Transcript No Slide Title

Diabetes Update
Marcia Johnson BSN RN CDE
[email protected]
(616) 391-9288
2
Overview of Today
Physiology / pathophysiology
Self-management areas and treatment goals
Physical activity guidelines
Nutritional management
Pharmacological therapies
Acute complications
Chronic complications
Special populations
3
Case management and self-management support
Objective #1
Contrast physiology of normal fuel metabolism with
pathophysiology of pre-diabetes, type 1, type 2 and
gestational diabetes.
4
Hey Sugar Sugar!
5
Fuel Metabolism: Fed State
1.
Carbs digest into blood glucose
2.
Glucose travels to cells
3.
Insulin is released
4.
Insulin allows glucose into cells
5.
Insulin inhibits breakdown of glycogen
6
insulin
Fuel Metabolism: Postabsorptive State
Liver releases glucose (glycogenolysis)
and makes glucose (gluconeogenesis)
Liver
SS
SS
Glucose (sugar)
Storage
7
Activity: different types of DM
8
Diabetes Risks– the Epidemic
If born since 2000 in the US:
1 in 3 will develop diabetes in their lifetime if white
1 in 2 if Hispanic or black
9
Testing for Type 2 DM in Children
Should be tested if over overweight, age 10 or more AND has 2
of these:
•
A family history of Type 2 diabetes in first and seconddegree relatives (e.g. parents, siblings, or grandparents)
•
High risk race/ethnic group (American Indian, AfricanAmerican, Hispanic, or Asian/Pacific Islander)
•
Signs of insulin resistance or conditions associated with
insulin resistance (acanthosis nigricans, hypertension,
dyslipidemia, polycystic ovarian syndrome).
10
Testing in Asymptomatic Adults
If overweight (BMI ≥25) AND other risk factors (or begin at
age 45 w/o risk factors):
•Physical
inactivity
•First-degree
•High
•Hx
relative with DM
risk race/ethnicity
GDM or baby > 9 lb
•Hypertension
•HDL
<35
•Polycystic
(PCOS)
•Prior
A1c ≥5.7, IGT or IFG
•Insulin
resistance
syndromes
•History
11
ovarian syndrome
of CVD
How are Diabetes & Pre-diabetes Diagnosed?
Normal
Fasting
2 Hr
A1c
Pre-Diabetes
70-99 mg/dL 100-125 mg/dL
under 140 140-199
<5.7%
5.7-6.4%
Diabetes
126 or more
200 or more
6.5% or more
Or random BG over 200 with symptoms
Gestational DM Screening at 24-28 Wks
ACOG Criteria
ADA-Proposed Criteria
50-g 1 hr OGTT for all
75-g 2 h OGTT for all
If high (most use >140):
100-g 3h OGTT
GDM = any of the below
Fasting
≥ 92 mg/dL
GDM = 2 or more below
1 Hr
≥ 180 mg/dL
Fasting
≥ 95 mg/dL
2 Hr
≥ 153 mg/dL
1 Hr
≥ 180 mg/dL
2 Hr
≥ 155 mg/dL
3 Hr
≥ 140 mg/dL
13
At 1st prenatal visit, if high
risk for DM: screen for
undiagnosed type 2 DM
with FBS or A1c
Natural History of Type 2 Diabetes
Obesity
Glucose
(mg/dL)
Relative
Function
(%)
350
300
250
200
150
100
50
250
200
150
100
50
0
Diabetes Uncontrolled Hyperglycemia
Post-meal
Glucose
Fasting
Glucose
Insulin Resistance
Insulin Level
-Cell Failure
-10
*IFG=impaired fasting glucose.
14
IFG*
-5
0
5
10
15
Years of Diabetes
20
25
30
Objective #2
Identify categories of diabetes self-management and glycemic
treatment goals.
15
AADE7™ Self-Care Behavior Categories
•
•
•
•
•
•
•
16
Healthy Eating
Being Active
Monitoring
Taking Medication
Problem Solving
Healthy Coping
Reducing Risks
Behavior: Monitoring
17
Targets
ADA
AACE
Pre-meal BG
70-130 mg/dL
70-110 mg/dL
Post-meal BG
peak <180 mg/dL
2 h <140 mg/dL
A1c
<7%
<6.5%
A1c
18
A1c
%
6
eAG (estimated
average glucose)
mg/dl
126
6.5
140
7
154
7.5
169
8
183
8.5
197
9
212
9.5
226
10
240
Glucose Meters
Possible technique errors:
•
Coding
•
Sites: fingers vs. other
•
Contaminants on finger
•
Squeezing finger too hard
•
Storage of supplies, expiration dates
19
Barriers to Monitoring
•
Cost, reimbursement, DME vs pharmacy
•
Discomfort
•
Nuisance
•
Don’t know what the numbers mean
•
No one uses the info
•
Why write the #’s down? They’re in the memory
•
High numbers = I’m bad
20
Strategies to Enhance BG Monitoring
1.
Make it meaningful: self-experiment
2.
Use the Noah’s Ark Principle (pairs,
pre/post meal)
3.
Actually review the pt’s results
4.
Congratulate the effort, not the #’s
5.
Challenge self-worth interpretations (not
good/bad #’s, just info and it’s all
valuable)
6.
Provide guidance in interpretation and
promoting action
21
Continuous Glucose Monitors (CGM)
Professional vs. Patient
• iPro
• Dexcom
• Pump-enabled
22
Objective #3
Summarize American Diabetes Asso/American College of
Sports Medicine guidelines on physical activity for prevention
of type 2 diabetes and for those with type 2 diabetes.
23
Behavior: Being Active
Physical Activity vs. Exercise
Use of word “exercise” with patients
24
25
How can being active help?
Helps to Lower:
Weight
Blood sugar, blood pressure
Risk of heart disease and stroke
Risk of some cancers
Stress
Strengthens bones and muscles
Sleep better
Live longer
And More!
Types of activity
Aerobic
Weight training / resistance
Benefits of combination of aerobic and resistance training
Mild activities (tai chi, yoga)
27
Flexibility
How much aerobic activity is needed?
ADA/Am. College of Sports Medicine:
•
At least 150 minutes/wk over at least 3 days
(may need more for weight loss)
•
No more than 2 days in a row w/o aerobic activity
•
Can break it up, but do at least 10 min.
•
Moderate to vigorous
Weight Training or Resistance Exercise
• Weights
•
Resistance bands
•
Machines at fitness centers
•
Do 2-3 days per week
•
Do not do 2 days in a row
•
Learn the “moves”
Adding Extra Steps
Safety Thoughts
General safety: Liquids
Pace
Cell phone
Feet:
Proper shoes
Check feet after
Low blood sugar
Barriers to Physical Activity
•
Time
•
Boredom
•
Fatigue
•
Pain
•
Weather
•
Cost
•
History of failure
And more!
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Summary of Part 1
Physiology and pathophysiology of DM
Categories of self-care and glycemic treatment goals
Physical activity guidelines
33
Break Time (go walk!!)
34
Objective #4
Explain nutritional management of diabetes, including
carbohydrate, protein and fat intake.
35
Behavior: Healthy Eating
Improves:
36
•
Blood sugar
•
Blood lipids / cholesterol and triglycerides
•
Weight
•
Blood pressure
Truth or Myth???
McD’s caramel sundae has same amount of
carbs as a Panera whole grain bagel
People with diabetes should have no sugar
People with diabetes need to eat snacks
A cup of rice and a Big Mac have the same
amount of carbs
What are Foods Made of?
•
Carbohydrate
•
Protein
•
Fat
What turns into blood sugar?
42
Healthy Eating Guidelines
•
Moderation (portion control)
•
Have 3 meals. Do not skip meals
•
Space meals 4-5 hours apart
•
Beverages
•
Variety
Good for the whole family
43
44
Methods of Meal Planning: Plate Method
45
Methods of Meal Planning: Exchanges
Carbohydrate
grams
Protein
grams
Fat
grams
Calories
Starches
15
0-3
0-1
80
Fruit
15
--
--
60
Milk
12
8
0-8
100-160
Sweets/
other carbs
15
Varies
Varies
Varies
Non-starchy veg
5
2
0
25
Meat/meat subs
Plant-based
0
Up to 15
7
0-8+
45-100
0
0
5
45
Fats
46
Methods of Meal Planning: Carb Counting
•
Carb Choices or Carb Grams
•
1 carb choice = 15 grams
General Guideline:
• Women: 3-4 carb choices (45-60 grams) per meal
•
Men: 4-5 carb choices (60-75 grams) per meal
•
Snacks: 1-2 carb choices (15-30 grams)
47
Carb Foods
•
Grains, beans, and starchy vegetables
•
Fruit and fruit juice
•
Milk and yogurt
•
Sweets
48
49
Carb Foods: Serving size for 1 carb choice
Grains, beans and starchy vegetables
•
1 oz. bread product (1 slice bread, ½ English muffin)
•
6 inch tortilla
•
1/3 cup pasta or rice
•
½ cup dried beans, corn, peas, mashed potato, cooked cereal
•
¾-1 oz. pretzels, crackers
50
Carb Foods: Serving size for 1 carb choice
Fruit and fruit juice
•
1 small piece fruit (apple, orange, peach)
•
½ large banana
•
1 cup berries, cherries or cut up melon
•
½ cup grapes, canned fruit or unsweetened applesauce
•
2 Tb dried fruit
•
4 oz. juice
51
Carb Foods: Serving size for 1 carb choice
Milk and yogurt
•
8 oz. milk
•
6 oz. plain or artificially sweetened yogurt
Sweets
•
½ cup ice cream or sugar free pudding
•
2 small cookies
•
2 inch square brownie or unfrosted cake
52
Vegetables
• Starchy kinds
•
53
Watery kinds
Reading Labels for Carbs
54
Fiber
55
•
What fiber helps
•
Drink more
•
Add fiber slowly
•
Fiber on label
5g = very good
2.5g = good
Adding Sugar?
Sugar Includes:
•
White or brown sugar
•
Honey or molasses
•
Fructose
•
Jelly, jam, syrup
1 Tbsp = 1 carb choice
56
Sugar Substitutes
Examples:
57
•
Sucralose
•
Aspartame
•
Saccharin
•
Acesulfame K
•
Stevia
Sugar Alcohols
“Sugar Free” or “Low Carb” foods
58
•
Do have carbs and calories
•
Do affect blood sugar
•
Laxative affect
•
Label: often end in “tol”
Sorbitol, Lactitol , Xylitol
59
Resources for Carb Info
60
•
Booklets from CDE or RD
•
Nutrition labels
•
Calorie King and other books
•
Apps (e.g. GoMeals.com)
•
Internet
Carb Scene Investigation: Count the Carbs
61
5 oz. sirloin steak
0
6 oz baked potato
2 (30 gm)
2 Tbsp. sour cream
0
½ cup cooked broccoli
free
2 oz. dinner roll
2 (30 gm)
1 tsp. margarine
0
frosted cake square (2 inch)
2 (30 gm)
1 cup ice cream
2 (30 gm)
8 oz. black coffee
0________
TOTAL
8 (120 gm)
Other Carb Thoughts
Counting carbs helps blood sugar
Choosing healthy foods is also important
• Whole grains
• Fruits and vegetables
• Variety and color
62
Meat / Protein
• No effect on overall blood sugar
•
Vary in amount of fat and calories
•
Choose leaner ones most often
Need to limit protein?
63
Meats (Protein)
Fish and tuna
Poultry
Pork
Beef
64
Meat Substitutes (Protein)
Cheese and cottage cheese
Peanut butter
Eggs or egg substitutes
Tofu
Plant-based proteins
65
Counting Meat / Meat Substitute Choices
1 choice:
•
•
•
•
1 oz. meat, fish, poultry, cheese
1 egg or ¼ cup egg substitute
1 Tbsp peanut butter
¼ cup cottage or ricotta cheese
Most meal plans have 6-10 meat/protein choices/day; spread
out any way preferred
66
How Many Meat and Carb Choices?
Cheeseburger
Breakfast Sandwich
3 oz. meat
1 egg
1 slice cheese
1 oz. cheese
Bun
1 oz. sausage patty
Lettuce
1 whole English muffin
Tomato
67
Fat
68
1.
In meats / proteins
2.
In some carb foods
3.
Some foods are mostly fat– add
these to foods or cook with them.
•
Calories / weight
•
“Bad” kind of fats for heart
Choose Healthier Types of Fats
Choose most: Mono-unsaturated
Choose sometimes: Polyunsaturated
Limit/Avoid: Saturated and Trans Fat
69
Watch Portion Sizes
Most meal plans have 2-4 added fat
choices/day (or 6-8 total fat choices)
One fat choice:
• 5 grams of fat (45 calories)
• Often 1 tsp is a serving
70
Check Food Labels
•
Compare Total Fat between
products
•
Quick check: Avoid food if it has
Saturated Fat more than 2 grams
per serving
•
Avoid if it has ANY Trans Fat
•
Low fat rule: For every 100
calories, choose foods that have
3 grams of fat or less
71
Label Reading Activity
1.
Serving size
2.
Total carb grams
3.
How much to have for 1 carb choice
4.
Is it heart healthy for fat -- Is it within the acceptable limit
for saturated and trans fat?
5.
Does it meet the “low fat rule”?
72
Free Foods
• Beverages
73
•
Sugar–free gelatin
•
Light jam or jelly
•
Sugar-free syrup
•
Green salads
Carb Scene Investigation Plus: Count All
10 oz. sirloin steak
10 meats
6 oz. baked potato
2 carbs (30 gm)
2 Tbsp. sour cream
1 fat
Tossed salad with 3 Tb ranch dressing
3 fats
2 oz. dinner roll
2 carbs (30 gm)
2 tsp. stick margarine
2 fats
frosted cake square (2 inch)
2 carbs (30 gm) +fat
1 cup ice cream
2 carbs (30 gm) +fat
8 oz. black coffee
0________
TOTAL: 8 carbs (120 g) and 10 meat and 6+ fats
Barriers to Healthy Eating
•
Habit
•
Hunger
•
Taste / food preferences
•
Cost
•
Social
•
Time / schedule
•
Lack of support
•
Lack of knowledge, recipes
75
Objective #5
Review pharmacologic therapies for glucose management
based on current evidence-based guidelines.
76
Behavior: Taking Medication
•
Oral medications
•
Injection therapies
•
Treatment algorithms
77
Sites of Action for Oral DM Medications
Organ
Organ effect on
BG
Problem
Liver
Glucose
production
Too much glucose 1 : Biguanides
production
2 : TZDs
Muscle &
Adipose
Tissue
Glucose uptake
Insulin resistance
decreases BG
uptake
1 :TZDs
2 :Biguanides
Pancreas
Insulin production
lowers BG
Too little insulin
production
Secretagogues:
Sulfonylureas &
Meglitinides
Gut
Carb digestion
into glucose
Carbs raise BG
too much
α-glucosidase
inhibitors
Gut hormones’
incretin effect
Decreased
incretin effect
DPP-4 inhibitors
78
Medication
Incretin and Other Therapies
GLP-1 (an incretin hormone in the gut) is too low in type 2 DM
Oral therapy:
DPP-4 inhibitors reduce the enzyme that metabolizes GLP-1
Injection therapy:
GLP-1 agonists increase GLP-1
Symlin replaces amylin
79
GLP-1 Actions
When food is ingested…
GLP-1 is secreted
from the L cells
in the jejunum
and ileum
80
• Stimulates insulin
secretion (glucose
dependent)
• Suppresses
glucagon secretion
• Slows gastric
emptying
• Increases satiety
Long-term effects
demonstrated in animals:
• Increases ß-cell mass
• Maintains ß-cell function
Insulin Therapies
•
Basal insulin (usually with oral agents)
•
Prandial insulin
•
Basal-bolus insulin
•
Premixed insulin
•
Older therapies: Regular and NPH
81
Insulin Profiles
Rapid-acting
Short-acting
Plasma Insulin Levels
Intermediate-acting
Long-acting
0
2
4
6
8
10
12
Time (hr)
82
14
16
18
20
22
24
Insulins by Action Time
Rapid-acting
Apidra
Humalog
NovoLog
Short-acting
Regular
Intermediate-acting
NPH
Long-acting
Lantus
Levemir
Pre-Mixes
83
Injection Options
Syringes
Pumps
Pens
“Insulin Resistance”
Patients:
Fears
Misconceptions
Providers:
Time/Hassle to convince pt, prescribe, arrange teaching, titrate
Patient Education (or validation):
Technique, sites, storage, disposal, side effects, dosing, etc.
85
Normal insulin release
Breakfast
Lunch
Supper
Bolus
Basal
4:00
8:00
12:00
Time
4:00
8:00
12:00
4:00
8:00
Basal Bolus Insulin
Breakfast Lunch Dinner
Fast–acting
Bolus insulin
Long-acting
Basal insulin
= insulin
shots
4:00
8:00
12:00
4:00
8:00
12:00 4:00 8:00
Basal Bolus Therapy
1. Basal (long-acting insulin) 1-2x/day
2. Bolus (rapid-acting insulin) for meals:
• Set dose with meals OR
• Flexible dose based upon carbs
3. Bolus as needed for high blood sugar (correction dose), may
be built into a scale with set doses.
Correction insulin ≠ sliding scale insulin
88
Example
BG is 270
Correction Factor Insulin Dose:
Target = 120

270 – 120 = 150 points above target (140)

150 ÷ 50 = 3 units of insulin to “correct” BG
CF = 50
Carbs
planned: 75
Food insulin dose:
I:C = 1:15

75 grams carb ÷ 15 = 5 units of insulin
Total insulin dose:

89
3 + 5 = 8 units
Medication Options
•
Many options
•
Most oral DM meds lower A1c a similar amount
•
Progressive disease needs progressive meds
•
Often need to combine
•
Need to treat to targets, not to appts
Future
90
AACE Consensus Algorithm 1/09
Tier 1 : (in addition to lifestyle)
Step 1
Step 2
Step 3
Metformin +
basal insulin
Metformin +
Basal Bolus
Insulin
At Diagnosis
Metformin
Metformin +
sulfonylurea
91
Barriers to Taking Medication
“Medication Compliance”
The average patient misses about ______ % of their oral
diabetes medications.
A.
2%
B.
5%
C.
10%
D.
25%
92
Barriers to Taking Medication
One out of ______ patients misses one or more insulin
injections per day.
A.
3
B.
5
C.
10
D.
20
93
Barriers to Taking Medication
•
Cost
•
Time / schedule / forget / travel
•
Don’t feel it working
•
Don’t want to take/increase, think = I’ve been bad
•
Lack of knowledge (when to take, why, etc.) or regimen too
complex
•
Fear or embarrassment of injections (esp. in public)
•
Skipped meal
•
Fear of hypoglycemia, weight gain
94
Objective #6
Identify signs/symptoms and management of acute diabetes
complications.
95
Behavior: Problem-Solving
•
Hypoglycemia
•
Hyperglycemia
•
Sick day guidelines
•
Pattern management
96
Symptoms of hyperglycemia
Tired and grumpy
Thirst
Urinate more
Blurred vision
97
Other: hunger, infections (skin, GU), wt loss, or no symptoms
What to do for hyperglycemia
Watch BGs
Fluids
Address possible causes
Follow meal plan
Get more activity, if possible
Take medications as directed
Corrective insulin?
May need to call physician
May need more diabetes
medication
98
What else could make it go up?
Stress
Illness or infection
Other: inaccurate BG checks, forgot medication or taking at
wrong time, effect of another medication, lack of sleep
99
DKA signs and symptoms: acts like “flu”
•
Ketones in urine
•
Stomach pain
•
Rapid, labored breathing
•
Fruity smelling breath
•
High blood sugar symptoms
•
Nausea, loss of appetite, vomiting
•
Drowsiness and confusion
Sick Day Rules
Continue medications
Drink extra liquids
Replace carbs
Over the counter medicines
Check blood glucoses
Call physician
101
Hypoglycemia
Who is at risk?
Taking insulin or secretagogue (sulfonylurea or meglitinide)
Common Causes
•
Delayed meal / too few carbs
•
Alcohol w/o food / carbs
•
More physical activity than usual
102
Hypoglycemia signs and symptoms
Hard to concentrate or think
Shaky, nervous
Cold sweats
Weak, dizzy, drowsy
Other: Extreme fatigue, confusion, headache, hunger, slurred
speech, nausea, tachycardia, numb lips/tongue
103
Hypoglycemia treatment
Check Blood Glucose, if possible
If under 70 “Follow the 15-15 Rule”
Take 15 grams of fast acting carbs
Re-Check in 15 minutes, re-treat if needed.
Examples of 15 grams
4 glucose tablets
4 oz. of juice or non-diet soda
104
What to do next
Eat soon
Figure out cause, so it doesn’t happen again
Notify doctor if frequent or severe
Glucagon
105
Hypoglycemia causes & prevention
Eating too few carbs or delayed meal
More active than usual
Too much DM medication taken or 
medication needs (recovering from illness or
losing weight)
Alcohol w/o food / carbs
106
Sam
Sam spends most evenings in front of the TV.
He has a hard time staying awake.
1. Do you think Sam’s blood sugars are too
high or too low?
2. What might be the cause(s)?
3. What could he do?
Bob
Bob has been having a busy day making
his deliveries. He did not eat much. In the
afternoon he feels weak and shaky.
1. Do you think his blood sugars
are too high or too low?
2. What might be the cause?
3. What could he do?
Pattern Management
Highlight highs and lows
Be a detective to determine what may cause highs or lows
• Food
• Exercise
• Medications
• Other (stress, illness, lack of sleep, etc.)
Practice
109
Barriers to Problem-Solving
•
Symptoms confusing
•
Hard to find causes or patterns
•
Lack of knowledge
•
Frustration with numbers
110
LUNCH TIME!
111
Objective #7
Identify key standards of care to delay, prevent, or minimize
chronic diabetes complications.
112
Type 2 Diabetes: A Continuum
Normal
Insulin Resistance
Prediabetes
Type 2 Diabetes
Macrovascular Disease
Starting??
113
Microvascular Disease
Categories of Complications
•
Macrovascular
• CAD
• CVD
• PAD
•
Microvascular
• Retinopathy
• Nephropathy
•
Neuropathies
114
Diabetes is a “Vascular Disease”
•
2/3 of pts with DM die of CAD or CVA
•
PAD (peripheral artery disease) can lead
to amputation
115
Microvascular Disease
Eye problems
Retinopathy
Changes in focusing
Cataracts
Glaucoma
Nephropathy
Diabetes: the leading cause of kidney failure
High blood pressure: the second leading cause
116
Standards of Care: Key checks (HEDIS red)
Test
Minimum Frequency
Target
A1c
3-6 months
<7%
BP
Each office visit
<130/80
Cholesterol -LDL
Each yr
<100, <70 w/CAD
Depression screening
Each yr
Eye exam (dilated or
photo)
Each yr
Foot exam
Each yr
Kidney checks
HEDIS: Nephropathy
attention
Each yr
Immunizations
Flu each yr, pneumovax
per guidelines
Tobacco assessment
117
Microalbuminuria: <30
Serum Creatinine: ≤1.5
GFR: ≥60
Cessation
Barriers to preventing chronic complications
•
Years of no symptoms
•
Tests/exams may not be done/ordered
•
Costs
•
Time
•
Fatalism
118
Heath Care Outcomes Continuum
Immediate
Outcomes
Learning
Knowledge
Skill Acquisition
119
Intermediate
Outcomes
Behavior
Change
Post-Intermediate
Outcomes
Improved
Clinical
Indicators
Long Term
Outcomes
Improved
Health
Status
Objective #8
Discuss diabetes management in special populations.
120
Pediatric Diabetes
•
Type 1 vs. Type 2
•
Age-specific responsibilities
•
Safety concerns
121
Pregnancy and Diabetes
Risks to baby
Risks to mom
•
Macrosomia
•
Infections
•
Hypoglycemia
•
Polyhydramnios
•
Jaundice
•
Mom with type 1 or 2 DM
•
Fetal anomalies
•
Miscarriage
122
If macrosomia
 length of labor,
chance of C-section

Pregnancy and Diabetes
Differences in treatment:
•
Lower BG goals, frequent BG checks
•
Nutrition: 3 meals, 3 snacks, no fruit/milk/processed cereal at
breakfast (Sweet Success guideline)
•
Medications:
• Glyburide common, metformin less common
• Insulin often NPH and Regular, sometimes NovoLog,
analogs controversial since most are category C
123
Diabetes in the Elderly
•
Safety
• Appropriate A1c/BG goals
• Prevent hypoglycemia
• Falls
• Possible cardiac arrhythmias
• Cognitive decline
• Can affect quality of life more than chronic complications
•
Support from family, others
•
Foot care
124
Objective #9
Discuss case management strategies for patients with diabetes
including self-management support.
125
Behavior: Coping
•
Compliance vs. Adherance
•
Behavioral approaches
• Empowerment
• Motivational interviewing
126
Patient Empowerment Approach
Old way: “Go Greyhound and
leave the driving up to us”
127
New way: “Let Hertz put you in
the driver’s seat today”
Empowerment
“
The cornerstone of the empowerment approach is
recognizing that the person with diabetes is completely
responsible for managing his or her illness.”*
Critical Steps:
1.
Identify barriers
2.
Prioritize barriers to address
3.
Set goals (clear what/when/how) and plan for roadblocks
* Anderson, Funnell. The Art of Empowerment: Stories and Strategies for Diabetes Educators. 2nd ed.
ADA; 2005.
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Motivational Interviewing
•
Help pt explore behavior for themselves
•
Analyze the cost/benefit ratio of status quo
•
Decrease potential resistance to change
•
Help move toward readiness to change
•
Help pt clarify goals
•
Guide developing realistic strategies
•
Non-threatening environment
http://motivationalinterview.org/
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Barriers
Depression
Cost of care
Fear
Age/physical limitations
Fatalism
Cultural beliefs/traditions
Denial
Lack of social support
Perfectionism
Lack of understanding, myths
of diabetes
Anxiety
Frustration
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Readiness to Change
How important is it to the pt to change?
How confident is the pt about making the change?
1
2 3 4 5 6 7 8 9 10
Low
131
High
Readiness to Change
How ready is the pt about making the change?
1
2
Not ready
3
4
Unsure
Pre-contemplation
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5
6
7
8
9
10
Somewhat ready
Very ready
Contemplation
Preparation
Action
Ongoingmaintenance
Principles of Motivational Interviewing
•
Develop discrepancy
• Their goals vs. their actions
•
Roll with resistance
• Explore positive and negative consequences of change
or continuing the current behavior
•
Build confidence
•
Express empathy
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Avoid
•
Questions where you expect a short answer
•
Confrontation, argument
•
Taking the expert role (ok as consultant help pt evaluate)
•
Labeling, blaming, preaching
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Promote Motivation through OARS
•
Open ended questions
•
Affirm
•
Reflective listening
•
Summarize
135
Case Management
•
•
•
•
Engagement
Assessment
Intervention
Planning strategies
Case Studies
136
Wrap-up
Taking care of diabetes is hard work, but it is
worth it! Keep supporting your patients in their
work!
Thanks for all you do!
Evaluations
Thanks for coming, from the bottom of
my pancreas--that’s like from the bottom
of my heart, but deeper!
137