1. Diabetes Education Programmes Vibhuti Mistry – Lead Diabetes and Obesity Dietitian LOGO Name

2. Newly Diagnosed Type 2 EDDI- EDucation Diabetes - 2 x 3hrs session - Venue: HDC ~30 courses a year - English speakers only -Non – English speakers referral for 1:1 with RD or Turkish X-PERT

3. Established Type 2 Diabetes X-PERT - Referral from EDDI after 1 year - 6 x 3hr session, ~ 35 courses/ year - Venue: HDC or Community venue - English or Turkish only - Health Profile X-PERT Insulin -6 x 3hr course for T2 DM patients on insulin -Referral after doing X-PERT -Safe management of insulin with carbohydrate and lifestyle -2 courses delivered

4. Established DM contd…… Choose to Lose -6 x 3 hour course -Delivered and written in-house by DM RDs -Weight management course for patients wanting support after attending X-PERT. -Input form Psychology and Physiotherapy team. Focus on behaviour change and mindfulness - 4 th course being delivered

5. Pre- Diabetes X-POD- Prevention Of Diabetes- - For patients ‘at-risk’ of developing T2 DM -2 nd course currently being delivered at Kenworthy Rd -Positive feedback from patients -?? Scope for patients to attend Choose to Lose after

6. Type 1 Diabetes BHICEP- Barts and the Homerton Insulin Carbohydrate Education Programme -4 x 6 hr sessions. 8-9 courses year -Focus on Insulin dose management with carbohydrate and lifestyle. Also DM emergencies, injection technique, pregnancy, driving etc… Carbohydrate Counting Workshop -Half day practical carbohydrate awareness and counting -Delivered by DM RDs -6-8 workshops/ year

7. What else? Walking Groups Diabetes Awareness Events Psychology Support ‘Drop in’ clinic - *new times* Monday 1.30- 2.30pm & Friday 9- 9.30 am

8. Staff Education Primary Care Course Half day Education session for G.Ps and PNs. Topics: DM emergencies, DM in pregnancy, BP in DM and weight management and DM Time : 1.30-5pm Date: 3 rd June 2014 E-mail :huh-tr.diabetesprimarycarecourse@nhs.net Therapies Management Course – under r/v District Nurse Training - on going in community

9. INTERNET http://www.homerton.nhs.uk/our-services/diabetes/ Information re: courses, how to refer, other HDC services

10. Diabetes and Ramadan For past 3 years the Diabetes Service has been running Diabetes and Ramadan sessions for patients who are planning to fast

11. Typical fasting day in 2014 Summary – fasting (no food or fluid) from sunrise to sunset Time of year is dependant on lunar calendar. Lunar calendar is 15 days shorter than solar calendar; therefore Ramadan comes 2 weeks early every year 2014 starts approx 28 th June- fast time will be ~19hours

12. Typical Day IFTAR- close of fast Time is ~ 9.25 pm Close fast with couple of dates and water Then pray at home or mosque ~ 10mins Sit down to meal. This meal is usually feast in most households- heavy meal(large amounts of CHO, fat and protein). Depending, men may set out to go to mosque for a longer prayer ~>1hour. Women will do the equivalent prayers at home (~10.30/11pm) Usually in previous shorter years, people would then go to sleep and wake for meal at SUHOOR (meal to start fast ) just before sunrise This year as the SUHOOR meal would need to be consumed before 2.48 am. Individuals may choose to stay awake for the last meal of the day, or not have this meal at all.

13. Implications for fasting Dehydration Fasting could cause problems for patients who have diabetes as their health and glucose levels are closely linked with diet, meal timings and medication Main concerns for anyone fasting during daylight hours is hypoglycaemia and a 5 fold increase in severe hypoglycaemia occ requiring hospitalisation has been seen in people with T2 DM. People with T1 DM who fast during Ramadan are at increased risk for developing DKA particularly if they have high blood glucose levels before the period of fasting. Large CHO meals and drinks: larger rise blood glucose levels

14. Exemption from fasting Islam specifically exempts people with a medical condition from the duty of fasting, especially if it might have harmful consequences. People with Diabetes fall into this category since it is a metabolic disorder which can place them at high risk for various complications if the pattern and amount of their meal and fluid intake are altered markedly. Nevertheless, many people with DM insist on fasting during Ramadan, this includes Type 1s, pregnant women, the ill and frail

15. Psychological impact of Ramadan The principle of fasting should be more than just abstinence of food and water but a period of humility; self reflection and charitable offerings. Individuals feel more spiritual by offering more prayers. Those who do not participate in Ramadan often feel guilty and left out from the spiritual reward that would be obtained in this time. In the past, healthcare professionals have advised people not to fast and because of this, some people have been reluctant to seek medical advice.

16. Structured Education Sessions Aims and Objectives Increase patients understanding of Diabetes Promote safe fasting Learn about healthy eating during fasting hours Monitoring their Diabetes Adjusting medication Encourage awareness of the risks and how to avoid the dangers

17. The Project Team Diabetes Specialists Dietitians Diabetes Specialists Nurses G.P - Dr Pathan from Fountayne Road The Hospital Imam

18. Content of Sessions Who is exempt from fasting (hospital imam) Diet Risks (including how to recognise and treat hypos) and the need for monitoring Medication Adjustments Insulin Question and Answers Multi lingual session One to one DSN support available

19. Case study Mrs X (d.o.b 15/02/1952) was changed from Novo Mix 30bd to Humalog mix 50bd when she attended the Ramadan session. Humalog mix 50 has less basal insulin which decreases the risk of a hypo during fasting. Following Ramadam Mrs Islam was kept on the same insulin and it was found it decreased her HBA1c by 2% If seen in 2014 – Mrs X would be put on Humalog 50 od, due to longer fasting period

20. Diabetes and Ramadan Saturday 21 st June 11am or 2pm Saturday 5 th July at 2.30pm Drop in: Any Monday 1.30-2.30 pm and Friday 9-9.30 am DSN at surgery