DIABETES SELF-MANAGEMENT

• Multiple studies have found that DSME is associated with

improved diabetes knowledge,improved self-care behavior

improved clinical outcomes, such as lowerA1C lower self-reported weight improved quality of life (8,11),healthy coping , and lower costs

The national standards provide patients with information across nine content areas that represent the core body of knowledge needed by patients with diabetes

• Diabetes disease process and treatment options

• Nutritional management

• Physical activity

• Using medications safely and for maximal therapeutic effectiveness

• Monitoring blood glucose and other parameters, and interpreting the results for self-management decisions

• Preventing, detecting, and treating acute complications

• Preventing, detecting, and treating chronic complications

• Personal strategies to address psychosocial issues and concerns

• Personal strategies to promote health and behavior change (eg, goal-setting)

Nutritional management

• WHY IS DIET IMPORTANT? — Many factors affect how well diabetes is controlled. Many of these factors are controlled by the person with diabetes, including how much and what is eaten, how frequently the blood sugar is monitored, physical activity levels, and accuracy and consistency of medication dosing. Even small changes can affect blood sugar control.

• Eating a consistent amount of food every day and taking medications as directed can greatly improve blood sugar control and decrease the risk of diabetes-related complications, such as coronary artery disease, kidney disease, and nerve damage. In addition, these measures impact weight control.

MEAL TIMING

• people, who take long-acting insulin (eg, NPH) and oral medications that decrease blood sugar levels (sulfonylureas or meglitinides

• people who take other types of oral diabetes medications (eg, insulin sensitizers such as metformin have more flexibility around meal timing.

Recommended calorie intake

• The number of calories needed to maintain weight depends upon your age, sex, height, weight, and activity level. In general:

• Men, active women - 15 cal/lb

• Most women, sedentary men, and adults over 55 years - 13 cal/lb

• Sedentary women, obese adults - 10 cal/lb

• Pregnant, lactating women - 15 to 17 cal/lb

• To lose 1 to 2 pounds per week (a safe rate of weight loss), subtract 500 to 1000 calories from the total number of calories needed to maintain weight.

• Between 25 and 35 percent of calories per day should be from fat

• less than 7 percent of calories per day should be from saturated fat; there should be minimal trans fat.

• Saturated and trans fats are found in solid fats like cheese, red meats, butter, and margarine .

• Total cholesterol intake should be less than 200 mg per day. The main sources of cholesterol in the diet are foods such as organ meats and egg yolks. Shrimp and squid are also moderately high in cholesterol but can be included in your diet occasionally because they are low in fat.

• Between 15 and 20 percent of calories should be from protein, except in people with certain kidney problems (chronic kidney disease or CKD). People with CKD are sometimes advised to eat a low-protein diet.

• A diet that is high in fiber (25 to 30 grams per day) may help to control blood glucose levels and hemoglobin A1c.

• A diet that is low in sodium (less than 1500 mg per day) and that is high in fruits, vegetables, and low fat dairy products, is recommended and can help manage blood pressure.

Avoiding weight gain • To avoid weight gain, the following tips are

recommended.

Measure your weight on a regular basis (eg, once weekly). Weight gains of more than 2 to 3 pounds indicate a need to decrease the amount you eat or increase activity.

Do not wait until weight increases by 10 or more pounds to take action.

It may be necessary to decrease your calorie intake by 250 to 300 calories per day to avoid weight gain.

If blood glucose levels are frequently low at a particular time of day, decrease the insulin dose or medication dose rather than add a snack.

Weight loss • Many people with type 2 diabetes are

overweight.• Losing even a small amount of weight (5 to 10

percent of total body weight) can help the body to produce and use insulin more efficiently

• There are several strategies that can aid in weight loss, including eating fewer calories, exercise, weight loss medications, and weight loss surgery.

• Previously, people with diabetes were told to avoid all foods with added sugar. This is no longer recommended, although sugar should be eaten in moderation.

• Artificial sweeteners do not affect blood glucose levels and may be consumed in moderation.

• FDA has tested and approved five artificial sweeteners: aspartame , saccharin , acesulfame-K , neotame, and sucralose .

•Sugar alcohols ( sorbitol , xylitol, lactitol, mannitol , and maltitol) are often used to sweeten sugar-free candies and gum, and increase blood glucose levels slightly.

• When calculating the carbohydrate content of foods, one-half of the sugar alcohol content should be counted in the total carbohydrate content of the food. Eating too much sugar alcohol at one time can cause cramping, gas, and diarrhea.

• If you take insulin, you should calculate your dose based upon the total number of carbohydrates in the food, which includes the sugar content, as described above.

• Products that are "sugar-free" or "fat-free" do not necessarily have a reduced number of calories or carbohydrates.

Exercise

• Advise people with diabetes to perform

at least 150 minutes per week moderate-intensity aerobic activity (50-70% of maximum heart rate)

• The activity should be distributed over at least three days each week no more than two consecutive days of inactivity. Diabetes Care Volume 37, Supplement 1, January 2014

Resistance training

• In the absence of contraindications,

patients with type 2 diabetes should be encouraged to do

at least two weekly sessions of resistance exercise

• with each session consisting of at least one set ( including 8 to 12

repetitions )of five or more different resistance exercises involving the large muscle groups .

Stretching exercise

• The guidelines suggest that adults also do muscle strengthening activities that involve all major muscle groups 2 days/ week.

• Certainly, high-risk patients should be encouraged to start with short periods of low-intensity exercise and increase the intensity and duration slowly.

• Vigorous exercise should be avoided in the presence of ketosis.

• However, it is not necessary to defer exercise based on mild hyperglycemia (<250 [13.9 mmol/L]), as long as the patient feels well and there is no ketonemia or ketonuria.

• If the pre-exercise blood glucose is <100 mg/dL insulin- or insulin secretagogue-treated patients:

should ingest extra food, in the form of 15 to 30 grams of quickly absorbed carbohydrate such as glucose tablets, hard candies, or juice

which should be taken 15 to 30 minutes before exercise and approximately every 30 minutes during exercise, based on repeat blood glucose testing during the exercise.

hypoglycemia Symptoms • Adrenergic symptoms • Neuroglycopenic symptoms

Risk factors • Timing, frequency, and carbohydrate content of meals• Acute illness• Exercise

TreatmentAsymptomatic avoiding critical tasks such as driving ingesting carbohydrates repeating the measurement in the near term adjusting the treatment regimen

Diabetologia 2009; 52:35.

Symptomatic

• fast-acting carbohydrate (such as glucose tablets, hard candy, or sweetened fruit juice) is available at all times.

• Fifteen to 20 grams is usually sufficient to raise the blood glucose into a safe range without inducing hyperglycemia.

• This can be followed by long-acting carbohydrate to prevent recurrent symptoms.

Severe

• Injection of 0.5 to 1.0 mg of glucagon will usually lead to recovery of consciousness within 10 to 15 minutes

Self-monitoring of Blood Glucose

Most patients on intensive insulin regimens should consider SMBG

prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are

normoglycemic, and prior to critical tasks such as driving

• The evidence is insufficient regarding when to prescribe SMBG and how often testing is needed for patients who do not use an intensive insulin regimen, such as those with type 2 diabetes using basal insulin or oral agents.

• It is important to evaluate each patient’s monitoring technique, both initially and at regular intervals thereafter.

• Optimal use of SMBG requires proper review and interpretation of the data, both by the patient and provider.

• Among patients who check their blood glucose at least once daily, many report taking no action when results are high or low .

Diabetes Care Volume 38, 2015