1. Diabetes Self Management Laura Wintersteen-Arleth, MN, RN,CDE

2. Learning Objectives Understand the impact of diabetes
Distinguish the different types of Diabetes
Identify treatment options for diabetes management
Identify methods of applying the Chronic Care Model to diabetes self-management
Describe tools which health care providers can use to empower patients
At the end of this lecture, you will be able to understand the following:
Understand the impact of diabetes
Distinguish the different types of Diabetes
Identify treatment options for diabetes management
Identify ways of applying the Chronic Care Model to diabetes self-management
Describe tools which health care provider can use to empower patients

3. Impact of Diabetes 220 million worldwide have diabetes
80% of deaths from diabetes in low and middle-income countries
Diabetes deaths will double between 2005 and 2030
Diabetes has significant financial impact
More than 220 million people worldwide have diabetes.
In 2005, an estimated 1.1 million people died from diabetes.
Almost 80% of diabetes deaths occur in low- and middle-income countries.
Almost half of diabetes deaths occur in people under the age of 70 years; 55% of diabetes deaths are in women.
WHO projects that diabetes deaths will double between 2005 and 2030.
Healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use can prevent or delay the onset of diabetes.
Diabetes and its complications have a significant economic impact on individuals, families, health systems and countries.
Reference: WHO Diabetes fact sheet:
Image used with permission of fotolia:

4. Diabetes
Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. This leads to an increased concentration of glucose in the blood
Diabetes is a chronic disease caused by a problem in the way your body makes or uses insulin.
Insulin, which is needed to move blood sugar (glucose) into cells, where it is stored and later used for energy.
When you have type 2 diabetes, the body does not respond correctly to insulin. This is called insulin resistance. Insulin resistance means that fat, liver, and muscle cells do not respond normally to insulin. As a result blood sugar does not get into cells to be stored for energy.
When sugar cannot enter cells, abnormally high levels of sugar build up in the blood. This is called hyperglycemia.
High levels of blood sugar often trigger the pancreas to produce more and more insulin, but it not enough to keep up with the body's demand.
People who are overweight are more likely to have insulin resistance, because fat interferes with the body's ability to use insulin.
Reference:
Image used with permission of AllRefer Health

5. Diabetes Type 1 Type 2 Gestational
LADA: Latent Autoimmune Diabetes of Aging
Pre-Diabetes
Impaired Glucose Tolerance (IGT)
Impaired Fasting Glucose (IFG)
Type 1 diabetes: Previously known as insulin-dependent (IDDM), juvenile or childhood-onset. Type 1 is characterized by pancreatic beta cell destruction. Insulin is not longer produced and the patient is required to be on insulin.
Type 2 diabetes: Previously called non-insulin-dependent (NIDM) or adult-onset, results from the body’s ineffective use of insulin. Type 2 diabetes comprises 90% of people with diabetes around the world, and is largely the result of excess body weight and physical inactivity. Type 2 in children is becoming an issue in management.
3. Gestational diabetes (GDM): is hyperglycemia with onset or first recognition during pregnancy. Symptoms of
gestational diabetes are similar to Type 2 diabetes. Gestational diabetes is most often diagnosed through
prenatal screening, rather than reported symptoms.
Latent Autoimmune Diabetes of Aging (Type 1.5 diabetes): Type 1.5 is one of several names now applied to
those who are diagnosed with diabetes as adults, but who do not immediately require insulin for treatment, are
often not overweight, and have little or no resistance to insulin. When special lab tests are done, they are found
to have antibodies, especially GAD65 antibodies, that attack their beta cells.
5. Pre-Diabetes refers to a person who has a fasting blood sugar of mg/dl or mm. This is the term used by
healthcare providers to say you do not have diabetes yet, but without lifestyle changes, you will probably go on to develop
Type 2 diabetes. Pre-diabetes will also be referred to as IGT and IFG Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) are intermediate conditions in the transition
between normality and diabetes. People with IGT or IFG are at high risk of progressing to type 2 diabetes,
although with proactive lifestyle changes, this is not guaranteed.
For the purpose of this presentation, the focus will be on Type 2 diabetes because of the large percentage of people with diabetes have Type 2 (90%)
Reference: WHO

6. In this drawing, the cells on the left show healthy, insulin producing cells. The one on the right shows beta cells which have been destroyed and are no longer capable of producing insulin. The girl is diagnosed with Type 1 diabetes. If there were still insulin producing cells present, then you would have Type 2 diabetes.
Clinical onset of diabetes may be abrupt, but the pathophysiologic insult is a slow, progressive phenomenon.
Hyperglycemia and symptoms consistent with the diagnosis of Type 1 diabetes develop only after 90% of the secretory capacity of the beta cell mass has been destroyed.
3. Genetics, environmental influences, viral infections and antibodies are involved in the onset of Type 1 diabetes
Reference:
Image used with permission of AllRefer Health

7. Risk Factors for Diabetes
Type 1
Under 30
Genetics
Autoimmune
Environment
Viral infection
Type 2
Older age
Overweight
Hypertension
Abnormal lipid levels
Genetics
Race/ethnicity
History of gestational diabetes
History of vascular disease
Inactivity
Risk of Type 1 in general population ranges from 1 in 400 to 1 in The risk rises substantially to 1 in 20 to 1 in 50 in the offspring of those with Type 1.
Genetic predisposition to Type 1 is the result of HLA-DQ coded genes for disease susceptibility off set by genes that are related to disease resistance. Genes that produce resistance are frequently dominant over those that produce disease susceptibility.
Antibodies: Positive GAD, Insulin and Islet Cells autoantibodies (IAA & ICAs)
Viral triggers are suggested by the association of Type 1 with congenital rubella and coxsackie B4 infection. Bovine serum albumin (BSA) is thought to be an environmental trigger. BSA specific antibodies are found in the majority of kids with newly diagnosed diabetes, thus early exposure to cow’s milk may be a potential determinant. There is a higher rate in non-breastfed women.
Environment: Some chemicals and drugs specifically destroy pancreatic cells.
Hyperglycemia and symptoms consistent with the diagnosis of DM develop only after 90% of the secretory capacity of the beta cell mass has been destroyed.
Type 2:
1. Typical: over 40…the older you get, the higher your risk goes. Although, Type 2 in children is becoming much more frequent.
2. People overweight are at higher risk.
3. Sedentary lifestyle increases your risk of developing Type 2. Excessive abdominal (visceral) fat introduces greater threat of Type 2 than does lower body obesity.
4. Family history….does not have to be first degree relative. No specific HLA type is identified. Where 1 identical twin is affected the incidence is close to 100%. Off springs have a 15% chance and 30% risk of Impaired Glucose Tolerance
Women who had gestational diabetes, have a 50% risk of developing Type 2 within 5-10 years
Certain ethnic groups increase the susceptibility to Type 2, such as African American, Native Americans, Asian, Pacific Islanders.

8. Clinical Manifestations: Comparisons
Type 1
Polyuria
Polyphagia
Polydipsia
Significant weight loss
Fatigue
Type 2
Fatigue
Dry, itchy skin
Numbness, tingling
Polydipsia
Polyuria
Blurred vision
Impaired healing
Yeast infections
Sexual dysfunction
Clinical manifestations in Type 1 will present themselves over a shorter time frame. The clinical manifestations include:
Polyuria: increased frequency of urination
Polyphagia: Increased appetite
Polydipsia: Frequent thirst
Clinical manifestations in Type 2 will appear over a long period of time and may be mistaken for other health problems and not diabetes.
Many people have diabetes an average of 5-7 years before diagnosis
Since many people with Type 2 are older, it is important to not just assume the symptoms are because someone is elderly. It is important to talk to your patients about the symptoms they are having and their risk factors.
Hyperglycemia causes you to be fatigued.
Dry skin: Skin provides an important defense mechanism against infection when it is intact and healthy. Hyperglycemia resulting in polyuria may be a cause of dehydration and subsequent dry skin. Anhidrosis, which is defined as an autonomic neuropathic condition of diabetes in which little or no perspiration is produced in the feet and legs, may lead to drying and cracking of the skin. People with poorly controlled diabetes complicated by vascular or neuropathic changes demonstrate an increased risk for skin infection caused by staphylococci beta hemolytic streptococci, and fungus.
Numbness and tingling not only in feet, but hands/fingers.
Diabetes is the number one cause of preventable blindness.
Increased blood sugar interferes with the healing process.
Increased sugars also cause yeast infections
Sexual dysfunction can occur in both men and women as a clinical manifestation.

9. Acute Complications of Diabetes
Dawn Phenomenon
Somogyi Phenomenon
Hypoglycemia
Diabetic Ketoacidosis
Hyperglycemia, Hyperosmolar Syndrome
Hormones (growth hormone, cortisol, and catecholamines) produced by the body cause the liver to release large
Dawn Phenomenon:
amounts of glucose into the bloodstream. These hormones are released in the early morning hours.
These hormones also may partially block the effect of insulin, whether it's insulin your body produces or insulin
from the last injection. If the body doesn't produce enough insulin blood sugar levels may rise. This may cause
high blood sugar in the morning before the person eats.
2. Somogyi:
Can occur when a person takes long-acting insulin for diabetes. Somogyi is caused by having too much insulin in
the blood during the night. If the blood sugar level drops too low in the early morning hours, hormones (such
as growth hormone, cortisol, and catecholamines) are released. These help reverse the low blood sugar level
but may lead to blood sugar levels that are higher than normal in the morning. A person's body responds to the
low blood sugar by causing a high blood sugar level in the early morning.
Hypoglycemia:
Hypoglycemia is one of the most common acute complications of diabetes and needs immediate treatment.
Treatment includes testing to see where your blood sugar is and treating with 15 grams of a quick acting
carbohydrate, such as juice, regular soda pop, glucose tablets, milk or glucose gel. Wait 15 minutes, test
again and treat til the blood glucose is above Instruct your patient that if they are going to eat within 45
minutes, then wait to eat, but if the next meal is more than 1 hour away, then have a snack of a protein and
carbohydrate. Be sure to keep track of the pattern of when the low blood sugars are so that changes can be
made to the patient’s routine.
Hypoglycemia is classified as either neuroglycopenic or neurogenic.
Neuroglycopenic: shortage of glucose in the brain. Central nervous system deprivation
Defects in hormonal counter regulation so delay or diminish the onset of autonomic symptoms, resulting in
reduced hypoglycemic symptoms awareness.
Neurogenic: or autonomic symptoms are the result of the perception of physiological changes caused
by the central nervous system-mediated sympathoadrenal discharge triggered by hypoglycemia.
4. Diabetic Ketoacidosis:
DKA is an acute complication of untreated/inadequately treated Type I diabetes caused by profound insulin
deficiency. Ketones are eventually burned for energy source instead of glucose causing acidosis. Many patients
have DKA when they are diagnosed with type 1 diabetes. Also, lower income can contribute to DKA, as people
try to make the insulin they have stretch, so do not receive adequate coverage or do not have the means to buy
testing supplies to know where they are with their blood glucose.
5. Hyperglycemia, Hyperosmolar Syndrome:
HHS is an acute complication of untreated/inadequately treated Type 2 diabetes. This is more common in the
elderly who are treated with medical nutrition therapy only, or medications, but not testing. Usually, the person
will have an illness predisposing them to HHS. Severe hyperglycemia leads to severe dehydration. The patient
usually has enough of their own insulin circulating to prevent ketosis.
Image used with permission of AllRefer Health

10. Even though diabetes is listed with only 2% of the deaths, it is thought that many of the cardiovascular deaths are related because of the significant number of people with diabetes who have cardiovascular complications.
WHO (2005). Preventing chronic diseases: A vital investment. Available at:

11. Chronic Complications of Diabetes
Microvascular
Retinopathy
Nephropathy
Neuropathy
All chronic complications are related to metabolic alterations activated by prolonged elevated blood glucose levels. When blood glucose levels are kept under control, research has shown significant decrease in the risk of long term complications of diabetes.
Retinopathy:
Diabetic retinopathy is described by the changes that occur in the retina, including microanueurysms, hard exudates, soft exudates, hemorrhages and peripheral retinopathy.
Duration of the disease is linked to Type 1, also with Type 2, but not studied as much.
Influenced by genetics: HLA DR3 and DR4 predispose for the development of this complication.
African Americans and Hispanics are more likely to develop than Caucasians.
Modified risk factors include: hyperglycemia, hypertension, dyslipidemia, abnormal mirocirulation and smoking
Retinopathy damages blood vessels in the retina, the light-sensitive tissue at the back of the eye that translates light into electrical impulses that the brain interprets as vision.
Nephropathy:
The microvascular complications of diabetes: retinopathy and nephropathy are thought to result from abnormal thickening of the basement membrane in muscle capillaries. Capillary basement thickening has been shown to increase with the length of time after diagnosis and with persistent hyperglycemia.
Nephropathy affects 30% of Type 1 and 4-20% of individuals with Type 2. Diabetic nephropathy accounts for 36% of cases of end stage renal disease (ESRD). Ethnic origins is a risk factor in the development of diabetic nephropathy, with African American and Native Americans experiencing an increased of ESRD as compared with Caucasians.
Characteristic lesion of diabetic nephropathy is glomerulosclerosis or thickening and hardening of the basement membrane of capillaries in the glomeruli.
Filtration, an essential component of kidney function occurs in the glomerulus.The first stage of diabetic nephropathy is an increase in the glomerular glow rate, or the rate of blood flow through the glomerulus. This increased rate leads to hyperfiltration in the glomerulus or a rise in the rate at which the blood is filtered. As hyperfiltration progresses, the glormeruli become damaged, which leads to leaking. Protein is seen in the urine, at first as small amounts (microalbumin) and then grossly (happens when you dip the urine). As nephropathy advances, the glomerular filtration rate drops and renal failure happens.
There is evidence that the use of ACE I may reduce the incidence or slow the progression of nephropathy. They reduce the pressure going into the glomeruli as well as reduce resistance within the glomeruli.
Modifiable risk factors: Hypertension, dyslipidemia, eating habits, smoking and frequent UTI
What is diabetic kidney disease?
Diabetic kidney disease (diabetic nephropathy) is a complication that occurs in some people with diabetes. In this
condition the filters of the kidneys, the glomeruli, become damaged. Because of this the kidneys 'leak' abnormal
amounts of protein from the blood into the urine. The main protein in the blood that leaks out from the damaged
kidneys is called albumin. In normal healthy kidneys only a tiny amount of albumin is found in the urine. A raised
level of albumin in the urine is the typical first sign that the kidneys have become damaged by diabetes.
Diabetic kidney disease is divided into two main categories, depending on how much albumin is lost through the
kidneys:
Microalbuminuria. This is when the amount of albumin that leaks into the urine is between 30 and 300 mg per
day. Microalbuminuria is sometimes called incipient nephropathy.
Proteinuria This is when the amount of albumin that leaks into the urine is more than 300 mg per day. Proteinuria
is sometimes called macroalbuminuria or overt nephropathy.
Neuropathy:
Neuropathy is defined as either peripheral neuropathy or autonomic neuropathy. The most common cause of
neuropathy in clinical practice is diabetes.
Peripheral neuropathy:
Develops in more than half of long term diabetics. Diabetes causes several types of neuropathy, which include
chronic symmetrical polyneuropathy, proximal neuropathy (diabetic amyotrophy) and mononeuropathies. The
pathogenesis of diabetic neuropathies is poorly understood. Many of them have an ischemic basis. A prominent
finding in diabetic neuropathy is thickening of arterioles due to increased deposition of basement membrane
material, similar to changes that occur in brain arterioles and glomerular capillaries.
Autonomic neuropathy:
Affects the nerves in your body that control your body systems. Affects your digestive system, urinary tract, sex organs, heart and blood vessels, sweat glands, and eyes.
Reference: Pathophysiology, 3rd edition: Copstead and Banasik
Image used with permission of AllRefer Health

12. Chronic Complications of Diabetes
Macrovascular
Cardiovascular Disease
Cerebral Vascular Accident
Peripheral Vascular Disease
Macrovascular complications: Involve damage to the large vessels providing circulation to the brain, heart and extremities. The 3 major types of macrovascular disease are cardiovascular disease (CVD), cerebral vascular accident (stroke) and peripheral vascular disease (PVD). Atherosclerosis, which is common in diabetes, is a soft hardening in which mounds of lipid material mixed with smooth muscle cells and calcium accumulate in the inner walls of blood vessels. These plaques become enlarged over time. Eventually the plaque may block blood flow, weaken and rupture its contents into the blood stream and/or cause the formation of a blood clot.
Risk factors include: lipid abnormalities, hypertension, smoking, obesity, physical inactivity, nutrition, hyperinsulinemia, insulin resistance.
Cardio vascular diseases are the most frequent, serious, lethal and costly of complications.
3. Persons with diabetes appear to be prone to cerebral vascular disease developing at an earlier age than non-diabetics. People with diabetes seem to be at risk for both TIAs and thrombotic CVAs.
4. Peripheral Vascular Disease is common, especially with long standing diabetes. Clinically characterized by intermittent claudication, lower-leg and vascular ulcers, often needing amputations.
Reference: Pathophysiology, 3rd edition: Copstead and Banasik
Image used with permission of:

13. Glucose Tolerance Categories
FPG
126 mg/dL
100 mg/dL
7.0 mmol/L
5.6 mmol/L
Impaired Fasting
Glucose
Normal
2-Hour PG or OGTT
200 mg/dL
140 mg/dL
11.1 mmol/L
7.8 mmol/L
Diabetes Mellitus
Impaired Glucose
Tolerance
It is important to know the normal levels of blood glucose readings. The treatment options are based on where the blood glucose levels are.
This is a different way of looking at glucose levels and how we diagnosis.
FBG: Fasting Blood Glucose
IFG: Impaired Fasting Glucose
IGT: Impaired Glucose Tolerance
OGGT: 2 hour oral glucose tolerance test
Draw a fasting blood glucose, drink 75gms of glucose and then test the blood glucose level 2 hours after
c by AllRefer Health
18 mg/dL = 1 mmol, therefore 18 mg/dL X 7 mmol = 126 mg/dL
Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:
1-2

14. Treatment Options for Diabetes
Nutrition
Activity
Medications
When we look at treatment options for both Type 1 and Type 2, it is important to look at the role that nutrition, activity and oral medications, as well as insulin plays in controlling diabetes.
Nutrition:
It is important to balance carbohydrate foods with non-carbohydrate foods. Complex carbohydrates provide
more nutrition than simple carbohydrate foods. We encourage a lower fat diet, moderate carbohydrate and
moderate protein. It is best to eat smaller meals throughout the day, instead of 1 or 2 large meals. When you
balance your meals, you keep your blood sugars from rising and dropping sharply.
2. Any activity which moves insulin through the muscle is beneficial. Activity of at least 30 minutes a day for 5
days a week is recommended.
For a patient with Type 1 diabetes, only insulin can be used to treat them. For a patient with Type 2 diabetes,
oral medications, injectables or insulin can be used to control diabetes. As you assess your patient, you will
determine which medication is the best in terms of efficacy.

15. Importance of Testing Blood Sugars
Testing blood glucose
Alternate times
Develop a pattern
Be sure to include 2 hours post prandial
Record the numbers
Discuss at visits
Use to revise treatment plan
Testing blood sugars are an important part of managing diabetes.
Depending on the patient and their resources, blood sugars can be done in a variety of patterns and times during the day. Some take their glucose levels several times a day, some only every other day as resources permit.
It is important to include at least some which are 2 hours post prandial as the blood sugar after eating is more closely linked to cardiovascular disease.
Encourage the patient to record their numbers in a log book or on paper so that they can discuss the patterns with their provider.
Use the blood glucose level as a way to tell if the current treatment plan of managing the diabetes is working.

16. Chronic Care Model and Diabetes
The Chronic Care Model (CCM) can be used for diabetes self-management. In the CCM, the patient and the provider work together as a team to control the diabetes. They work in partnership as goals are set and treatment plans are decided on. Team based care has been shown to improve outcomes. In the self-managing chronic conditions module, the Chronic Care Model was introduced. We are going to use the information presented from the presentation on the CCM to assist the patient with diabetes.
Reference: Linda Siminerio, RN, PhD, CDE; Janice Zgibor, RPh, PhD; and Francis X. Solano Jr.,MD. (2004). Implementing the Chronic Care Model for Improvements in Diabetes Practice and Outcomes in Primary Care: The University of Pittsburgh Medical Center Experience. Clinical Diabetes April 2004 vol. 22 no

17. Chronic Care Model and Diabetes
The patient becomes knowledgeable and the expert in diabetes and its complications
The patient understands the importance of taking control of their diabetes
The patient has people who are important to them and their management of diabetes and the provider includes them as the patient wants
The provider will take time to build a relationship with the patient and understands their beliefs, values, culture
According to the previous presentation:
The goal of the CCM is for patients and providers to work together to define problems, set priorities, establish goals, create treatment plans and to solve problems as they are encountered. To do so, patients need to be activated and informed.
The patient can become knowledgeable by attending classes, using online education, using their healthcare provider to give them knowledge.
As the patient understands the basics of diabetes and what is happening to their bodies, then they can begin to understand the importance of taking control and learn tools they need to accomplish this. In the previous slides, you have been given information on diabetes, which providers can use as they work with their patients.
Being able to include people who are important in the life of the patient is vital to success. This person or persons become support and provide encouragement. It is important for the provider to include this person or persons in conversations as the patient wants. It is a team effort for success.
It takes time to develop a relationship with the patient where they will gain trust. By taking time to understand where the patient is in terms of their beliefs, values and knowledge, the provider will be able to move forward and assist the patient in taking control of their diabetes.

18. Maslow’s Theory
As we begin to discuss the CCM and methods of empowering patients, it is important to understand where patients are in their readiness to learn and take control of their diabetes.
The basis of Maslow's motivation theory is that human beings are motivated by unsatisfied needs, and that certain lower factors need to be satisfied before higher needs can be satisfied. According to Maslow, there are general types of needs (physiological, survival, safety, love, and esteem) that must be satisfied before a person can act unselfishly. He called these needs "deficiency needs." As long as we are motivated to satisfy these cravings, we are moving towards growth, toward self-actualization. Satisfying needs is healthy, while preventing gratification makes us sick.
Physiological Needs:
Physiological needs are those required to sustain life, such as: Air, Water, Food, Sleep
According to this theory, if these fundamental needs are not satisfied then one will surely be motivated to satisfy them. Higher needs such as social needs and esteem are not recognized until one satisfies the needs basic to existence. For example, if a patient is worried about where they are getting their next meal of any kind, it is difficult to discuss with them the need to monitory their blood sugars 4 times a day. As the provider takes time to realize where the patient is, it will help guide them in providing the knowledge their patient needs. The provider will set the patient up to fail if they do not take time to understand where the needs are.
Safety Needs:
Once physiological needs are met, one's attention turns to safety and security in order to be free from the threat of physical and emotional harm. Such needs might be fulfilled by: Living in a safe area, Medical insurance, Job security, Financial reserves
According to the Maslow hierarchy, if a person feels threatened, needs further up the pyramid will not receive attention until that need has been resolved.
Social Needs:
Once a person has met the lower level physiological and safety needs, higher level motivators awaken. The first level of higher level needs are social needs. Social needs are those related to interaction with others and may include: Friendship, Belonging to a group, Giving and receiving love
Esteem Needs:
After a person feels that they "belong", the urge to attain a degree of importance emerges. Esteem needs can be categorized as external motivators and internal motivators.
Internally motivating esteem needs are those such as self-esteem, accomplishment, and self respect.  External esteem needs are those such as reputation and recognition.
Self Actualization:
Self-actualization is the summit of Maslow's motivation theory. It is about the quest of reaching one's full potential as a person. Unlike lower level needs, this need is never fully satisfied; as one grows psychologically there are always new opportunities to continue to grow.
Reference:

19. Using the 5 “A’s” With Diabetes
Assess
Advise
Agree
Assist
Arrange
The 5 A’s were introduced in a previous presentation on chronic condition management. We will use the 5 A’s as we work with patients with diabetes.
Assess: What does the patient know about diabetes. Are they ready to learn? What are their values and culture?
Advise: Prioritize an individual plan for your patient in partnership with them.
Agree: Start with goals patient has identified and assist them in creating ways to meet their goals.
Assist: Develop a long-term plan for the patients which is agreed upon by both patient and provider. Assist patient in identifying barriers to success.
Arrange: Continue to follow-up and assist patient

20. Empowering Patients: 4 Important Lessons Patient Need to Learn
Their illness is serious
Their condition is essentially self-managed
They have options
They can change their behavior
If patients don’t believe their diabetes is serious, they will not make the changes necessary to improve their health.
Communicate with the patients the choices they make each day affect their health. For example, do they decide to go for a walk or eat healthy.
There is not one way to treat a patient with diabetes. They need to know what their options are so that they can be involved in the decision making process.
Teach patients that significant changes in their lives need to be done by setting small goals at a time and then realizing they can have success.

21. Helping Patients Set Goals
Start at the problem
Develop a collaborative goal
Validate their goal and plan
When we see patients, we often start talking with them about the issues we have identified as important, for example discussing their lab values. Instead, you might start the conversation with “tell me what concerns you about your diabetes today” This will open up the door for conversations between patient and provider.
Validate the patient’s concern. Allow them to process. Continue to ask questions such as, what have you tried before or what has worked before. The patient will eventually be able to set their goal and what they need to do to reach their goal. Allow them to come up with a solution themselves, but then then provider can add their own suggestions as well.
Have the patient write their goal down and how they plan on accomplishing their goal. Write their goal and plan in their chart as a starting point for discussion at the next visit.
Reference: Wagner EH, Austin BT, Von Koroff M. Improving outcomes in chronic illness. Managed Care Quarterly. 1996;4(2):12-25

22. Old Model vs New Model: Being put on Insulin
New Empowering Model
If you don’t start to control your blood glucose, I am going to have to put you on insulin and you will have to take shots. Your diabetes is not getting any better.
You have been working to control your blood glucose, but often a patient will need some assistance form insulin. Research shows that starting someone on insulin sooner than later, assists them in getting better control. What about insulin concerns you?
This is an example of using the patient empowerment tools.
In the old model, the provider just assumes, the patient is not doing anything to control their blood glucose and uses insulin as a threat.
In the new empowering model, the provider acknowledges the patient has been trying to reach their goals. The provider lets the patient know that it is not their fault. They work as a team. The provider also allows the patient to voice their concerns.

23. World Health Organization and Diabetes
The mission of the WHO Diabetes Program is to prevent diabetes
Core Functions
Diabetes Action Now
World Diabetes day
The mission of the WHO Diabetes Program is to prevent diabetes whenever possible and, where not possible, to minimize complications and maximize quality of life.
The core functions of the WHO Diabetes Program are:
To oversee the development and adoption of internationally agreed standards and norms for the diagnosis and
treatment of diabetes, its complications and risk factors.
To promote and contribute to the surveillance of diabetes, its complications and mortality, and its risk factors.
To contribute to building capacity for the prevention and control of diabetes.
To raise awareness about the importance of diabetes as a global public health problem.
To act as an advocate for the prevention and control of diabetes in vulnerable populations.
Diabetes Action Now is a joint program of the World Health Organization and the International Diabetes Federation which provides information and tools to support the implementation of the Diabetes Program.
It is supported by a World Diabetes Foundation Grant to IDF and WHO funds for an initial period of three years.
The overall goal is to raise awareness about diabetes and its complications, particularly in low- and middle-income countries, and to stimulate effective measures for the surveillance, prevention and control of diabetes.
Key areas of activity for Diabetes Action Now
Work to achieve a major increase in awareness about diabetes, its complications, and its prevention, particularly among health policy makers in low- and middle-income countries and communities
initiate and support projects to generate and widely disseminate new knowledge on awareness about diabetes and its economic impact in low- and middle-income communities produce and widely disseminate a new scientifically-based review on the prevention of diabetes and the complications of diabetes produce up-to-date, practical guidance for policy makers in low- and middle-income countries on the contents, structure and implementation of national diabetes programs provide and maintain a web-based resource to help policy makers implement national diabetes programs
World Diabetes Day is in November of each year. This is a day set aside to bring awareness to diabetes worldwide.

24. Summary Diabetes is a chronic condition affecting millions worldwide
Self-management techniques can delay or prevent complications
Empowering the and becoming a partner with them, will help provide positive results of control
Tools were given to assist the provider in understanding diabetes and thus assisting their patients
By providing healthcare providers with the knowledge of diabetes and its complications and treatments, they can then partner with the patient and assist them in gaining the knowledge they need to take control of their diabetes.

25. Questions and Discussion
These slides were authored by:
Laura Wintersteen-Arleth RN MN CDE
Instructor
WSU College of Nursing
PO Box 1495
Spokane, WA
USA

26. Contact Information
Laura Wintersteen-Arleth, MN, RN,CDE