2 marcia johnson bsn rn cde marcia.johnson@spectrumhealth.org (616) 391-9288 diabetes update

2

Marcia Johnson BSN RN CDE

marcia.johnson@spectrumhealth.org(616) 391-9288

Diabetes Update

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.

85

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

99

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

103

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

105

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?

109

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

110

LUNCH TIME!

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Objective #7

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

112

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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

115

• 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

118

Heath Care Outcomes Continuum

119

ImmediateOutcomes

Improved Health Status

ImprovedClinical

Indicators

BehaviorChange

LearningKnowledge

Skill Acquisition

IntermediateOutcomes

Post-IntermediateOutcomes Long Term

Outcomes

Objective #8

Discuss diabetes management in special populations.

120

Pediatric Diabetes

• Type 1 vs. Type 2

• Age-specific responsibilities

• Safety concerns

121

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

122

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.

125

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

134

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!