1.   The Cystic Fibrosis Foundation Education Committee is happy to introduce the CF-Related Diabetes (CFRD) Teaching Flip Chart. This educational tool was developed by Michelle Nosky, R.N., M.S., C.R.N.P., C.D.E., Nurse Coordinator and Diabetes Educator at the Johns Hopkins Adult CF Program, and is specifically designed to introduce the basic concepts of CFRD physiology and management. It is provided in Microsoft Power Point format but is most effectively utilized by printing out each slide on a separate page (ideally in color) and placing them in a binder with plastic page covers. It may also be helpful to use tabs to divide the flip chart into its subsections for easy reference.
Once assembled, the flip chart provides a wonderful format for a CF team member providing diabetes education to sit with a patient and introduce the key concepts of CFRD physiology and management. The individual teaching slides allow the caregiver to easily tailor the educational program for each patient no matter where they are in the diabetes continuum. This may mean spending more time in the introduction section for individuals being evaluated for impaired glucose tolerance, or jumping to the treatment section for those with CFRD with fasting hyperglycemia. Centers wishing to emphasize particular aspects of diabetes education can modify the slides provided or add new slides to the flip chart to make it unique to their center. Most centers have utilized the flip chart for initial one-on-one CFRD teaching, and then provided patients with the outstanding manual Managing Cystic Fibrosis Related Diabetes (CFRD): An Instruction Guide for Patients & Families by Hardin, Brunzell, Schissel, Schindler & Moran.
As new information and management techniques are developed for CFRD we will update the flip chart. We encourage you to make suggestions for improvement in the flip chart and provide tips for its effective use. These can be forwarded to Leslie Hazle at the Cystic Fibrosis Foundation Our hope is that this flip chart will assist you in providing outstanding CFRD care and teaching for the patients and families at your center.
The Cystic Fibrosis Foundation Education Committee
March, 2003

2. Cystic Fibrosis Related Diabetes Teaching Guide
Developed by: Michelle Nosky, MS, CRNP, CDE Johns Hopkins Adult Cystic Fibrosis Program Baltimore, MD

3. Introduction

4. How Does the Body Use Food?
When you eat, the food is digested into glucose (sugar). A hormone called insulin helps your body use the glucose for energy. Insulin acts as a key that opens the door of each cell in the body to let the glucose inside.
Food Glucose Blood Body Cells
Metabolized Travels Insulin carries into

5. What is Insulin?
Insulin is a hormone produced in the Beta cells of the pancreas. The pancreas is a small organ that sits behind the stomach.

6. What happens without insulin?
Body cannot turn carbohydrates into energy
Extra glucose builds up in the blood and spills over into the urine
Losing glucose in the urine causes frequent urination and thirst

7. What happens without insulin?
Protein breaks down and muscle is lost
Loss of muscle affects breathing because lung function depends on good muscle strength
Body’s fat stores are depleted and weight loss occurs

8. CF and Blood Glucose

9. Why is Less Insulin Made in People with CF?
CF causes damage to the pancreas (which is why enzymes are needed for meals)
Pancreas contains beta cells that make insulin
If enough beta cells are damaged, the body can’t make enough insulin to use the food that is eaten
Decreased amounts of insulin higher blood glucose levels food can’t be used by the body

10. Insulin, Glucoses, & Exacerbations
Body needs more insulin when sick
With infections, stress or when on steroids - body is more resistant to the insulin
Weight loss can occur rapidly because of low insulin levels and high glucose levels
People who usually have normal blood glucoses may have high blood glucoses when sick

11. Why is Glucose Control Important For People With CF?
Decline in lung function and nutritional status is associated with high glucoses
Insulin therapy can improve weight and pulmonary function
Are sicker patients at higher risk of getting diabetes or does diabetes make you more sick?

12. Tests for CF Related Diabetes (CFRD)
Blood Glucose
Fasting –Does your body make enough “background” insulin?
After meals – Can your body make enough insulin to use the food you eat?
Can be checked in the lab or with a meter at home

13. Glucose Tolerance Test
Tests for CFRD
Glucose Tolerance Test
Shows us what your blood glucose does after a large amount of carbohydrate
Similar to what happens to your blood glucose after you eat a meal
Does your body make enough insulin to use the food that you eat?

14. Tests in CFRD Hemoglobin A1C
Picture of the “average” blood glucose over past 3 months
Amount of glucose that is “stuck” to the red blood cells
Gives a picture of overall glucose control (average of highs, normals and lows)

15. Blood Glucose Testing Normal glucose levels 70-110mg/dl
Monitor to evaluate need for treatment or -
To adjust amount of insulin needed
to cover food
during illness or with steroids
prevent high and low blood glucoses

16. Hyperglycemia - High Glucose
Blood glucose >126
Goal: Keep glucose as normal as possible
Symptoms:
thirst
hunger
frequent urination

17. Hyperglycemia - High Glucose
Causes:
not enough insulin
infection
steroids
Side Effects
damage to blood vessels (eyes, kidneys)
easier to get and harder to fight off infections
weight loss

18. Types of Diabetes

19. Types of Diabetes
Type 1 (Insulin Dependent Diabetes Mellitus, Juvenile diabetes)
destruction of cells that make insulin
pancreas doesn’t make any insulin
ketoacidosis without insulin
insulin, exercise
Type 2 (Non-insulin Dependent Diabetes, Adult Onset Diabetes)
insulin resistance
older, overweight
pills and/or insulin, diet, weight loss, exercise

20. Types of Diabetes CF Related Diabetes (CFRD)
different than other types of diabetes
15-50% of adults with CF have diabetes
damage to the pancreas beta cells that make insulin = insulin deficiency
insulin resistance with infection
associated with pancreatic insufficiency
can make lung function worse
can make nutritional status worse

21. Types of Diabetes Gestational Diabetes
More common in women with CF than without
Onset may be earlier in pregnancy with CF
Insulin should be started at first sign of diabetes
Well-controlled blood glucoses are needed for healthy pregnancy (for both mom and baby)
If already have CFRD, will need close monitoring and insulin dose adjustments throughout pregnancy

22. CF Related Diabetes
Depending on how much insulin your body is making, you may fall into one of three CFRD categories:
Impaired Glucose Tolerance
CFRD without fasting hyperglycemia
CFRD with fasting hyperglycemia
Your health (lung function, weight) and your blood glucose levels help determine if you need to take insulin
CFRD can be chronic (all the time) or intermittent (with illness, steroids)

23. CF Related Diabetes Impaired Glucose Tolerance
fasting normal (<126)
after meals high ( )
CFRD without fasting hyperglycemia
after meals high (>200)
may require insulin
CFRD with fasting hyperglycemia
fasting high (>126)
requires insulin

24. CFRD Treatment
Diet: Carbohydrate monitoring – shouldn’t limit calories, fat, protein, or salt
Medicine: Oral medications are now being used, including Metformin.(updated 8/2007)
Insulin is primary treatment (one or more may apply to you)
Daily, long acting and/or short acting
With high CHO meals/snacks only
During an exacerbation or when on steroids

25. Nutrition and Diet

26. CFRD and Nutrition
Myth of “Diabetic Diet” – especially not true in CFRD
Need to maintain fat, protein and calories
Carbohydrate (starch, sugar) is the main nutrient that increases blood glucose levels
A rise in glucose level is seen the most after eating

27. CFRD and Nutrition Carbohydrates Needed for calories and energy
Starches and sugar : Fruits, Breads, Rice, etc.
Causes increase in blood glucose levels without enough insulin
Fat, Protein
Needed in high amounts in CF diet
Does not raise blood glucose very much
Fat may slow absorption of carbohydrates
Many food are combinations:
Pizza (carbohydrate protein and fat)
Ice Cream (carbohydrate, protein and fat)

28. CFRD and Nutrition
All foods with carbohydrate raise blood glucose to about the same degree
Adjust insulin to food intake
Match carbohydrates to peaks in long-acting insulin, or match short acting insulin to amount of carbohydrates eaten
May need to have less high-sugar foods or drinks (juice, soda)
Work with team on insulin adjustments for shakes/supplements

29. Nutrition Facts/Food Labels
CFRD and Nutrition
Nutrition Facts/Food Labels
Lists the carbohydrate content for each serving
Look carefully at serving size (are you eating ½ cup or 3 cups?)
Look at grams of Total Carbohydrates
Do not look at Sugars or % Daily Value for carbohydrates

30. CFRD Treatment

31. Medication for CFRD Need to be treated with insulin
Insulin can only be given by injection
Pills have been shown to work, due to insulin resistance that occurs with CFRD (updated 8/2007)
When body doesn’t make enough of it’s own insulin, you need to give extra insulin

32. Types of Insulin Short Acting Intermediate Acting Long Acting
Regular (peaks 2-3 hours)
Humalog, NovoLog (peaks ½ - 1½ hours)
Intermediate Acting
NPH (peaks 6-8 hours)
Long Acting
Ultralente (peaks hours)
Lantus (last 24 hours, no peak)

33. Insulin for CFRD
“Background insulin” - your body may make this or it may need to be from insulin injection
Meal coverage/Carbohydrate counting – the amount of insulin your body needs to use what you eat and drink; normal pancreas produces insulin every time you eat
Correction/Sliding scale - extra insulin to bring your glucose to normal range when it’s high

34. Insulin for CFRD How many shots? Multiple injections (4)
better blood glucose control
more flexibility
2 injections/day
not as good blood sugar control
less flexibility with meals
eat too much = high blood glucose
eat too little/skip meal = low blood glucose

35. Background insulin made by body or Glargine (Lantus) injection
Insulin for CFRD
Rapid Acting Insulin (Humalog or NovoLog)
Insulin Effect
Background insulin made by body or Glargine (Lantus) injection
Breakfast Lunch Dinner Overnight
Intermediate acting insulin (NPH) and Rapid Acting (Humalog or NovoLog)
Insulin Effect
Breakfast Lunch Dinner Overnight

36. Insulin Injection Insulin can only be given by injection Needle length
Syringes
Insulin pens
©Lilly

37. Stomach has the most even insulin absorption
Insulin Injection
©Lilly
Stomach has the most even insulin absorption

38. Insulin for CFRD Insulin Pump Basal rate - background insulin
Boluses - to cover food
Short acting insulin only
©Medtronic MiniMed

39. Hypoglycemia - Low Glucose
Blood glucose <70
Symptoms:
confusion
numbness (mouth, face)
blurry vision
irritability
shaking
sweating

40. Hypoglycemia - Low Glucose
Causes:
too much insulin
not enough food
too much exercise
Treatment:
fast acting carbohydrate (glucose tablets, sugar, juice, soda, candy) (12-15g of carbohydrates)
If on long acting insulin, follow with snack

41. Glucagon Hormone that raises the blood glucose level
Given by injection for severe hypoglycemia
Use: when glucose is so low you can’t eat or drink, administered by someone else
Mix liquid and powder together
Inject into fat or muscle

42. Miscellaneous

43. CFRD and Exercise Exercise helps your body use insulin better
Will need more food or less insulin for exercise
Exercise is important in both CF and CFRD
Preserves and increases muscle tone
Increases lung efficiency

44. Complications from CFRD
CF Complications: infection, decline in lung function, weight loss
Kidney damage (important for transplant)
Delayed healing, especially of feet
Eye damage, can lead to blindness
Nerve damage

45. But The Good News is ….
…with control of blood glucoses you can prevent or delay the onset of these complications and improve your overall health

46. When You Are Sick…
Treat the underlying illness (call your doctor or nurse to discuss)
Prevent dehydration (high blood glucose can make you dehydrated)
You won’t need meal coverage insulin if you aren’t eating, but probably will need background insulin
Your body may need more insulin to cover the extra stress of the infection
When on steroids, you’ll need to monitor glucoses more and will probably need more insulin

47. Daily Management Not something else!/I can’t do anymore!
Juggling daily pulmonary treatments, nutrition, and diabetes care
Customize treatment to your life
Share your concerns
End benefit=better health

48. Credits/Resources
All images are from Microsoft word online clip art unless otherwise noted (
Eli Lilly and Company -
Medtronic MiniMed -