2 marcia johnson bsn rn cde [email protected] (616) 391-9288 diabetes update
TRANSCRIPT
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
6 insulin
Fuel Metabolism: Postabsorptive State
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Liver
Glucose (sugar)Storage
SSSS
Liver releases glucose (glycogenolysis) and makes glucose (gluconeogenesis)
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
•Physical inactivity
•First-degree relative with DM
•High risk race/ethnicity
•Hx GDM or baby > 9 lb
•Hypertension
•HDL <35
•Polycystic ovarian syndrome (PCOS)
•Prior A1c ≥5.7, IGT or IFG
•Insulin resistance syndromes
•History of CVD11
If overweight (BMI ≥25) AND other risk factors (or begin at age 45 w/o risk factors):
How are Diabetes & Pre-diabetes Diagnosed?
Fasting
2 Hr
A1c
NormalNormal
70-99 70-99 mg/dLmg/dL
under 140under 140
<5.7%<5.7%
Pre-DiabetesPre-Diabetes
100-125 100-125 mg/dLmg/dL 140-199140-199
5.7-6.4%5.7-6.4%
Diabetes
126 or more 200 or more
6.5% or more
Or random BG over 200 with symptoms
Gestational DM Screening at 24-28 Wks
ACOG Criteria ADA-Proposed Criteria
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50-g 1 hr OGTT for all
If high (most use >140):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
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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050
100
150200250
-10 -5 0 5 10 15 20 25 30
Years of Diabetes
Glucose(mg/dL)
Relative Function(%)
Insulin Resistance
Insulin Level-Cell Failure
*IFG=impaired fasting glucose.
50100150200250300350
Fasting Glucose
Post-meal Glucose
Obesity IFG* Diabetes Uncontrolled Hyperglycemia
Natural History of Type 2 Diabetes
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
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Targets ADA AACE
Pre-meal BG 70-130 mg/dL 70-110 mg/dL
Post-meal BG peak <180 mg/dL 2 h <140 mg/dL
A1c <7% <6.5%
A1c A1c%
eAG (estimated average glucose)
mg/dl6 126
6.5 140
7 154
7.5 169
8 183
8.5 197
9 212
9.5 226
10 24018
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
• Don’t know what the numbers mean
• No one uses the info
• Why write the #’s down? They’re in the memory
• High numbers = I’m bad
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Strategies to Enhance BG Monitoring
1. Make it meaningful: self-experiment
2. Use the Noah’s Ark Principle (pairs, pre/post meal)
3. Actually review the pt’s results
4. Congratulate the effort, not the #’s
5. Challenge self-worth interpretations (not good/bad #’s, just info and it’s all valuable)
6. Provide guidance in interpretation and promoting action
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!
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
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”
Adding Extra Steps
Safety Thoughts
General safety: Liquids Pace
Cell phone
Feet: Proper shoes Check feet after
Low blood sugar
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
Truth or Myth???
McD’s caramel sundae has same amount of carbs as a Panera whole grain bagel
People with diabetes should have no sugar
People with diabetes need to eat snacks
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
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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 subsPlant-based
0 Up to 15
7 0-8+ 45-100
Fats 0 0 5 45
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
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 label5g = very good2.5g = 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
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)61
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
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Plant-based proteins
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
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1. In meats / proteins
2. In some carb foods
3. Some foods are mostly fat– add these to foods or cook with them.
• Calories / weight
• “Bad” kind of fats for heart
Choose Healthier Types of FatsChoose most: Mono-unsaturated
Choose sometimes: Polyunsaturated
Limit/Avoid: Saturated and Trans Fat
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Watch Portion SizesMost 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
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
• Sugar–free 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
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 MedicationsOrgan Organ effect on
BGProblem Medication
Liver Glucose production
Too much glucose production
1: Biguanides2: TZDs
Muscle &AdiposeTissue
Glucose uptake Insulin resistance decreases BG uptake
1:TZDs2:Biguanides
Pancreas Insulin production lowers BG
Too little insulin production
Secretagogues:Sulfonylureas & Meglitinides
Gut Carb digestion into glucose
Carbs raise BG too much
α-glucosidase inhibitors
Gut hormones’ incretin effect
Decreased incretin effect
DPP-4 inhibitors78
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
Long-term effects demonstrated in animals: • Increases ß-cell mass • Maintains ß-cell function
When food is ingested…
GLP-1 is secreted from the L cells in the jejunum
and ileum
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
0 2 4 6 8 10 12 14 16 18 20 22 24
Pla
sma
Insu
lin L
evel
s
Short-acting
Intermediate-acting
Time (hr)
Long-acting
Rapid-acting
Insulins by Action Time
Rapid-acting ApidraHumalogNovoLog
Short-acting Regular
Intermediate-acting NPH
Long-acting LantusLevemir
Pre-Mixes
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Injection Options
Syringes
Pumps
Pens
“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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4:004:00 4:004:00 8:00 8:00 12:0012:00 4:004:00
BreakfastBreakfast LunchLunch SupperSupper
8:008:0012:0012:008:008:00
TimeTime
Basal
Bolus
Normal insulin release
Basal Bolus Insulin
4:004:00 4:004:00 8:00 8:00 12:0012:00 4:004:00
BreakfastBreakfast LunchLunch DinnerDinner
8:008:0012:0012:008:008:00
= insulin shots
Fast–acting
Bolus insulin
Long-acting
Basal insulin
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
I:C = 1:15
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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Metformin
Metformin + basal insulin
AACE Consensus Algorithm 1/09
Tier 1 : (in addition to lifestyle)
Step 2
Metformin + sulfonylurea
Step 3Step 1
At Diagnosis
Metformin + Basal Bolus Insulin
Barriers to Taking Medication
“Medication Compliance”
The average patient misses about ______ % of their oral diabetes medications.
A. 2%
B. 5%
C. 10%
D. 25%
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Barriers to Taking Medication
One out of ______ patients misses one or more insulin injections per day.
A. 3
B. 5
C. 10
D. 20
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Barriers to Taking Medication
• Cost
• Time / schedule / forget / travel
• Don’t feel it working
• Don’t want to take/increase, think = I’ve 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
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
Figure out cause, so it doesn’t happen again
Notify doctor if frequent or severe
Glucagon
Eat soon
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Hypoglycemia causes & prevention
Eating too few carbs or delayed meal
Too much DM medication taken or medication needs (recovering from illness or losing weight)
Alcohol w/o food / carbs
More active than usual
Sam
Sam spends most evenings in front of the TV. He has a hard time staying awake.
1. Do you think Sam’s blood sugars are too high or too low?
2. What might be the cause(s)?
3. What could he do?
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
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 Prediabetes Type 2 Diabetes
Macrovascular Disease
Microvascular DiseaseStarting??
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Categories of Complications
• Macrovascular• CAD• CVD• PAD
• Microvascular• Retinopathy• Nephropathy
• Neuropathies
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• 2/3 of pts with DM die of CAD or CVA
• PAD (peripheral artery disease) can lead to amputation
Diabetes is a “Vascular Disease”
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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
Standards of Care: Key checks (HEDIS red)
Test Minimum Frequency Target
A1c 3-6 months <7%
BP Each office visit <130/80
Cholesterol -LDL Each yr <100, <70 w/CAD
Depression screening Each yr
Eye exam (dilated or photo)
Each yr
Foot exam Each yr
Kidney checksHEDIS: Nephropathy attention
Each yr Microalbuminuria: <30Serum Creatinine: ≤1.5GFR: ≥60
Immunizations Flu each yr, pneumovax per guidelines
Tobacco assessment Cessation117
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
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ImmediateOutcomes
Improved Health Status
ImprovedClinical
Indicators
BehaviorChange
LearningKnowledge
Skill Acquisition
IntermediateOutcomes
Post-IntermediateOutcomes Long Term
Outcomes
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 driver’s 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:
1. Identify barriers
2. Prioritize barriers to address
3. 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 10Not ready Unsure Somewhat ready Very ready
Pre-contemplation Contemplation Preparation Action
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
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
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Thanks for coming, from the bottom of my pancreas--that’s like from the bottom of my heart, but deeper!
