slides current until 2008 self-management. curriculum module iii-1 slide 2 of 38 activity slides...

Slides current until 2008

Self-management

Self-managementCurriculum Module III-1

Slide 2 of 38ACTIVITY


The impact of diabetes

• Think of someone you know in your personal

or social life who has diabetes

• What is your understanding of how they are

managing their diabetes? How do you know?

Do you know… really?

• What do they tell you?

• What don’t they tell you, if anything?




The impact of diabetes

• What do you feel is supportive behaviour from close family, friends, or the healthcare professional?

• What is not supportive?

• If you had diabetes, what would you expect from the people listed above?


Slide 4 of 38


Why is self-care important?

• Not enough healthcare providers for day-to-day management

• 24-hours-a-day management is necessary

• Better long-term outcomes

Bergenstal 1996




• Consider barriers to self-care in your culture

• Examples:

– financial resources

– discrimination

Barriers to self-care


Slide 6 of 38


Barriers to self-care

• Lack of knowledge and skills• Lack of support• Lack of resources:

– experienced, knowledgeable people– testing equipment, urine tests,

meters, access to laboratories– money for medication

• Attitude(s) of healthcare professionals • Knowledge of healthcare professionals


Slide 7 of 38


Self-management abilities

The ability to self-manage is enhanced by:

• Considering the individual’s need(s)

• Teaching skills to carry out medical regimens

• Guiding behavioural change

• Providing emotional supportVon Kroff 1997


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Self-care

“Medical care for chronic illness is rarely effective in the absence of adequate

self-care.”

“Self-care and medical care are both enhanced by effective collaboration

among chronically ill patients and their families and healthcare providers.”

Von Kroff 1997


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Self-care

• Shared goals

• Sustainable working relationships

• Mutual understanding of roles and responsibilities

• Requisite skills for carrying out their roles


Slide 10 of 38


Importance of monitoring

• Only way to know how diabetes is managed on day-to-day basis

• Results in glucose levels closer to target

• Teaches how to interpret and act on results

• Helps make changes to meals, medication or activities on a daily basis

Karter 2001, Jones 2003


Slide 11 of 38


Urine glucose testing

• Less reliable than blood glucose testing

– renal threshold

– time delay

– colour-dependant

• “Better than nothing”

• Sometimes more acceptable than pricking finger

• Result should always be negative!


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Urine ketone testing

• To determine diabetic ketoacidosis (DKA) primarily in type 1 diabetes:

– blood glucose over 14mmol/L (252mg/dl)

– during illness

• For people with type 2 diabetes that are very sick


Slide 13 of 38


Blood ketone testing

• Blood ketone testing is available in some areas

• Especially important in type 1 diabetes

• Identifies increases in ketones very early:

– DKA prevention

– early treatment


Slide 14 of 38


Blood glucose testing

Using meters • Advantages:

– reliable– fast– portable– more acceptable and convenient

• Disadvantages:– more expensive for some– pricking finger sometimes painful


Slide 15 of 38



Self-monitoring

• Best way to learn how nutrition, activity, medical therapy and blood glucose are linked

• When regular, it can help adjust doses of oral agents or insulin in relation to food or exercise anticipated in next meal period


Slide 16 of 38



When to monitor • There is no absolute

recommendation• Testing times may depend on:

– medication regimen– age– stability of blood glucose – personal preference– finances


Slide 17 of 38



Keeping a diary • Explain how to keep a blood glucose

diary• Give reasons for keeping a diary• Emphasize importance of entering ALL

results• Encourage comments when daily

activity is different than usual• Most meters have memories and can

be downloaded to computers either at home or in the pharmacy, doctor’s office or diabetes clinic


Slide 18 of 38



Keeping a diary


Slide 19 of 38



Details to be learned

• How well did the last medication work?

• When did each insulin dose or tablet have the most or least effect?

• How did the food eaten affect levels?

• What was the benefit of physical activity?


Slide 20 of 38


Post-meal glucose testing

When to test?

• Suspected post-meal hyperglycaemia

• Monitoring treatment specifically aimed at lowering post-meal glucose

• Hypoglycaemia in post-meal state

• For information on glycaemic effect of meal

Post-meal hyperglycaemia may be associated with increased risk of cardiovascular disease in type 2 diabetes.

Ceriello 2004




• Blood glucose levels do not coincide with how one feels

• Not enough blood on strip

• Finger prick may be painful

• Results do not reflect HbA1c

Common problems


Slide 22 of 38


HbA1c

• Average reading for last three months, weighted to last four to six weeks

• Reliable

• No fasting or other preparation needed

• Percentage reading

• Normal for people without diabetes: <6% (0.06)


Slide 23 of 38


HbA1c

• Target for people with diabetes: <7% (0.07), or lower if achievable without too much hypoglycaemia

• If target HbA1c is not met, intensification of the treatment must be considered:– improving lifestyle factors– increasing or adding oral

medication– adding insulin to oral medication– intensifying insulin regimens


Slide 24 of 38


HbA1c

Frequency

• Every three months or more if treatment changes

• Result weighted towards most recent month:

– 50% reflects blood glucose in past month

– 25% from previous month

– 25% from month before that


Slide 25 of 38


HbA1c

Causes of inaccurate results

• Haemolytic diseases, such as sickle cell anaemia

• High levels of haemoglobin F, S or C

• Possible anaemia or recent large blood loss

http://www.HbA1cnow.com (18 May 2004)


Slide 26 of 38


HbA1c

Comparison with blood glucose

• Mean plasma glucose increase of 2 mmol/L (36 mg/dl) results in 1% HbA1c increase

• HbA1c of 5%: mean plasma glucose 5.5 mmol/L (100 mg/dl)

• HbA1c of 6%: mean plasma glucose 7.5 mmol/L (135 mg/dl)

• Etc

Rohlfing 2002


Slide 27 of 38


Blood glucose targets

1CDA 2003, 2ADA 2004, 3IDF 2005

HbA1C Pre-meal 2 hours post-meal

Target for people who can achieve it (without too much hypoglycaemia)1

< 6% 4-6 mmol/L 5-8 mmol/L

Target for most people with diabetes

<7% 4-7 mmol/L1

90-130 mg/dl*2

5-10 mmol/L1

<180 mg/dl2

IDF Global Guideline for Type 2 diabetes3

<6.5% <6.0 mmol/L

<110 mg/dl

<8.0 mmol/L

<145 mg/dl


Slide 28 of 38


Other target values

Lipids

IDF – type 2 diabetes LDL <2.5 mmol/L (<95 mg/dl)

Triglyceride <2.3 mmol/L (<200 mg/dl)

HDL cholesterol >1.0 mmol/L (>39 mg/dl)

Canada

Primary targetSecondary target

LDL-C </= 2.0 mmol/LTC:HDL-C <4.0 mmol/L

United States LDL <100 mg/dl

Triglycerides <150 mg/dl

HDL >40 mg/dl

Blood Pressure <130/80 mmHg

IDF 2005, CDA 2006, ADA 2004


Slide 29 of 38


Other target values

Urinary albumin level

IDF – type 2 diabetes

Urine dipstick for protein

Urine albumin creatinine ratio (ACR)

Negative <2.5 mg/mmol in men

< 3.5 mg/mmol in women

United States & Canada

Negative <2.0 mg/mmol (men)<2.8 mg/mmol (women)


Slide 30 of 38


Summary

• Self monitoring of blood glucose improves HbA1c

• Regular testing improves self-management

• Final goal: delay or prevent complications

• Monitoring leads to a positive outcome


Slide 31 of 38


Review question

1. Encouraging people with diabetes to perform self-management activities means:

a. Following their diet, exercising regularly and taking their medications as prescribed

b. Making informed decisions about their own diabetes care

c. Allowing us to empower them

d. Managing their diabetes independently of the healthcare team


Slide 32 of 38


Review question

2. Which of the following is NOT needed for self-management?

a. Monitor and respond to symptomsb. Adapt decisions and actions to

different circumstances and conditions

c. Know when and how to access help and social support when needed

d. Study and understand anatomy and physiology of diabetes


Slide 33 of 38


Review question

3. How would you help people build their self-efficacy?

a. Allow them to practice one step at a time

b. Offer lectures and group discussions in diabetes education classes

c. Provide demonstrations by experts d. Elicit a physiologic response, such as

sweaty palms from being nervous


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Review question

4. Developing working personal targets for treatment for people with diabetes results in:

a. Increased stress for healthcare professionals because it is time consuming

b. Increased chance that the therapeutic strategies developed are implemented

c. People setting unrealistic goals for their health

d. Frustration that the healthcare professional is not looking after the person with diabetes


Slide 35 of 38


Review question

5. What is the most useful aspect of self blood glucose monitoring?

a. It helps obtain the information for healthcare professionals to determine treatment

b. It provides feedback about daily care and self-management activities

c. It helps individuals correlate symptoms with their blood glucose levels in order to interpret them

d. It reminds people to watch what they eat


Slide 36 of 38


Answers

1. b

2. d

3. a

4. b

5. b


Slide 37 of 38


References

1. Bergenstal R, Callahan T, Johnson M, et al. Management principles that most influence glycemic control: a follow up study of former DCCT participants. Diabetes 1996; 45 (Suppl 2): 124A.

2. HbA1cNow. Professional-Use Product Insert. (cited 2004 May 18) (1 page) Available from URL: http://www.HbA1cnow.com

3. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2004; 27(1): S15-35.

4. Bastyr E. Therapy focused on lowering postprandial glucose, not fasting glucose, may be superior for lowering HbHbA1c. Diabetes Care 2000; 23: 1236-41.

5. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab 2003; 27(suppl 2).

6. Jones H, Edwards L, Vallis TM, et al. Changes in diabetes self-management behaviors make a difference in glycemic control: the Diabetes Stages of Change (DiSC study). Diabetes Care 2003; 26: 732-7.

7. Karter AJ, Ackerson LM, Darbinian JA, et al. Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes Registry. Am J Med 2001; 111: 1-9.

8. Rohlfing CL, Wiedmeyer HM, Little RR, et al. Defining the relationship between plasma glucose and HbA1c. Diabetes Care 2002; 25(2): 275-8.


Slide 38 of 38


References

9. Von Kroff M, Gruman J, Schaefer J, et al. Collaborative management of chronic illness. Ann Intern Med 1997; 127(12): 1097-102.

10. Ceriello A, Hanefeld M, Leiter L, et al. Postprandial glucose regulation and diabetic complications. Archives of Internal Medicine 2004; 164(19): 2090-5.

11. IDF Clinical Guidelines Task Force. Global guideline for Type 2 diabetes. Brussels: International Diabetes Federation, 2005.

12. Canadian Diabetes Association. Dyslipidemia in Adults with Diabetes. Canadian Journal

of Diabetes 2006; 30(3): 230-240.

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