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DIABETES 1

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DIABETES Housekeeping items Washrooms Refreshment breaks Introductions 2

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Learning Objectives DIABETES To identify how the body produces insulin, how it is used and causes that reduce the efficiency of insulin production. To discuss the two types of Diabetes. Describes Hyper and Hypoglycemia signs/symptoms and interventions. 3 To understand the nutrition guidelines for healthy eating as it pertains to diabetes. Discuss causes of Type II diabetes and ways to decrease the risks. Discuss blood glucose testing, insulin pumps, medications and current trends in managing diabetes. (2009 Canadian Diabetes guidelines will be used)

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DIABETES FACTS: The prevalence of diabetes has reached epidemic proportions. 3 Million people in Canada have Diabetes. 10% have Type I 90% have Type II 4 80% of Type II diabetes is preventable by changing diet, increasing physical activity and improving the living environment. Diabetes is responsible for over one million amputations each year, a large percentage of cataracts, and at least 5% of blindness worldwide. http://www.worlddiabetesfoundation.org/composite-35.htm (World Health Organization-WHO

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DIABETES What is it? Metabolic disorder that occurs when the body cannot produce enough insulin or the insulin being produced is not being used effectively. Basically means, the body cannot properly use the energy from the food that is ingested. 5

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The Pancreas Is located in the abdomen. Contains the beta cell that synthesizes and secretes insulin. Beta cells are located near blood vessels and can easily respond to changes in blood glucose levels by adjusting insulin production. Insulin helps with uptake of glucose, the main fuel source, into cells of tissues such as muscle. 6 http://commons.wikimedia.org/wiki/File:Illu_pancreas e.jpg

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Glucose and Insulin Glucose and Insulin Glucose: Is produced when the body breaks down the food eaten. Carbohydrates (starches) and sugars, into a simple sugar, called glucose. Is the bodys main source of fuel and is used in the cells for energy. 7 Insulin: Is a hormone produced in the pancreas to control the amount of sugar in the blood. It helps the glucose (sugar) leave the blood stream and enter body cells.

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Figure 7.1. Insulin Production in the Human Pancreas( 2001 Terese Winslow, Lydia Kibiuk) Figure 7.1. Insulin Production in the Human Pancreas( 2001 Terese Winslow, Lydia Kibiuk) 8

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Types of Diabetes Type I Type I The body makes little or no insulin. Type II Type II Body still produces some insulin but it cannot be used properly. Gestational Diabetes Gestational Diabetes Temporary diabetes that some women develop during second half of pregnancy. Most women return to non-diabetic state following delivery. 9

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Type I (Immune- Mediated) Is a disease process where the pancreas does not produce insulin. Defect in immune system that destroys beta cells that create insulin. Glucose builds up in the blood and cannot transport to the cells (Hyperglycemia). Is NOT caused by eating too much sugar or obesity. 10 Usually develops in childhood or adolescence. Affects approx. 1 in 500 children. Daily injections of insulin are required for life (although researchers are working hard on alternatives i.e. insulin pumps). Is manageable by monitoring blood glucose levels, diet and exercise and insulin therapy.

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Signs and symptoms of diabetes include the following: Unusual thirst. Frequent urination/bed wetting. Weight change (gain or loss). Extreme fatigue or lack of energy. Blurred vision. Frequent or recurring infections. Cuts and bruises that are slow to heal. Tingling or numbness in the hands or feet. Trouble getting or maintaining an erection. http://www.diabetes.ca/about-diabetes/what/facts/ 11

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Treatments 1. Education All persons need to be educated about the signs and symptoms of diabetes and importance of healthy living. 12 2. Lifestyle Changes Learning how to manage stress will help with managing diabetes. Exercise lowers blood glucose, helps with weight loss and stress. Extra planning (food) needed for extra activity days (check with family).

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Treatments 3. Nutrition Good blood glucose control is achieved through balanced use of Canadas Food guide http://www.hc-sc.gc.ca/fn- an/food-guide- aliment/order- commander/index- eng.php#2 13 The important information regarding food to follow is child specific. Children with Diabetes are often followed by Registered Dieticians (RD). Here is some general information on foods that work with diabetes:

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Dietary Guidelines (please follow individual childs food plan!) Meals and snacks should be provided at same time each day. Encourage child to complete food provided (lunches and snacks provided by families are planned to prevent low blood glucose levels). Under-eating can cause dangerously low blood sugar (hypoglycemia). 14 Fiber-rich foods help to slow digestion, keep you feeling full longer and may help control blood glucose. Water is best choice for thirst (avoid fruit juices and soda pop as sugar content is high). Choose food with low glycemic (sugar) index. http://www.bcchildrens.ca/NR/rdonlyres/3A88BDC3 -DEE3-4380-BF27- 759019456034/20419/glyindex.pdf

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4. Medications Medication (oral pills) are sometimes prescribed to help lower blood glucose levels in children with Type II diabetes and occasionally for Type I. Two common medications: 1. Glyburide assists the body in production of insulin (at beta cell level). 2. Metformin: limits the amount of sugar absorbed into the body from the diet. makes insulin receptors more sensitive (helping the body respond better to its own insulin). reduces the amount of sugar made by the liver. Side-effects to watch for: Hypoglycemia (low blood sugar) 15 A. Oral Medications

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4. Medications Every time we eat, blood glucose rises. In Type I diabetes, no insulin is produced, so insulin must be administered daily. Goal is to keep blood glucose levels close to target range, without causing hypoglycemia. Insulin doses are child specific based on activity and lifestyle. 16 B) INSULIN (Type I and occasionally Type II and Gestational Diabetes) INSULIN INJECTIONS

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Other Methods of Insulin Delivery 17 Insulin Pen All trademarks owned by Novo Nordisk A/S and used by Novo Nordisk Canada Inc. Novo Nordisk Canada Inc., www.novonordisk.cawww.novonordisk.ca Insulin Pump http://adam.com/healthsolutions.aspx

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5. Blood Glucose Monitoring Determines the level of your blood sugar. Can help determine medication dosages (for both oral and insulin). Show how your food intake, exercise, stress and medications are affected. Quick method of determining hypo and hyperglycemia. Target ranges: Children 5-12yrs old 4-10mmol/liter 13-18yrs 4-7mmol/liter (Canadian Diabetes Association 2009) 18

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Hypoglycemia 19

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Managing Hypoglycemia Low blood sugar (below 4mmol/l) can be a medical emergency (9-1-1) if symptoms proceed to severe. Unconsciousness Convulsions/seizures Ensure you know the emergency plan for the child your working with! Diabetes management plans are written by NSS coordinator or Public Health nurse in consultation with childs family). 20 http://www.bcchildrens.ca/ NR/rdonlyres/5A86081E -411F-423D-B09A- DAD44A15B013/46009/ hypoglycemia.pdf BC Childrens Hospital guidelines for managing low blood sugar in children.

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Hyperglycemia 21

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Hyperglycemia Increase of carbohydrates in diet (carbs turn to sugar) or increased food intake. Illness causes stress on the body and glucose levels are released from the liver. Stress. Missed or not enough medications. Liver can release more glucose overnight resulting in higher morning blood sugar before eating. Other medications that cause increased blood sugar levels. 22 Causes of High blood sugar Managing High blood sugar Always take your medication and/or insulin. Follow your meal plan. Drink plenty of water. Check blood glucose levels. Report high blood sugars if over 15mmol\liter.

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Risks of High Blood Sugars in Lifetime Blindness; Heart disease; Reduced blood supply to the limbs, leading to amputation; Nerve damage; Erectile dysfunction; and Stroke. www.hc-sc.gc.cawww.hc-sc.gc.ca (Health Canada) 23

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Potential Effects of Diabetes in Classroom Interrupted classroom time affecting students concentration: Due to highs or low blood sugars that can cause: Extreme tiredness Headaches Mood changes Missed class time due to: Blood sugar testing Medical appointments Frequent trips to washroom if sugars are high Extra time and assistance to catch up missed information may be required. 24

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Our Role in Diabetes http://www.bcchildrens.ca/NR/rdonlyres/28B5FDC1-DEF1- 464E-8A8D-06C7CD103648/45400/schoolinfo.pdf 1. Education about Diabetes for ourselves, our students and colleagues. 2. Recognition of Signs and Symptoms of both hypoglycaemia and hyperglycaemia. 3. Learning and following the child specific treatment plans for Emergency interventions. 4. Reporting changes to families and NSS nurses. 5. Encouraging, supporting and assisting our students when Diabetes may interfere with school (missed days, difficult concentration and peer interactions). 25