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 (lhazle@cff.org). 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

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

Introduction

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

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.

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

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

CF and Blood Glucose

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

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

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?

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

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?

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)

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

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

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

Types of Diabetes

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

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

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

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)

CF Related Diabetes Impaired Glucose Tolerance fasting normal (<126) after meals high (140-200) CFRD without fasting hyperglycemia after meals high (>200) may require insulin CFRD with fasting hyperglycemia fasting high (>126) requires insulin

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

Nutrition and Diet

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

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)

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

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

CFRD Treatment

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

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 10-13 hours) Lantus (last 24 hours, no peak)

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

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

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

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

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

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

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

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

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

Miscellaneous

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

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

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

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

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

Credits/Resources All images are from Microsoft word online clip art unless otherwise noted (http://dgl.microsofe.com/?cag=1) Eli Lilly and Company - www.lilly.com Medtronic MiniMed - www.applied-medical.co.uk/MiniMed/508.htm