Gems from AADE and ADA 2008

Affiliate Conference Call 9/24/08

An Unmet Need: Enhancing Diabetes Care in Skilled Nursing FacilitiesElaine D. Sullivan, MS, RN, CDE

Karen McAvoy, MSN, RN, CDE

Differences Sub-acute vs. LTC Residents

• Sub-acute residents

Tight BG control to promote healing and prevent long term complications

Demonstrate independence in diabetes survival skills before discharge

• Frail LTC residents

Avoid hypoglycemia

Prevent hospitalization for acute and chronic complications

Why Do People With Diabetes in SNF End Up In The Hospital?

• Severe hypoglycemia can cause: Falls

Heart attacks and strokes

• Infection and/or dehydration can cause severe hyperglycemia (HHNS)

• Amputations due to neglected foot injuries

• All the reasons other people go to the hospital Higher risk for cardiac events, stroke and

infection

The Joslin Program to Improve SNF Care• Staff and physician orientation and

ongoing education

• Verification of staff competence

• On site Diabetes Care Coordinator

• Joslin patient education and materials

• Joslin guidelines and protocols

• Data collection and analysis

• Endocrinologist/nurse practitioner consultation

Case Example—Short Stay Patient• V.B. - 73 yo white female with type 2 dm x 10 years

Never received any diabetes education Not taking care of her diabetes at home

• Admitted to the facility for pulmonary edema 1 ½ month stay, received OT and PT services and diabetes education

• Admission A1c 9.4% (4/14/08); 1 low at bedtime• On Levemir 13 units and Novolog 12 ac• Levemir adjusted slightly, Novolog 14 with breakfast and 9

with lunch and dinner• 5/22/08

Fructosamine 312 umol/L(Non-diabetes normal range 190-270 umolL) FBS range 96 – 154 mg/dl before discharge

• Post- discharge A1C 7.5% (7/14/08)• LaGreca’s Self Care Inventory on admission 61; 1 month post

discharge 75

Physical Activity, Exercise,

and Obesity: Clearing the Hurdles to

Success

AADE 35th Annual MeetingWashington, D.C.

August 9,2008

Karen Kemmis, PT, DPT, MS, CDEkemmisk@upstate.edu

Donna Wolf, PhD, ACSMESwolfd@upmc.edu

Objectives1. Discuss the benefits of physical activity, state

the components of an exercise prescription, and describe the current evidence-based guidelines for physical activity/exercise for individuals with diabetes.

2. List common barriers to physical activity and identify strategies to overcome these barriers for those who are overweight or obese.

3. Create a successful physical activity/exercise plan for the person with obesity to prevent or treat diabetes.

Summary of benefits of physical activity

Improved glycemic control

Increased fat free (muscle) mass

Reduction in visceral adipose tissue and sub-Q adipose tissue

Increased insulin response

Decreased plasma triglycerides

Thomas DE et al Cochrane Collaboration 2006

Stronger muscles, bones, joints

Increased endurance Improved CV

parameters Psychological benefits Weight

loss/maintenance Improved ease of ADLs Decreased mortality

Pain: Options for exercise Walking (running) Stationary bike Outdoor bike Exercise video/DVD

(walking, dancing, sitting)

Elliptical Glider

Recumbent stepper Water exercise Swimming Exercise programs/

classes Fitness clubs Resistance training Physical therapy

AADE Position Statement “Diabetes educators play a vitally important role

in overcoming barriers to regular exercise participation.

…be prepared to apply counseling strategies that will enhance adoption and long-term maintenance of a physical activity habit.

…include assisting in a plan to introduce exercise in a safe and progressive manner, emphasizing proper selection of goals and rates of progression.”

Hayes C et al The Diabetes Educator 2008

Prevention of Diabetes Prevention of Diabetes Through School-Based Through School-Based Nutrition InterventionsNutrition Interventions

By: Sheri Hotchkiss, RD, LD, CDE, Ericka Pine, RD, LD

Healthy Moves ProgramHealthy Moves Program

Goal is to improve food choices and increase activity in school-aged children.

Requested by middle school teacher as part of health curriculum.

Includes an interactive nutrition lesson, cooking demonstration and physical activity.

Healthy Moves SessionsHealthy Moves SessionsExercise = Fun!Jump Start With BreakfastWhole-ly Great Grains!Green-Light, Red-Light – Healthy Snacking Made

Easy!Sugar, Sugar Everywhere!Fast Fat FactsFruit and Veggies: Meet Our Family – “Uncle Fight-

O-Chemical and Antie Oxidant”The Calcium Scramble Game: Make It or Break It!

Standardized newslettersIncentive program that works? Of adding a web componentGrant

Changes for future programsChanges for future programs

Other Highlights from AADE…

Humor: Facilitating the Laugh-Learn Connection with Your Patients with DiabetesTheresa Garnero, APRN, BC-ADM, MSN, CDE

• Benefits of using humor in your practice Laughing lower glucose levels Reduces stress and pain Improves immune function Allows for expression of anger Minimizes professional burnout Turns a “ha ha” moment into an “aha” moment

Humor: Facilitating the Laugh-Learn Connection with Your Patients with Diabetes• Possible negative “side effects” of humor

Can be hurtful Some people can get offended Can distract from the message Can promote anger

• Practice Pearls Assess – test the waters, assess readiness for humor Ask if humor is helpful Watch the eyes and listen to the tone of the laugh Too much laughing may indicate high stress Apologize if offense is taken Less is more! If you use cartoons in your presentations, you must get

permission from the author

Dietary Supplements for Diabetes: The Intriguing IntricaciesLaura Shane-McWharter, PharmD

• Diabetes patients 1.6x more likely to use complementary/alternative medicine

• 20-30% of people with DM take supplements; 28% use herbal products

• Cinnamon: increases insulin sensitivity may lower BG and lipids, but not A1C ½ -1 tsp powdered cinnamon per day should be water-extracted

Dietary Supplements for Diabetes: The Intriguing Intricacies• Chia (salvia)

As seen on Oprah! Seeds are used; very high in fiber and alpha linolenic acid May decrease postprandial BG and blood pressure But may increase TG levels and risk for prostate CA

• Salacia Roots and stems used Inhibits alpha-glucosidase in brush border More potent than Precose Can lower postprandial BG Dose: 240-1000 mg per day

Motivational InterviewingSummary

Two speakers-

Elaine Massaro, MS, RN, CDE

Micheal Goldstein, MD

MI- Definition

• (Previous) A skillful clinical style for eliciting pts own motivation, and guiding them towards effective use of Self-Management strategies

• (New)“A skillful clinical style for eliciting from pts their own motivation for making changes in the interest of their health”

•Micheal Goldstein, MD Institute for HC Communication- New Haven, CT / (Rollnick, Miller, Butler “Motiv interviewing in HC”—2 008)

The key- Core Skills

* Core skills for Motivational Interviewing-Build a relationship-Explore the person’s needs, expectations, values-Share Information-Use Collaboration when goal setting-Engage in shared Action Planning-Build Skills for problem solving

* Follow up on progress/ achievements

(new health partnerships: www.newhealthpartnershhips.org)

Key Elements

• Expressing empathy, Roll with resistance;

develop discrepency; support self efficacy• Use a “guided” communication style:

asking; informing; listening;

use equal amounts of all three. (Rollnick,2008) • Use “open ended” questions;

affirmations; reflective listening; summaries

Remember:

The Pt has the Freedom of choice….

The Professional offers advice….

when asked….

What other tidbits did you bring back from AADE, ADA or other

national meetings???