Marcia Johnson BSN RN CDE

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Diabetes Update

• Marcia Johnson BSN RN CDE
• marcia.johnson_at_spectrumhealth.org
• [phone]

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Overview of Today

• Physiology / pathophysiology
• Self-management areas and treatment goals
• Physical activity guidelines
• Nutritional management
• Pharmacological therapies
• Acute complications
• Chronic complications
• Special populations
• Case management and self-management support

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Objective 1

• Contrast physiology of normal fuel metabolism
  with pathophysiology of pre-diabetes, type 1,
  type 2 and gestational diabetes.

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Hey Sugar Sugar!
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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

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Fuel Metabolism Postabsorptive State
Liver releases glucose (glycogenolysis) and
makes glucose (gluconeogenesis)
S
S
S
S
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Activity different types of DM
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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

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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
  second-degree relatives (e.g. parents, siblings,
  or grandparents)
• High risk race/ethnic group (American Indian,
  African-American, Hispanic, or Asian/Pacific
  Islander)
• Signs of insulin resistance or conditions
  associated with insulin resistance (acanthosis
  nigricans, hypertension, dyslipidemia, polycystic
  ovarian syndrome).

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Testing in Asymptomatic Adults
If overweight (BMI 25) AND other risk factors
(or begin at age 45 w/o risk factors)

• HDL lt35
• Polycystic ovarian syndrome (PCOS)
• Prior A1c 5.7, IGT or IFG
• Insulin resistance syndromes
• History of CVD

• Physical inactivity
• First-degree relative with DM
• High risk race/ethnicity
• Hx GDM or baby gt 9 lb
• Hypertension

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How are Diabetes Pre-diabetes Diagnosed?
Fasting 2 Hr A1c
Normal 70-99 mg/dL under 140 lt5.7
Pre-Diabetes 100-125 mg/dL 140-199 5.7-6.4
Diabetes 126 or more 200 or more 6.5 or more
Or random BG over 200 with symptoms
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Gestational DM Screening at 24-28 Wks

• ACOG Criteria

• ADA-Proposed Criteria

50-g 1 hr OGTT for all If high (most use gt140) 100-g 3h OGTT GDM 2 or more below 50-g 1 hr OGTT for all If high (most use gt140) 100-g 3h OGTT GDM 2 or more below
Fasting 95 mg/dL
1 Hr 180 mg/dL
2 Hr 155 mg/dL
3 Hr 140 mg/dL
75-g 2 h OGTT for all GDM any of the below 75-g 2 h OGTT for all GDM any of the below
Fasting 92 mg/dL
1 Hr 180 mg/dL
2 Hr 153 mg/dL
At 1st prenatal visit, if high risk for DM
screen for undiagnosed type 2 DM with FBS or A1c
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Natural History of Type 2 Diabetes
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Objective 2

• Identify categories of diabetes self-management
  and glycemic treatment goals.

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AADE7 Self-Care Behavior Categories

• Healthy Eating
• Being Active
• Monitoring
• Taking Medication
• Problem Solving
• Healthy Coping
• Reducing Risks

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Behavior Monitoring
Targets Targets ADA AACE
Pre-meal BG 70-130 mg/dL 70-110 mg/dL
Post-meal BG peak lt180 mg/dL 2 h lt140 mg/dL
A1c lt7 lt6.5

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A1c
A1c eAG (estimated average glucose) mg/dl
6 126
6.5 140
7 154
7.5 169
8 183
8.5 197
9 212
9.5 226
10 240
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Glucose Meters

• Possible technique errors
• Coding
• Sites fingers vs. other
• Contaminants on finger
• Squeezing finger too hard
• Storage of supplies, expiration dates

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Barriers to Monitoring

• Cost, reimbursement, DME vs pharmacy
• Discomfort
• Nuisance
• Dont know what the numbers mean
• No one uses the info
• Why write the s down? Theyre in the memory
• High numbers Im bad

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Strategies to Enhance BG Monitoring

1. Make it meaningful self-experiment
2. Use the Noahs Ark Principle (pairs, pre/post
   meal)
3. Actually review the pts results
4. Congratulate the effort, not the s
5. Challenge self-worth interpretations (not
   good/bad s, just info and its all valuable)
6. Provide guidance in interpretation and promoting
   action

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Continuous Glucose Monitors (CGM)

• Professional vs. Patient
• iPro
• Dexcom
• Pump-enabled

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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.

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Behavior Being Active

• Physical Activity vs. Exercise
• Use of word exercise with patients

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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!

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Types of activity

• Aerobic
• Weight training / resistance
• Benefits of combination of aerobic and resistance
  training
• Mild activities (tai chi, yoga)
• Flexibility

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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

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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

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Adding Extra Steps
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Safety Thoughts

• General safety Liquids
• Pace
• Cell phone
• Feet Proper shoes
• Check feet after
• Low blood sugar

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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

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Break Time (go walk!!)
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Objective 4

• Explain nutritional management of diabetes,
  including carbohydrate, protein and fat intake.

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Behavior Healthy Eating

• Improves
• Blood sugar
• Blood lipids / cholesterol and triglycerides
• Weight
• Blood pressure

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Truth or Myth???
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McDs caramel sundae has same amount of carbs as
a Panera whole grain bagel
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People with diabetes should have no sugar
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People with diabetes need to eat snacks
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A cup of rice and a Big Mac have the same amount
of carbs
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What are Foods Made of?

• Carbohydrate
• Protein
• Fat
• What turns into blood sugar?

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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

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Methods of Meal Planning Plate Method
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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
Fats 0 0 5 45
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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)

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Carb Foods

• Grains, beans, and starchy vegetables
• Fruit and fruit juice
• Milk and yogurt
• Sweets

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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

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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

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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

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Vegetables

• Starchy kinds
• Watery kinds

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Reading Labels for Carbs
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Fiber

• What fiber helps
• Drink more
• Add fiber slowly
• Fiber on label
• 5g very good
• 2.5g good

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Adding Sugar?

• Sugar Includes
• White or brown sugar
• Honey or molasses
• Fructose
• Jelly, jam, syrup
• 1 Tbsp 1 carb choice

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Sugar Substitutes

• Examples
• Sucralose
• Aspartame
• Saccharin
• Acesulfame K
• Stevia

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Sugar Alcohols

• Sugar Free or Low Carb foods
• Do have carbs and calories
• Do affect blood sugar
• Laxative affect
• Label often end in tol
• Sorbitol, Lactitol , Xylitol

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Resources for Carb Info

• Booklets from CDE or RD
• Nutrition labels
• Calorie King and other books
• Apps (e.g. GoMeals.com)
• Internet

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Carb Scene Investigation Count the Carbs

• 5 oz. sirloin steak
• 6 oz baked potato
• 2 Tbsp. sour cream
• ½ cup cooked broccoli
• 2 oz. dinner roll
• 1 tsp. margarine
• frosted cake square (2 inch)
• 1 cup ice cream
• 8 oz. black coffee
• TOTAL

• 0
• 2 (30 gm)
• 0
• free
• 2 (30 gm)
• 0
• 2 (30 gm)
• 2 (30 gm)
• 0________
• 8 (120 gm)

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Other Carb Thoughts

• Counting carbs helps blood sugar
• Choosing healthy foods is also important
• Whole grains
• Fruits and vegetables
• Variety and color

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Meat / Protein

• No effect on overall blood sugar
• Vary in amount of fat and calories
• Choose leaner ones most often
• Need to limit protein?

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Meats (Protein)

• Fish and tuna

Poultry
Pork
Beef
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Meat Substitutes (Protein)

• Cheese and cottage cheese

Peanut butter
Eggs or egg substitutes
Tofu
Plant-based proteins
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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

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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

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Fat

• In meats / proteins
• In some carb foods
• Some foods are mostly fat add these to foods or
  cook with them.
• Calories / weight
• Bad kind of fats for heart

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Choose Healthier Types of Fats

• Choose most Mono-unsaturated
• Choose sometimes Polyunsaturated
• Limit/Avoid Saturated and Trans Fat

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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

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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

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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?

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Free Foods

• Beverages
• Sugarfree gelatin
• Light jam or jelly
• Sugar-free syrup
• Green salads

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Carb Scene Investigation Plus Count All

• 10 oz. sirloin steak
• 6 oz. baked potato
• 2 Tbsp. sour cream
• Tossed salad with 3 Tb ranch dressing
• 2 oz. dinner roll
• 2 tsp. stick margarine
• frosted cake square (2 inch)
• 1 cup ice cream
• 8 oz. black coffee

• 10 meats
• 2 carbs (30 gm)
• 1 fat
• 3 fats
• 2 carbs (30 gm)
• 2 fats
• 2 carbs (30 gm) fat
• 2 carbs (30 gm) fat
• 0________

TOTAL 8 carbs (120 g) and 10 meat and 6 fats
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Barriers to Healthy Eating

• Habit
• Hunger
• Taste / food preferences
• Cost
• Social
• Time / schedule
• Lack of support
• Lack of knowledge, recipes

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Objective 5

• Review pharmacologic therapies for glucose
  management based on current evidence-based
  guidelines.

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Behavior Taking Medication

• Oral medications
• Injection therapies
• Treatment algorithms

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Sites of Action for Oral DM Medications
Organ Organ effect on BG Problem Medication
Liver Glucose production Too much glucose production 1? Biguanides 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 a-glucosidase inhibitors
Gut hormones incretin effect Decreased incretin effect DPP-4 inhibitors
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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

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GLP-1 Actions

• Stimulates insulin secretion (glucose dependent)
• Suppresses glucagon secretion
• Slows gastric emptying
• Increases satiety

When food is ingested
GLP-1 is secreted from the L cells in the
jejunum and ileum

• Long-term effects
• demonstrated in animals
• Increases ß-cell mass
• Maintains ß-cell function

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Insulin Therapies

• Basal insulin (usually with oral agents)
• Prandial insulin
• Basal-bolus insulin
• Premixed insulin
• Older therapies Regular and NPH

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Insulin Profiles
Rapid-acting
Short-acting
Intermediate-acting
Plasma Insulin Levels
Long-acting
2
4
6
8
12
14
16
18
20
22
24
0
10
Time (hr)
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Insulins by Action Time

Rapid-acting Apidra Humalog NovoLog
Short-acting Regular
Intermediate-acting NPH
Long-acting Lantus Levemir
Pre-Mixes
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Injection Options

• Syringes
• Pumps

Pens
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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.

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Normal insulin release
Breakfast
Lunch
Supper
Bolus
Basal
400
400
800
1200
400
800
1200
800
Time
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Basal Bolus Insulin
Breakfast
Lunch
Dinner
Fastacting Bolus insulin Long-acting Basal
insulin
insulin shots
400
400
800
1200
400
800
1200
800
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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

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Example

• Correction Factor Insulin Dose
• 270 120 150 points above target (140)
• 150 50 3 units of insulin to correct BG
• Food insulin dose
• 75 grams carb 15 5 units of insulin
• Total insulin dose
• 3 5 8 units

BG is 270 Target 120 CF 50 Carbs planned 75
IC 115
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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

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AACE Consensus Algorithm 1/09
Tier 1 (in addition to lifestyle)
Step 2
Step 3
Step 1 At Diagnosis
Metformin Basal Bolus Insulin
Metformin basal insulin
Metformin
Metformin sulfonylurea
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Barriers to Taking Medication

• Medication Compliance
• The average patient misses about ______ of
  their oral diabetes medications.
• 2
• 5
• 10
• 25

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Barriers to Taking Medication

• One out of ______ patients misses one or more
  insulin injections per day.
• 3
• 5
• 10
• 20

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Barriers to Taking Medication

• Cost
• Time / schedule / forget / travel
• Dont feel it working
• Dont want to take/increase, think Ive 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

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Objective 6

• Identify signs/symptoms and management of acute
  diabetes complications.

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Behavior Problem-Solving

• Hypoglycemia
• Hyperglycemia
• Sick day guidelines
• Pattern management

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Symptoms of hyperglycemia

• Tired and grumpy

Thirst
Urinate more
Blurred vision Other hunger, infections (skin,
GU), wt loss, or no symptoms
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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

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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
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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

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Sick Day Rules

• Continue medications

Drink extra liquids Replace carbs Over the
counter medicines
Check blood glucoses Call physician
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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

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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 Decrease or loss of consciousness
Seizures
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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

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What to do next

Eat soon
Figure out cause, so it doesnt happen again
Notify doctor if frequent or severe Glucagon
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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

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Sam

• Sam spends most evenings in front of the TV. He
  has a hard time staying awake.
• 1. Do you think Sams blood sugars are too
  high or too low?
• 2. What might be the cause(s)?
• 3. What could he do?

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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?

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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

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Barriers to Problem-Solving

• Symptoms confusing
• Hard to find causes or patterns
• Lack of knowledge
• Frustration with numbers

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LUNCH TIME!
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Objective 7

• Identify key standards of care to delay, prevent,
  or minimize chronic diabetes complications.

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Type 2 Diabetes A Continuum

Normal
Insulin Resistance
Type 2 Diabetes
Prediabetes
Macrovascular Disease
Starting??
Microvascular Disease
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Categories of Complications

• Macrovascular
• CAD
• CVD
• PAD
• Microvascular
• Retinopathy
• Nephropathy
• Neuropathies

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Diabetes is a Vascular Disease

• 2/3 of pts with DM die of CAD or CVA
• PAD (peripheral artery disease) can lead to
  amputation

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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

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Standards of Care Key checks (HEDIS red)
Test Minimum Frequency Target
A1c 3-6 months lt7
BP Each office visit lt130/80
Cholesterol -LDL Each yr lt100, lt70 w/CAD
Depression screening Each yr
Eye exam (dilated or photo) Each yr
Foot exam Each yr
Kidney checks HEDIS Nephropathy attention Each yr Microalbuminuria lt30 Serum Creatinine 1.5 GFR 60
Immunizations Flu each yr, pneumovax per guidelines
Tobacco assessment Cessation
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Barriers to preventing chronic complications

• Years of no symptoms
• Tests/exams may not be done/ordered
• Costs
• Time
• Fatalism

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Heath Care Outcomes Continuum
Immediate Outcomes
Intermediate Outcomes
Post-Intermediate Outcomes
Learning Knowledge Skill Acquisition
Long Term Outcomes
Behavior Change
Improved Clinical Indicators
Improved Health Status
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Objective 8

• Discuss diabetes management in special
  populations.

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Pediatric Diabetes

• Type 1 vs. Type 2
• Age-specific responsibilities
• Safety concerns

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Pregnancy and Diabetes

• Risks to baby
• Macrosomia
• Hypoglycemia
• Jaundice
• Mom with type 1 or 2 DM
• Fetal anomalies
• Miscarriage

• Risks to mom
• Infections
• Polyhydramnios
• If macrosomia ? length of
  labor, ? chance of C-section

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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

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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

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Objective 9

• Discuss case management strategies for patients
  with diabetes including self-management support.

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Behavior Coping

• Compliance vs. Adherance
• Behavioral approaches
• Empowerment
• Motivational interviewing

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Patient Empowerment Approach

• Old way Go Greyhound and leave the driving up
  to us

• New way Let Hertz put you in the drivers seat
  today

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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
• Identify barriers
• Prioritize barriers to address
• 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
• Fear
• Fatalism
• Denial
• Perfectionism
• Anxiety
• Frustration

• Cost of care
• Age/physical limitations
• Cultural beliefs/traditions
• Lack of social support
• Lack of understanding, myths of diabetes

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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
High
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Readiness to Change

• How ready is the pt about making the change?

1 2 3 4 5 6
7 8 9 10 Not ready
Unsure Somewhat ready Very ready
Action
Pre-contemplation
Contemplation
Preparation
Ongoing- maintenance
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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

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Case Management

• Engagement
• Assessment
• Intervention
• Planning strategies
• Case Studies

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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--thats like from the bottom of my
heart, but deeper!
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