Arab Minch University

Diabetes healthy life style training

(Self-management)

For diabetes
In Arab Minch Zuria Woreda

Feb , 2020
 Training Objectives
On completion of this Training , you will be able to:
• Promote and support healthful eating patterns

• Understand overall health life principles for diabetes:

• Understand individualized glycemic goals
• Understand exercise techniques to control blood glucose level

• Self administration of insulin

• Foot care
• Complication readiness and prevention

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Is healthy living with diabetes possible?
Diabetes self-management interventional areas

Diabetes self-management interventional areas

Diabetic interventions to improve self-
management habit on DM patients will focus on
IDF components which are on
– diet
– Exercise
– medication
– self-monitoring of blood glucose
Diabetes self-management interventional areas

– Modalities of treatment: Insulin and oral

hypoglycemic agent’s administration,
information of diet, level of blood glucose and
ketones monitoring.
– Identifications, prevention and treatment of
acute complications: Hypoglycemia and
Hyperglycemia
– Pragmatic information: Source and storage of
insulin syringes and monitoring of glucose
supplies and map road to physician
 Definition

Diabetes mellitus is a group of metabolic disorders

characterized by elevated levels of glucose in the blood
(hyperglycemia) resulting from defects in insulin
secretion, insulin action, or both.

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 CLASSIFICATION OF DIABETES
MELLITUS

• Type 1
• Type 2
• Gestational

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 Risk Factors for Diabetes
Type 1 Type 2
• Under 30 • Older age
• Genetics • Overweight
• Autoimmune • Hypertension
• Environment • Abnormal lipid levels
• Viral infection • Genetics
• Race/ethnicity
• History of gestational diabetes
• History of vascular disease
• Inactivity
Type 1
 Usually under 30
Rapid onset
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
 Normal or underweight
 Little or no insulin
 Ketosis common
 Make up 15% of cases
 Autoimmune
environmental factors
 Low familial factor
 Treated with insulin, diet and
exercise
Type 2
 Usually over 40
 Gradual onset
 80% are overweight
 Most have insulin resistance
 Ketosis rare
 85% of diagnosed cases
plus
 Metabolic insulin resistance
syndrome
 Strongly hereditary
 Diet & exercise, progressing to
tablets, then insulin
 Diagnostic Criteria

* Symptoms of diabetes plus casual(random) plasma

glucose concentration > 200 mg/dl. Or
* Fasting plasma glucose > 126 mg/dl on two separate
occasions. I.E. No caloric intake for at least 8 hours. Or
* OGTT level > 200mg/dl after 2 hrs (not recommended
for routine clinical use)

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Cornerstones of Diabetes Management

Nutritional management
Exercise
Monitoring
Pharmacologic therapy
Education

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 Mangt cont’d….

Type one: insulin + healthy eating + exercise

Type two:

Healthy eating + exercise

Then healthy eating + exercise + OHA

Then healthy eating + exercise + OHA + insulin

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 Health eating
• Aim to eat mostly fruits, vegetables, whole-
grain foods, low-fat dairy products, and lean
meat, poultry, fish or meat alternatives.
• Developing a plan with a registered dietitian
knowledgeable about diabetes-specific
nutrition is a good idea, especially if you’re
just starting out. 
Include
Fiber-rich Whole Grains
(for example: oatmeal, barley, brown rice,
whole grain pasta, whole wheat, and corn)
Non-fried fish at least twice per week,
especially those high in omega-3 fatty acids
(such as: salmon, lake trout, mackerel, and
herring)
Chicken or turkey
(without the skin)
Lean meats
(round, sirloin, chuck, and loin)
Fruits and Vegetables
(deeply colored such as spinach, carrots, peaches and
berries)
Vegetable oils and margarines
(soft/tub or liquid)
Fat-free, 1-percent fat, and low-fat dairy products
Unsalted nuts, seeds, and legumes
Limit
Sweets and added sugars
(for example: table sugars sucrose, glucose, fructose, maltose, dextrose,
corn syrups, high- fructose corn syrup, concentrated fruit juice, honey,
soda, fruit drinks, candy, cake, and jellies)
Fatty and processed meats
(such as: fatty beef and pork, salami and hot dogs)
Sodium
(consume less than 2,300 milligrams (mg) a day and an ideal limit of less
than 1,500 mg per day for most adults.)
Cholesterol
(consume less than 300 mg per day)
Partially hydrogenated or trans fats
(contained in hard margarine, shortening, cakes, cookies, crackers, pastries, pies,
muffins, doughnuts, and French fries)
Saturated fats
(contained in dairy products such as butter, whole milk, 2% milk and cheese, fatty
meats and poultry, coconut oil and palm oil, hydrogenated oils, and foods made with
these ingredients).
Alcohol
(females should limit to one drink/day; males limit to two drinks/day)
 
 Health eating cont’d…

 Avoided excessive salt intake particularly restricted in

people with hypertension and those with
nephropathy.
 Moderate alcohol
 Spreading meals evenly with the addition of snacks if
necessary, helps to prevent hypoglycemic reactions
and maintain overall blood glucose control.

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 Exercise
 lowers blood glucose by:
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Increasing uptake of
glucose by muscles and
improves insulin utilization

improving circulation
and muscle tone
decreasing total
cholesterol and
triglyceride levels
 Precautions during
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exercise

 Need to monitor BS before,

during and after exercise
 Not exercise until urine test
negative for ketones and blood
glucose levels are near to normal
 If on insulin, eat 15g snack before
beginning
 …precaution cont’d
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 Carry a quick source of • Regular exercise 20-30

sugar when exercising minutes, aerobic
 It should be moderate and exercise such as jogging,
regular walking, swimming etc.
 Avoid trauma to the feet 3 – 4 days is

It should be under recommended.

physician supervision.
 Monitoring
 Self-monitoring of blood glucose
• Patients on insulin should check sugars 2-4 times per
day(usually before meals and at bedtime).
• Not on insulin, at least 2 -3 times per week
• For all patients, testing is recommended whenever
hypoglycemia or hyperglycemia is suspected, with changes
in medications, activity, or diet, and with stress or illness.
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 OHGA

 Not recommended for diabetes in pregnancy

 Are not the first line therapy in diabetes diagnosed
during stress, such as infections.
 When indicated, start with a minimal dose, while
reemphasizing diet and physical activity.
 An appropriate duration of time (2-16 weeks
depending on agents used).
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 Who should have insulin therapy?

Newly diagnosed type 1

In type 2 diabetic on maximum tablets,
contraindications to OHA (renal failure, poor
tolerance)
Stress or situations such as surgery, corticosteroid
therapy, infections, treatment for DKA, HHNS
Pregnancy; gestational diabetes who are not
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adequately controlled with diet.
Insulin preparations
– Rapid acting (lispro, asparte)
– Short acting (regular)
– Intermediate acting (Lente)
– Long acting

-Ultralente
-Glargine/lantus

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33
 Adverse effects of insulin therapy

 Hypoglycaemia
 Local allergic reaction( itching, erythema, and burning
around injection site)
– Usually occur during the beginning stages of therapy
– Antihistamine may be taken 1 hour before the
injection
 Systemic allergic reactions (urticaria and anaphylactic
shock)-rare
– Treatment is desensitization, small doses of insulin
administered in gradually increasing amounts 34
 …adverse rxn cont’d

 Insulin lipodystrophy
– Atrophy or hypertrophy of subcutaneous fat at
injection sites
– Rotate within site to prevent the problem
 Insulin insensitivity or resistance
– Being obese (common cause)
– Interrupting insulin therapy for several months
– Require high dose of insulin/more concentrated
insulin preparation
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 …adverse rxn cont’d

Morning hyperglycemia -can be due to

Insulin waning; progressive rise in blood glucose from
bedtime to morning
• Managed by increasing evening dose
Dawn phenomenon; relatively normal blood glucose
until about 3 am, when the level begins to rise
• Result from nocturnal surges in GH secretion
• Change time of injection of evening insulin from
dinnertime to bedtime.

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 …adverse rxn cont’d

Somogyi Effect
 Normal or elevated blood glucose at bedtime, a
decrease at 2–3AM to hypoglycemic levels, and a
subsequent increase caused by the production of
counter regulatory hormones
 Managed by decreasing the evening dose, or increase
bedtime snack.
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 Insulin administration sites
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 Abdomen- more stable and rapid

absorption
 Posterior arms
 Anterior thighs
 Hips
 Inject at appropriate angle
(45-90) depending on depth of
subcutaneous tissue
 Do not inject insulin to limb
which will be used to exercise.
 Rotation
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Use same anatomic area at the same

time of day
Rotation within site must occur to
prevent lipodystrophy and to promote
consistency in absorption (0.5 to 1
inch away)from the previous injection.
Not to use the same site more than
once in 2 to 3 weeks
 Teaching Patients to Self-Administer
Insulin
• Basic information includes explanations of :

Insulin Storage-insulin vial in use should be kept at room

temperature
Selecting Syringes- Syringes must be matched with the insulin
concentration
Mixing Insulins- regular insulin can be drawn up first
– longer-acting insulins must be mixed thoroughly before
drawing into the syringe
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 ….education cont’d

• Withdrawing Insulin- instruct patients to inject air into

the bottle of insulin equivalent to the number of units
of insulin to be withdrawn
• Selecting and Rotating the Injection Site
• Preparing the Skin-use of alcohol to cleanse the skin is
not recommended

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 ….edc cont’d
Inserting the Needle -for a normal or
overweight per-son, a 90-degree angle is the
best insertion angle
– aspiration is not recommended
Removing the needle and holding cotton ball
over site
Disposing of Syringes and Needles

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Acute complications of Diabetes Mellitus

Hypoglycemia
 abnormally low blood glucose level occurs
when the blood glucose falls to less than 50 to
60 mg/dL.
is caused by
– Overdose of insulin or hypoglycemic agents
– Missing of meal
– Strenuous exercise
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Clinical manifestations

Early: cold sweat, tremor, hunger, tachycardia,

palpitations.
Late: dizziness, inability to concentrate,
blurring, headache, numbness of the lips and
tongue, difficulty arousing from sleep,
nightmares, seizure and coma
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 Management

Treatment must be immediate

Quickly check BGL if able. if in doubt, treat as a
hypoglycemia.
If conscious and safely able to swallow; 15 g of fast-
acting carbohydrate given orally
3 or 4 commercially prepared glucose tablets or
4 to 6 oz of fruit juice or
6 to 10 hard candies or
2 to 3 teaspoons of sugar or honey
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 ….Magt cont’d

Recheck BS after 15 minutes, if it is less than 70 to 75

mg/dl , repeat treatment.

If the symptoms persist more than 10 to 15 minutes

after initial treatment, the treatment is repeated even if
blood glucose testing is not possible.

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After improvement, a snack containing protein and
starch (e.g., milk or cheese) is recommended.

Prolonged unconsciousness requires administration of

glucagon (1mg)Sc or IM injection or 25 to 50 mL of
50% dextrose in water (D50W) IV.

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 Teaching prevention techniques

 Consistent pattern of eating, administering

appropriate dose of insulin, and exercising
 Snacks may be needed to counteract the maximum
insulin effect
 Need for routine blood glucose tests
 Advice to wear an identification bracelet or tag stating
that they have diabetes
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 ….teaching cont’d

• Patients and family members must be instructed to

recognize the symptoms of hypoglycemia.

• Patients with DM especially those receiving insulin,

learn to carry some form of simple sugar with them
at all times.

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Complications
 Diabetic Ketoacidosis

• DKA is caused by an absence or markedly inadequate

amount of insulin.
• It is often the reason a person with undiagnosed type 1
diabetes first seeks help
• The three main causes of DKA
– Decreased or missed dose of insulin
– Illness or infection
– Undiagnosed or untreated diabetes

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 Clinical Features

Three main clinical features:

– Hyperglycemia

– Dehydration and electrolyte loss

– Acidosis(ketosis)

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 ….s/s cont’d

 Polyuria and polydipsia

Extreme fatigue and weakness
 Dry tongue and bucal mucosa , poor skin turgor
and hypotension
 Nausea and vomiting, abdominal pain
 Kussmaul respiration : deep and fast breathing
(hyperventilation)
 Acetone ("fruity") odour of breath
 The patient may be alert, lethargic, or comatose
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55
 Treatment of Foot Ulcers

• Bed rest
• Antibiotics
• Debridement
• Good control of blood glucose (usually increases with
infection).
• Amputation may be necessary to prevent spread of
infection
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• Shoes should not be to thigh or loose
 Essentials of Foot Care
Examination
– Annually for all patients
– Patients with neuropathy-visual inspection of feet at every visit
with a health care professional
Advise patients to:
– Use lotion to prevent dryness and cracking
– Cut toenails weekly or as needed
– Reducing risk factors, such as smoking and elevated blood
lipids, that contribute to peripheral vascular disease
– Always wear socks and well-fitting shoes
– Good foot hygiene
– Notify their health care provider immediately if any foot
problems occur(daily assessment) 58
Glycemic control is the
key in preventing
complications

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Chronic Care Model and Diabetes
 Chronic Care Model and Diabetes
• The patient becomes knowledgeable and the expert in
diabetes and its complications
• The patient understands the importance of taking control of
their diabetes
• The patient has people who are important to them and their
management of diabetes and the provider includes them as
the patient wants
• The provider will take time to build a relationship with the
patient and understands their beliefs, values, culture
Maslow’s Theory
Using the 5 “A’s” With Diabetes

• Assess
• Advise
• Agree
• Assist
• Arrange
 Empowering Patients: 4 Important
Lessons Patient Need to Learn

• Their illness is serious

• Their condition is essentially self-
managed
• They have options
• They can change their behavior
Helping Patients Set Goals

• Start at the problem

• Develop a collaborative goal
• Validate their goal and plan
 Old Model vs New Model:
Being put on Insulin
Old Model New Empowering Model
If you don’t start to control You have been working to
your blood glucose, I am control your blood glucose,
going to have to put you on but often a patient will
insulin and you will have to need some assistance form
take shots. Your diabetes insulin. Research shows
is not getting any better. that starting someone on
insulin sooner than later,
assists them in getting
better control. What about
insulin concerns you?
World Health Organization and Diabetes

• The mission of the WHO Diabetes

Program is to prevent diabetes
• Core Functions
• Diabetes Action Now
• World Diabetes day
 Summary
• Diabetes is a chronic condition affecting millions
worldwide
• Self-management techniques can delay or
prevent complications
• Empowering the and becoming a partner with
them, will help provide positive results of
control
• Tools were given to assist the provider in
understanding diabetes and thus assisting their
patients
Summery…
Questions and Discussion