1. Presenter Disclosure Information In compliance with the accrediting board policies, the American Diabetes Association requires the following disclosure to the participants: NAME OF PRESENTER: Janis Roszler, RD, CDE, LD/N Consultant: dLifeTV (LifeMed Media) Other: Animas Corp

2. Diabetes on Your OWN Terms! A Personal Approach To Diabetes Self-Care Janis Roszler, RD, CDE, LD/N

3. Kris Freeman US Olympic Cross Country Skier

4. Diagnosed with type 1 while preparing for 2002 Winter Olympics Told he must stop competing Took a personal approach and competed in the 2006 Olympics

5. Douglas Cairns – First to Fly Solo Around the World Flight instructor with Britain’s Royal Air Force Lost license when diagnosed with type 1 Told by Air Force, “You are a diabetic and you WERE a pilot.” Took a personal approach and flew 159 days around the world.

6. Advice from Kris and Douglas: “Learn as much as you can about the disease…learn as much as you can about the treatments…learn as much as you can about [which] diets will work for you to help you achieve whatever dream you have.”

7. Why a Personal Approach? Patients will carry out self-management tasks more consistently and over a longer period of time if they were freely chosen by patients.* Anderson RM, Funnell MM. (2005) The Art of Empowerment: Stories and Strategies for Diabetes Educators. 2 nd Ed. Alexandria, VA: ADA

8. Why Encourage a Personal Approach? Makes patient more self-sufficient Reduces emergencies – They can treat more issues before they become urgent…without calling YOU. Relieves us of guilt – we give them “Roots and Wings.”

9. How to Encourage Personalized Care Guilt Options

10. Remove the Guilt “Perfect control isn’t possible, even when we’re doing everything perfectly…and no one does, because we’re humans first and we live with diabetes second.” Betty Brackenridge - coauthor Diabetes Myths, Misconceptions, and Big Fat Lies

11. How Many Patients Think We See Them

12. Asked of 6,500 dLife.com Message Board Members… “Did your health care provider ever say or do anything that could make patients lose the desire to care for their diabetes?”

13. Shelly… “When I was a kid my doctor told me that I was the worst type 1 diabetic that he had ever seen! That wasn't really too motivating for me. I just continued down the same path. Why take care of it?”

14. Rich… “If my endo didn’t think your numbers were good enough, he chewed you out and said that HE had given you the right instructions and if you had followed them you would have good numbers. He was so condescending. He treated his patients like they were naughty children.”

15. Options

16. Begin with Comforting Facts With good care, you can live a long, healthy life with diabetes. Your diabetes is not your fault. Diabetes doesn’t have to run your life. Ref: behavioraldiabetes.org

17. Personalizing Blood Glucose Control Laura Menninger, the “Glucose Goddess” “Your meter is like a compass to a mountain climber. It tells you where you’re at so you can reach your goal.”

18. Tom… “Do not tell your patients they only need to test their blood once a day. This seems to be the result of the view that diabetics are non- compliant. Patients can learn to be compliant. Testing once a day is not enough and should not be an option.”

19. Blood Glucose Testing Let your patients know: – When to check their blood – How to interpret the results – What to do with the results – That you care about their results…(PLEASE look at their testing diaries!)

20. Chuck… “I can live with a lot, but a doctor that simply knows the numbers for the average diabetic and doesn't adjust them for the individual, will not see me a second time.”

21. Treatment for Abnormal BG Levels Low blood glucose 15/15 rule – Eat 15 grams rapid-acting carbohydrate – Wait 15 minutes – Check again. Repeat if needed

22. High BG prior to a meal: – Wait a bit before eating – Take smaller portion of next meal – Do light activity – brisk walk – Break up upcoming meal into small snacks or save fruit for later – Take medication, if instructed to do so

23. High BG following a meal – Take a gentle walk or do light exercise – Drink generous serving of water – Delay next snack – Take additional medicine as directed or use insulin correcting technique

24. Insulin Correcting Estimate number of insulin units you take in typical day Divide total into 1,800 Answer is insulin correction number – the amount of points a single unit of rapid-acting insulin should bring blood glucose level down within ~4 hours Extremely empowering!

25. Set Personal Goals

26. AADE-7 Choose focus and document Set goal Follow-up on set date Maintain communication – keep copy in patient’s folder, patient receives copy also

27. A Personal Approach to Behavior Change

28. “Jump Start Pledge” Guilt-free way to add new health behaviors to your life Choose a small, measureable goal Pledge to keep it for a single week At the end of one week… 1.Renew your pledge 2.Change your pledge to fit you better 3.Add another pledge to your week

29. Jump Start Pledge “I like the Jump Start Pledge. It has given me something to strive for. It makes me commit to a goal and be accountable. It has created good habits and made me let go of bad ones. In my Jump Start pledge, I pledged to exercise 4 days this week. I have met that goal and now it’s a habit. -Clarissa “HURRAY! I kept my JSP from last week. I walked all 7 days. The weather was so good yesterday and today that I walked outdoors. That was great!” -Richard

30. Jump Start Pledge Totally guilt-free. If you were unable to complete your pledge, it wasn’t right for you. Adjust it to fit you better and try again. Post Jump Start Pledges at www.dearjanis.com

31. A Personal Approach to Meal Planning Meet with an RD/CDE – Can create a personalized meal plan – Will help patient succeed on current plan

32. Carb Counting/Carb Factors Great flexibility Match insulin to carbohydrate intake Minimum 130g digestible carb/day* Carb factors for favorite/homecooked foods: – Food weight (grams) x Carb factor = Carb count Pumping Insulin, Walsh & Roberts *ADA Clinical Practice Recommendations, 2009; Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC, National Academies Press: 2002.

33. The Plate Method

34. Glycemic Index – Enhance Personal Options “…use of glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone.” - ADA Clinical Practice Recommendations, 2009

35. Glycemic Index High (gushers): – White bread, bagel, English muffin, microwaved potato Medium – Split pea soup, quick oats Low (tricklers): – 100% Whole grain bread, tomato juice, old fashioned oats

36. Glycemic Load Enables patients to enjoy favorite and home cooked foods Glycemic Load = (grams carb in serving x GI of the food) ÷ 100 Helps predict how BG level will respond A large portion of a low-GI food will cause glucose spike Bottom line: portion size counts!

37. 2-Hour Post-Prandial BG testing Confirms food choices and portion sizes Enhances confidence Allows patient to “cheat” Target range options : <180mg/dl (ADA) <160mg/dl (Joslin) <140mg/dl (AACE ; IDF)

38. Personal Approach to Medication Include patient in medication decision Explain how they work and what they do “The last medication my doctor considered, he picked up his computer and checked the side effects because he knew I would as soon as I got home! He has also become more positive over the years because he knows I take care of my self and pay attention.” - Roger

39. Personal Options - Information Diabetes.org Joslin.org dLife.com Childrenwithdiabetes.com Webmd.com dLifeTV on CNBC Calorieking.com Medlineplus.gov Quackwatch.com

40. Books for your patients Diabetes on Your OWN Terms, J. Roszler Diabetes Burnout, W.H. Polonsky Complete Guide to Carb Counting, H. Warshaw and K. Kulkarni Think Like a Pancreas, Gary Scheiner Your First Year With Diabetes, Theresa Garnero

41. Empower Your Patients Respect their opinion Be open to the information they bring Focus on them during appointments Don’t insult them, especially when they offer alternative suggestions Stay current and offer new information

42. Missy Foy First person with diabetes to qualify for Olympic marathon trials. Diagnosed with type 1 10 years ago. Ranked 9 th in America for 50 mile ultra- marathon

43. Missy Foy “Not succeeding was not an option.”

44. Final Word “The best things my doctor ever told me is that it is in my hands as to how much of a negative impact diabetes is going to have on my health and life, and that he believes in me.” – Shire (type 2)