When prescribing exercise or physical activity for a person with diabetes (PWD), diabetes educators should be specific. Research shows that an individual is more likely to perform exercise as recommended when those recommendations are specific. We give specifics when educating about medications, meal planning and blood glucose monitoring (i.e., how much and how often). Why would it be different with exercise? An individualized exercise or physical activity plan can be made specific by using the FITT Principle where F=frequency, I=intensity, T=type and T=time.
• If the person can not only talk, but also sing, the exercise is considered light intensity. This is useful when a person is getting started with exercise or if they have health concerns making moderate exercise unsafe.
This simple talk test method for determining exercise intensity has been compared to exercise tests where heart rate is monitored and has been determined to be safe and accurate. In fact, if a person is taking a beta blocker medication, it is generally safer than monitoring of heart rate (which is blunted by the medication). Obviously, this test doesn’t work in all situations, for example when swimming. In this case, a person can determine their intensity by doing water exercise and comparing their effort to how they feel when swimming.
So, when prescribing exercise or physical activity for a PWD, let’s be specific with exercise intensity and teach the talk test.
In my next blogs, I will review the specifics of frequency, type and time of exercise so stay tuned!
Recently, I received an email from Diabetes Care about articles published ahead of print. My eye was drawn to read a position statement of the American Diabetes Association (ADA) on type 1 diabetes. In a 20-page publication, Chiang and colleagues provided background information and clinical guidance for the management of individuals with type 1 diabetes from infancy to an older age.
Here are some highlights from the article:
- Pancreatic autoantibodies should be used to confirm the diagnosis of type 1 diabetes. Since my practice site is located in a rural area, I have not recommended obtaining these laboratory tests, but most commercial laboratories do not have reliably sensitive or specific assays for certain autoantibodies.
- As recommended in the 2014 ADA guidelines, relatives of patients with type 1 diabetes should be referred to a clinical research study. You can refer to sites by the National Institute of Health and Juvenile Diabetes Research Foundation for research information and location of centers.
- There is a lot of great information about development issues (Table 2), clinical evaluation (Table 4), and DSME content (Table 6) for patients with type 1 diabetes from infancy to an older age. This section would be a great topic for discussion and presentation at the AADE15 meeting in New Orleans, LA.
- I was familiar with celiac disease among patients with type 1 diabetes, but did not know the statistics – 1-16% versus 0.3-1% in the general population, respectively.
- There has been change in desired A1C goals for the youth. Previous goals were: <8.5% for children younger than 6 years, <8% for children 6 to 12 years of age, and <7.5% for adolescents 13 to 19 years of age. In this position statement, the ADA recommended an A1C goal of <7.5% for all pediatric age groups.
- A growing area of research is beta-cell replacement therapy. On page 2047 of the position statement, recommendations of patient candidates for pancreas transplant and islet transplantation are provided.
- Pramlintide and some incretin agents have been studied as adjunctive therapy among patients with type 1 diabetes. While the studies have been small in sample size and short in length, the evidence is promising (i.e. reduction in A1C, reduction in total insulin dose, and promotion of weight loss). However, additional evidence is needed to have stronger conclusions and clinical application for patients with type 1 diabetes.
For more information, you can refer to the article: Chianga JL, Kirkman MS, Laffel LMB, Peters AL. Type 1 diabetes through the life span: a position statement of the American Diabetes Association, published in Diabetes Care on June 16, 2014 (DOI: 10.2337/dc14-1140).
A number of years ago I began to work in the hospital and was shocked at how many folks were in for foot wound debridement and amputations. Even though I have some patients in the outpatient world that have neuropathy and need medications to help them tolerate pain, and some who have lost a foot to an amputation, I was totally unprepared for the number of foot and below the knee amputations that were performed on a regular basis. And unfortunately, patients with excellent blood glucose management now, but poor control earlier in their lives with diabetes, were not immune.
Approximately 50% of patients with diabetes will develop neuropathy at some point in their lifetime, most experiencing peripheral neuropathy involving the lower extremities. Those with poor diabetes management are at highest risk.
As diabetes educators, it is important for us to include education about self-foot examinations in most of our education sessions. Visually inspecting feet should be done at most visits, with a thorough foot exam at least annually by a trained individual, be it a diabetes educator or medical provider. The annual exam should include visual examination of the feet as well as sensory assessment. In cases when problems are detected, referring to a podiatrist with a strong understanding of diabetes is a must. The new 3rd edition of The Art and Science of Diabetes Self-Management Education Desk Reference is a wonderful resource for providing information on frequency of screenings, explaining the visual foot assessment, and providing information on what should be included in a comprehensive foot exam.
In addition to screenings, prevention of complications starts with teaching patients to pay attention to their feet. Ask your patient if they wash their feet regularly? Dry between their toes? Take off their socks each night and check for any sores, dry or red areas. If the individual cannot see the bottoms of their feet, encourage the use of a mirror. Have a sample of one in your office and help them look at their feet. Remind them of the importance prompt medical attention if their assessment reveals any question about the health of their feet.
I can remember many years ago attending a session at an American Diabetes Association Annual Meeting, where the presenter showed slides of foot and leg complications of diabetes due to poor management. I was young and so surprised that something so destructive could be occurring, often undetected.
I am now no longer surprised, but saddened. Prevention is really the answer, and teaching patient to care and examine their feet, along with managing their blood glucose values, can go a long way to help reduce the risks of irreparable damage.
We as a nation have an obsession with food. Being in the diabetes arena brings it even more to the forefront as it has a significant impact on patients’ lives and glycemic control. It is a fine balance between eating properly, taking the correct medication for your food choices, and not feeling guilty if the choices were not exactly what the CDE had recommended. A major portion of each of our Diabetes Classes is spent discussing food choices – and it continues to be the part that patients find the most challenging.
I knew there was a day soon where we would see several alternatives to pricking fingers for regular blood glucose monitoring. Isn’t it neat when new technology and healthcare cross paths? Have you heard of the GlucoTrack glucose measuring device by an Israeli company, Integrity Applications? Looking through the history, it appears as though it’s been going through testing for several years and approved for use in several countries. It is completely noninvasive device that looks like a smart phone with a headset. You just clip the measuring device on one ear lobe and a minute later, the screen displays your current blood glucose.
The device supports up to three users but each user needs a personal ear clip since they are calibrated separately. Then the user just needs to re-calibrate the device every six months when they change to a new ear clip. The device has a USB port and downloads data to your computer and also uses a touch screen display like a smart phone.
The GlucoTrack uses a combination of three technologies to get an accurate reading of the patient’s blood glucose: Ultrasound, Electromagnetic, and Thermal. The results are weighted and it uses a patented algorithm to display blood glucose results. On their website, they have several poster presentations from conferences. From October 31, 2013 at the Annual Diabetes Technology Meeting, they demonstrated how various factors that affect tissue characteristics such as age, gender, and body mass do not produce a variance in blood glucose results.
Though it does have CE mark approval, the GlucoTrack is still undergoing research before it is approved for use in the USA. Please comment below if you have heard of the GlucoTrack or similar noninvasive blood glucose measuring devices.
Have you had patients complain about calf cramps at night? They can be incredibly bothersome and painful. When I see a patient with diabetes and ask about pain, I am often told about annoying calf cramps. They can come without warning and wake a person up from a sound sleep. Most people will wriggle and stretch and get up from bed to try to walk them out.
What causes them? There are several possibilities. Here are a few common ones:
What to do? It is best if the cause of the cramps can be identified and managed. But, there are those situations when it isn’t determined. Sometimes, it is necessary to just treat the symptom.
In either case, I have found a substantial decrease in report of cramps if calf muscle stretches are done routinely before going to bed. Interestingly, when I did a search for the evidence, I didn’t find support. But, since this is a pretty low-risk intervention, it seems worth a try. This is the stretch I most often suggest to manage those annoying cramps:
• Stand facing the wall at arm’s length from the wall, feet shoulder-width apart.
I love the virtual meeting!! AADE did a great job providing access to the general and selected breakout sessions. This morning, I spent some time listening to Thursday’s sessions and catching up on the electronic newsletter. I have thoroughly enjoyed all the breakout sessions, but wanted to mention a few highlights from “Nutrition Adequacy of Various Popular Diets”. I listened to this presentation since I do not have a background in nutrition, but I am constantly reading articles or peer-reviewed publications on the topic. I think it is important to be able to teach and answer questions for patients about nutritional information.
Here are the selected highlights from this session:
• Diabetes has increased by 69% over the past 20 years.
It was interesting to learn about the various religious fasting days, which can be up to 180 days in a year. There was great information about potassium, calcium, vitamin K, zinc, and fiber intake.
Listening to the selected sessions reminded me about how exciting the AADE meeting can be and I hope to attend the meeting again in the future.
AADE14 has wrapped up. As I reflect on the meeting, I feel so good about the general session speakers, breakout sessions, the exhibit hall, the 5 K run/walk, and the social events. The Celebration of Giving was a great time! The dance floor was packed! If you didn’t go this year, definitely put it on the schedule for next year.
But, my main reflection for this blog is going to be about, I almost hate to put the words here for fear you will stop reading, the Business Meeting. There was a nice turnout. We didn’t have anything that had to be voted on. So, the meeting agenda focused on getting thoughts from the members about the future of diabetes education/educators and AADE. We have just started work on the 2016-2018 Strategic Plan. You will see more about the process and be able to provide input as the work progresses. The business meeting gave us a chance to hear what diabetes educators think are key trends for our future.
I jotted down notes as the attendees spoke. I am sure some of the trends/comments will resonate with you; others may be things you haven’t thought of. Here are some of the trends put forth:
What great ideas! Can you think of other trends that should be shaping our future as we move forward in the creation of AADE’s Strategic Plan for 2016-2018?
It’s a little difficult to give up hiking beside a mountain stream, fly-fishing and river rafting during the summer in Montana to head to the air-conditioned rooms and warm, moist outdoor air of the southeast, but off I go to attend AADE's Annual Meeting. Each year as I assess the greater financial contribution I need to make to attend the Annual Meeting, and time away from family, I realize that I make the choice to attend because I feel so good about being there. I love diabetes educators as a lot, and feel at home chatting with everyone from those who live in Florida to those who live in Alaska and Hawaii and all states in between. The bond in being a diabetes educator is strong, regardless of discipline. Our jobs are about helping people and each day I go home after a day at work, camp, or as a volunteer for Tour de Cure feeling a sense of contentment.
The Annual Meeting offers a wonderful place to learn more, relax with old acquaintances, meet new people and get re-energized and ready to return to work with new ideas and approaches. This year, for those of us that have been in diabetes education for eons, a new Masters level has been added. I look forward to an update on the most recently introduced medications, insulin pumps and other great technologies. I’ll network with other CDEs who volunteer at diabetes camps across the nation, and perhaps even find yet another one to attend! I will go to some committee meetings, judge research posters and moderate sessions. And when I return home I will hopefully be better informed, certainly recharged, and looking forward to incorporating both new and reaffirmed practices that will meet the needs of my patients.
Hope you are attending AADE's Annual Meeting either in Orlando or virtually and enjoying all that the Annual Meeting has to offer. And if you can’t make it this year, I encourage you to consider attending in 2015!
You can feel the energy in the air!! Diabetes educators from around the world are gathered for 4 full days of education and excitement. I love the tagline for AADE14 – REFRESH.RECHARGE.RENEW.
I always look forward to AADE Annual Meetings and I’m bummed when I can’t attend! I have really loved the option of the Virtual Meeting since I am a mom of two little ones. Traveling several days with a baby at home can be a challenging childcare puzzle. I’m sure many of you can relate! I have done the Virtual Meeting since it has been offered and every year the user interface continues to improve and it is really quite simple to navigate. I love being able to fit it in to my schedule or watch a session after my kids have gone to bed.
“Nutrition Adequacy of Various Popular Diets” is one of the sessions offered and I’m really looking forward to that one. Fad and trendy diets have always intrigued me and I love staying up to date on the latest ones so I can educate my patient on the pros and cons as well as dangers. I want to know about the trends before my patients ask my opinion.
I’m also looking forward to learning about “Musculoskeletal Complications of Diabetes”. We don’t hear enough about the musculoskeletal complications. There have been many times when a patient with diabetes is sharing with me a list of ailments that they have and asking if it is related to diabetes. Of course, I refer them to their physician- but I would love to learn more about the connection between joints and muscles and blood glucose control since there is not much information about this type of complication.
It’s not too late to register for the Virtual Meeting! I would highly recommend it if you cannot attend the annual meeting this year.
When I think about what I am most looking forward to at the Annual Meeting, my first thought is what I can learn at the educational sessions and in the exhibit hall. But, I have to be honest; I am most looking forward to refreshing, recharging and renewing with other diabetes educators.
As I reflect on the past annual meetings I have attended, I can think of meeting people in a variety of situations; at the airport, waiting for a session to start, at a reception or social event, and even in line in the ladies’ room! It is amazing how a chance encounter can forge a long-term relationship.
This week, I look forward to seeing friends and colleagues I have met in the past and to starting new relationships. If you can come to AADE14, I hope you learn much in the sessions and exhibit hall. And, I hope you meet and start relationships with other diabetes educators who can become a major part of your professional and personal future.