the blood stream
• Since red blood cells live for 2 - 3 months, A1c
gives the average blood sugar over the last 60 –
90 days
Interpretation of A1c / eAG
A1c
Estimated Average
Glucose (eAG) mg/dl
A1c
Estimated Average Glucose
(eAG) mg/dl
5%
97
9%
212
5.5%
111
9.5%
226
6%
126
10%
240
6.5%
140
10.5%
255
7%
154
11%
269
7.5%
169
11.5%
283
8%
183
12%
298
8.5%
197
•76
•77
Importance of A1c
Maintaining an A1c level at 6.5% or less has
been shown to reduce, delay or prevent
complications by as much as:
▫ 76% for retinopathy (eye disease)
▫ 60% for neuropathy (nerve disease)
▫ 35% for nephropathy (kidney disease)
Complications of Diabetes
•78
Large Blood Vessel Damage
Stroke
Heart attack
Poor circulation
Cardiovascular disease is the #1 complication of diabetes
•79
Atherosclerosis
• Fatty substances like
cholesterol, called plaque,
build up in the inner
lining of an artery
• Plaque narrows the blood
vessels, reducing blood flow
to the heart, brain and/or the
extremities
•80
Heart Attack
A heart attack happens
when a blood clot forms
in an artery that feeds
the heart (a coronary
artery)
Warning Signs of a
Heart Attack
•
•
•
•
•
•
Chest pain
Pressure/tightness of chest
Pain in jaw or arm
Shortness of breath
Nausea/vomiting
Palpitations, fainting
If a heart attack is suspected, call
911
•81
•82
Stroke
A stroke happens when a blood clot forms in
an artery that feeds the brain (a cerebral artery)
•83
Warning Signs of a Stroke
• Sudden weakness or numbness of face, arm or
leg on one side of the body
• Sudden dimness or vision loss in one eye
• Loss of speech or trouble talking or
understanding
• Sudden severe headache
• Unexplained dizziness or falls
If a stroke is suspected, call 911
•84
Controllable Risk Factors
▫ Elevated cholesterol and triglycerides
▫ Smoking/second-hand smoke
▫ High blood pressure
▫ Diabetes
▫ Obesity
▫ Physical inactivity
•85
Cholesterol
• A fat, waxy-like substance found in all our cells
• Carried in the blood stream via lipoproteins
(HDL and LDL)
• It comes from two sources:
- made by the liver
- in the food we eat
• Total cholesterol goal:
• less than 200 mg/dl
•86
Types of Cholesterol
HDL (High Density Lipoprotein)
▫ Contains very little cholesterol
▫ Called “helper” or “healthy” cholesterol
▫ Removes LDL cholesterol from the blood
and brings it to the liver for disposal
▫ Increase HDL levels by increasing
exercise!
▫ Goal: Men more than 40mg/dl
Women more than 50mg/dl
•87
Types of Cholesterol
LDL (Low Density Lipoprotein)
▫ “L” stands for “lethal” – bad cholesterol
▫ Responsible for build-up of cholesterol
in artery walls
▫ Reduce cholesterol by reducing intake of
fried foods, full fat cheese, butter, ice
cream and processed meats plus
exercise!
▫ Goal: less than 100 mg/dl
•88
Triglycerides
• Form of fat carried in the blood stream
• Elevated levels increase risk of heart
disease
• Higher levels are seen with insulin
resistance, sweet intake and alcohol
consumption
• Consuming omega 3 fatty acids may help
to lower triglycerides such as salmon,
flaxseed or chia seeds.
• Reducing refined carbohydrate intake may
reduce triglyceride levels such as pasta,
cookies, bread, ice cream, candy, etc.
• Goal: less than 150 mg/dl
High Blood Pressure
• More common in people
with diabetes
• Can accelerate
complications of diabetes
• Reduce blood pressure
levels by adding exercise
and limiting salt
consumption with meals
• Goal: below 130/80
•89
Kidneys Disease
• Nephrons filter the blood to
eliminate body’s waste
products
• Nephrons are made up of
small blood vessels
• High blood sugar levels and
increased blood pressure can
damage the vessels over time
• Your physician may run yearly
labs to check kidney function
•90
•91
Kidney Disease Prevention
• Good blood sugar control
• Control of high blood pressure
• Stop smoking
• Medication may be prescribed
(such as an ACE Inhibitor) to help
keep pressure in the kidneys low
Diabetic Retinopathy
Caused by damage
to the small blood
vessels that nourish
the retina
•92
•93
Retinopathy Symptoms
• Often there are no early symptoms
• Usually detected during a comprehensive eye
examination (dilation)
• Can be treated with laser surgery
• Permanent visual loss may occur if not treated
• See your eye Dr. for any change in vision:
 blurred or fluctuating vision
 increase in floaters
 distortion of straight lines
•94
Peripheral Neuropathy
• Caused by swelling and scarring of nerves
• Transmission of nerve impulses decline
• May cause pain, tingling, burning or numbness
in hands and feet
• Symptoms may come and go, or eventually
there may be no feeling at all
•95
Prevention/Treatment of
Peripheral Neuropathy
•
•
•
•
Good blood sugar control
Good foot care
Stop smoking
Visit the MD/Podiatrist
▫ Annual foot exam
▫ Sensory and vibratory checks
• Medications may help relieve
symptoms
•96
Foot Care
•Never walk barefoot
•Wear soft, comfortable, well fitting shoes
•Change your socks/stockings daily
•Always inspect the inside of your shoes
•Cut nails straight across
•Do not soak feet
•Lanolin cream OK (not between toes)
•Never use a sharp instrustrument such as
razor on your feet
•97
Inspect Feet Every Day
Check each foot for:
Changes in color
Blisters and ulcers
Calluses
Dry skin
Cuts, cracks and sores
Redness
Swelling
Corns
Use a mirror or ask someone for help
•98
NEUROMETRIX TEST
• Nerve conduction test
• Evaluates the function of
the nerves
• Used to diagnose
peripheral neuropathy
• Painless and non-invasive
* This test is available at
Palm Beach Diabetes
•99
Dental Care
• Increased risk of gum disease with diabetes
• Have teeth cleaned and oral exam at least every
6 months (more often if recommended)
• Brush teeth twice daily, floss once daily
• Tell your dentist you have diabetes
•100
Dental Care
• See a dentist immediately if you
experience:
▫ Pain in gums or jaw
▫ Unable to chew hard foods such as fresh
fruits and vegetables due to pain
▫ Foul breath odor
▫ Bleeding gums
 ** These could be signs of gingivitis or
Dental carries
Smoking
• Greatly increases the risk
of cardiovascular disease
• Creates free radicals
which damage blood
vessels and cause cancer
• Responsible for 1 of every
5 deaths in the US
•101
•102
STRESS
• Is the build-up of physical and emotional reactions to
anything that changes ones usual state of functioning.
• External Stress:
• noise, traffic, weather
• misplacing something, waiting in lines
• Internal Stress:
• Physical – illness, pain, alcohol or drug use
• Emotional – unrealistic expectations, tragic
experiences, feeling out of control, self-criticism,
fear of failure
•103
STRESS
Possible Stress Related Outcomes:
Obesity
Hypertension
Heart Disease
Back Pain
Skin Disease
Ulcers
Allergies
Diabetes
Asthma
Migraines
Colitis
Insomnia
Phobias
Unmanaged stress is a physical time bomb!
•104
STRESS
• Our brain equates stress with DANGER and
produces the “fight or flight” response for
survival
• This leads to:
• The release of glucose by the liver
• The release of stress hormones which compete with
insulin and make it less effective
• BOTH responses lead to High Blood Sugar
•105
Managing Stress
Make time
For hobbies
and leisures
Try a
Relaxation
method
Learn from
experience,
No one is perfect
•106
Ways to Deal With Stress
•
•
•
•
•
•
•
•
Know your stressors and eliminate them if you can
Prioritize activities; Create a to-do list in that order
Lower expectations, set achievable goals
Enhance and use your support system
Forgive and let go of unhealthy anger
Think of ways to simplify life
Balance work with pleasure
Laugh – it reduces stress hormones and aids in
digestion
• EXERCISE, EXERCISE, EXERCISE
•107
Stress Management
• Be kind to yourself; learn to say no
• Find time to read, listen to relaxing music, walk on the
beach
• Stop and smell the flowers
• Put things in perspective
• Find a hobby that you feel passionate about
• Get a massage
• Practice yoga, meditation, relaxation breathing
• Get adequate sleep and appropriate nutrition
• Reduce caffeine, nicotine, and sugar intake
•108
Summary
Check your blood sugar as directed
GOALS: 70 – 110 before meals
Less than 140 two hours after meals
Take medications as directed
Keep your A1c at 6.5% or lower
Keep cholesterol levels in desirable
range
Keep blood pressure less than 130/80
Maintain a desirable weight
Exercise
Manage Stress
Don’t Smoke
ADA Management Recommendations
Test/Exam
Hemoglobin A1c
Dilated Eye Exam
Foot Exam
Lipid Profile
Frequency
Every three months
Yearly by an
ophthalmologist
Yearly by a
podiatrist (more
often with
complications)
Yearly
•109
ADA Management Recommendations
Test/Exam
Frequency
Fasting Blood Glucose Yearly
(venous draw)
Urinalysis for protein Yearly
BUN, Creatinine,
Microalbumin
(kidney function)
Yearly if urinalysis for
protein is negative
Blood Pressure
Each diabetes visit
Each diabetes visit
Weight
•110
•111
RESOURCES
• Juvenile Diabetic Research Foundation International
800-533-2873
www.jdrf.org
• American Diabetes Association
800-342-2383
www.diabetes.org
• Academy of Nutrition and Dietetics
800-877-1600
www.eatright.org
• American Association of Diabetes Educators
www.diabeteseducators.org
Look on line for:
• Glucose meter company websites, ex. Accu-Check
• Diabetes drug and supply manufacturing companies such as:
Eli Lily, NovoNordisk, www.BD.com
• Try www.DLife.com for information and TV schedule
•112
Palm Beach Diabetes and
Endocrine Specialists
Thank you!