I recently attended a regional diabetes gathering to learn what has been happening with certified diabetes educators in upstate South Carolina. I also attended the gathering to refresh my memory on the 2015 American Diabetes Association (ADA) Standards of Medical Care. It was a great review by a medical science liaison. I will be honest – I spent most of the time reflecting on the new pneumococcal recommendations. The Centers of Disease Control (CDC) and Advisory Committee on Immunization Practices (ACIP) provides the annual schedule for childhood and adult immunizations. When thinking about the constant changes in immunizations, I wanted to write about the hepatitis B virus and its recommendations.
In 2011, the ACIP voted 12-2 to recommend the hepatitis B virus immunizations among patients with diabetes. The series is recommended for any patient 19 to 59 years of age with diabetes, whereas it is the physician’s choice to vaccinate a patient with diabetes and older than 60 years. For patients over the age of 60 years, the physician should determine the patient’s risk of contracting hepatitis B since the vaccination’s effectiveness decreases with age. In addition, patients living in nursing homes may be at higher risk of contracting hepatitis B virus, than someone living along at home. Some certified diabetes educators may have a difficult time with physicians accepting this recommendation. Patients may even look puzzled when mentioning the hepatitis B virus immunization as a preventative strategy against the disease. Explaining why patients with diabetes are at a high risk of hepatitis B may improve rates of immunizations among this special population.
First, blood or other bodily fluids is the common source of hepatitis B transmission. If an infected patient shares diabetic supplies, such as needles, pens, syringes, then she or he is putting other individuals at risk of transmission and infection. All patients should be educated on methods of transmission and strongly encouraged not to share any diabetes supply item. Second, people may think hepatitis is only an active infection of the liver. Yes – there is acute infection, but most often, people develop chronic hepatitis B infection, requiring indefinite treatment with anti-virals. Furthermore, liver complications can develop from hepatitis B. Third, the best method of prevention is the hepatitis B virus vaccination series. Patients should be educated about receiving the three injections over a 6 month period. According to the CDC, the injections can be given intramuscularly at 0, 1, and 6 month. Patients can be informed that this series is lifelong and will not require re-vaccination. Additional information can be found from the CDC.
I hope this information is helpful. Do not forget to speak with patients about hepatitis as May is Hepatitis Awareness Month.
For all of my adventuring around the world, I’m a fan of following tradition, even if it doesn’t always seem to make sense. St. Patrick's Day is a holiday laden with tradition, but for me, the green holiday holds a different kind of significance.
Over the last few years, I've developed a tradition of doing a fun and exciting thing (or just anything out of the ordinary) each year around my "diaversary"--the anniversary of when I was diagnosed with type 1, which falls on St. Patrick's Day (March 17th). Why does it often end up being something really dramatic? Because doing something challenging and fun that coincides with commemorating a diagnosis of something challenging and not always 100% fun makes the situation a little bit better, I think! Past diaversaries have involved celebrating St. Patrick's Day in Dublin, Ireland, celebrating St. Patrick's Day in Boston, and heliskiing in the Italian Alps.
We recently had a very undernourished gentleman admitted to the hospital with multiple problems, one of them, a new diagnosis of diabetes with no detectable c-peptide. He was started on basal bolus insulin appropriately and the blood glucose control was leveling off reasonably. I was at the nurses’ pod reviewing his notes, when I was tapped on the shoulder and a student nurse asked if I could help her figure out where to give his insulin injections. He was so thin that she was having difficulty finding any subcutaneous tissue. We discussed optional locations, the 45 degree angle for the injections and she went into the patient room to help with the shot. I decided to take a look at the one-use needles we were using, and noted they were 8 mm needles. I was surprised to find out it was all we stocked! In further investigation I learned some parents of the children bring in their own pen needles due to the child’s discomfort when injected with the hospital needles, not to mention their inappropriateness. Not exactly a good protocol in the hospital – but hats off to the parents finding a way to minimize the discomfort for their child.
In all the concern over the change in policy, nursing education, changing IV drip to subcutaneous insulin equations, writing insulin pump protocols, I have missed a simple change that could make a difference not only in comfort, but in the successful delivery of insulin in most patients.
So I am once again reminded of how important it is to remember the simple things in this complex and relentless disease. To review on a consistent basis the things we have learned about taking care of persons requiring insulin that may make a difference.
I pulled out an article I had cut and saved “Translating the Research in Insulin Injection Technique: Implications for Practice” in the October 2012 issue of The Diabetes Educator and reread it. Research that investigated injection technique, teaching insulin administration, and of length of the insulin needles and reviewed it for clarity.
So along with needle length – here are a few simple reminders when reviewing insulin administration with patients, nurses, and care providers:
1. Check needle length, 4-5 mm is enough – there are still some folks with 12 mm needles – in fact I was horrified last year to see some had been shipped to kids’ camp!
As we work with our patients, both inpatient and outpatient – it is often the little things we can forget. Appropriate needle length is just one of those details and an easy thing miss when there is so much work to be done to help take care of our patients. Needless to say, we are already working to resolve this issue!
Happy spring!! It is definitely warming up here in the South. After some much needed rain, the spring flowers are popping up in yards and fields. The hummingbirds have returned. It is time to start encouraging our patients and ourselves to be more active - especially after being cooped up inside during this long cold winter. I know most people dread the word exercise but there are lots of less ominous options. Pruning trees and bushes – raking leaves – joining the kids for spring ball games. It is a great time to start taking walks at the local parks or riding a bike around the neighborhood. There are lots of small ways to increase activity in fun and interesting ways that do not seem like exercise.
Another way to get ready for summer activities is to improve eating habits. This is a good time to assess and reorganize the kitchen. Being organized makes it less likely to have to make spur of the moment unhealthy choices. Here are a couple of things you and your patients can do to increase the chances of making a good decision.
Make your own snacks – When you are hungry and short on time, it’s easy to grab what you can. Make sure that healthy snacks are readily available. Buy fresh fruit and veggies already cut up or spend some time prepping and cutting into proper portion sizes that are ready to eat. Put in snack sized bags that are ready to grab and go. Make it a family activity by having younger children help with weighing or measuring proper portions.
Keep cabinets full – Keep the pantry and fridge stocked with healthy snacks or quick to prepare foods so when timing gets tight, you can avoid the impulse to hit the high calorie drive- thru. Spend a bit of time at the grocery looking for healthy food choices to keep in the pantry or freezer. This is especially important at breakfast time when people are running late and poor choices often become the norm.
Hide the high calorie beverages – If you have to have them in the house, put high calorie drinks and juices out of reach. Make water the easiest option when thirsty. Use smaller bowls and plates - Most of us just eat too much. We have developed “portion distortion” issues. Use smaller bowls especially as those are typically the serving vessels for high carbohydrate desserts.
Stash high carbohydrate cereals – Make it harder to grab those sugary cereals as a snack. In one study, those who kept their cereal out and accessible weighed as much as 20 pounds more than those who kept cereals stashed in the back of the cabinet.
Cut the clutter in the kitchen – Make sure your kitchen table is accessible for its true purpose. Those who mindlessly eat in the living room or in front of the TV, tend to eat more.
Remember to start now. Summer is right around the corner and no more hiding under bulky winter clothes.
See you at the beach!
Even though I don’t work with insulin pumps on a daily basis, I have always been amazed by their advancing technology. This weekend I was talking to a high school student with type 1 who wore a pump without tubing. It just made me think of what a big deal it is especially for a high school student to have a tube-free pump for social reasons. He is a senior this year and about to go away to college. That is usually a trust test to see how a freshman in college handles all the newness and stress of their first year and also works every day to manage his blood glucose and insulin.
A statement from the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group was just published in the “Online Ahead of Print” section in Diabetes Care describing their efforts. As diabetes educators we know all the benefits of a pump and how life changing it can be. We also know with any type of insulin therapy, there are major life threatening risks. This group asserts that we need to be doing a better job looking at the safety of pumps from a clinical perspective. The “adverse events” (AE) reports on the US Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database is not being used to its potential and the European Databank on Medical Devices (EUDAMED) is not publicly available. They want more real life usage data and AEs to be public so that public observational studies and clinical trials can be ongoing reviewing the safety of a particular pump.
Based on their assessment of current standards, they recommend:
1. The regulators (EU/FDA) should:
2. Pump manufacturing companies should be required to provide with transparency to the regulators:
3. International and national professional societies should:
4. International and national research funding bodies should:
5. Healthcare teams should:
How do you feel the industry is doing to continually review their pumps and provide education to users and healthcare professionals? If you have given feedback to a pump company, was action taken? Again, I am truly in awe of the advances in technology from pump companies and am excited about the future, but equal effort needs to be given to ensure safety and training for current pump users.
When you think diabetes, do you think osteoporosis or fracture? Maybe not. Unfortunately, there is an association between type 1 and 2 diabetes and fracture.
We have known for a long time that there is a relationship with type 1 diabetes and osteoporosis. Now, we also know there is an increased risk of fracture with type 2 diabetes, even with average or better than average bone density.
Osteoporosis, or porous bone, is a disease where the bone is not thick and/or strong enough leading to increased risk of fracture, especially in the hip, spine and wrist. It is estimated that 10 million people in the US have osteoporosis and another 43 million have low bone density putting them at risk for osteoporosis and fracture. About 1 in 2 women and 1 in 5 men will have a fracture related to osteoporosis! A fracture can cause many problems including risk of decreased mobility, admission to a nursing home, and even death.
There are some steps that can be taken to decrease the risk of osteoporosis, low bone density, and fracture. It is important to start early, during childhood and the teenage years, to build bone. During adulthood, we can work to modestly increase bone density and strength. Later in life, we can work to maintain density and strength but the main focus it to decrease the risk of falls to avoid a fracture.
Let’s look at the steps to protect bones with specifics for a person with diabetes (PWD):
• Do regular exercise/physical activity: This is important for all of us! The recommendations for exercise are basically the same to prevent osteoporosis and fracture and for a PWD. We should aim for about 30 minutes per day, most days of the week, of moderate exercise. To help build or maintain bone density, try for impact activities (brisk walking, hiking, stair-climbing, dancing, jogging or jumping rope). If a person has pain or other problems that would be increased with impact, try activities with less impact (elliptical, water exercise, bicycling). Strength training is also helpful for a PWD and to improve bone density. If a person hasn’t done strength training, it is best to work with a trainer who can help with best form for safe exercise.
• Eat healthy: A well-balanced diet will provide most of the important nutrients for bone health. This includes fruits and vegetables and healthy proteins (the building blocks for strong bones). When a PWD follows a healthy meal plan for diabetes, bones will be healthy, too!
• Get enough calcium and vitamin D: The recommended allowances vary by age. For vitamin D, children need 400 to 600 international units (IU) and adults need 600 to 800 IU per day. For calcium, children need from 200 to 1300 mg, increasing with age, and adults need 1000 to 1200 mg. It is good to have calcium-rich foods/beverage options with low, moderate, and high carbohydrate content to fit an individual’s diabetes meal plan. It is also helpful to know dairy-free and gluten-free options for individuals with lactose intolerance and gluten sensitivity or celiac disease. A PWD can work with a dietitian to include these nutrients in his/her meal plan.
• Limit alcohol: Generally, we should limit alcohol intake to 1-2 drinks per day. Taking in more can get in the way of healthy nutrition and increase the chance of a fall/fracture.
• Don’t smoke: Smoking is harmful to the bones and increases the risk of complications of diabetes. If a person does smoke, this is one more reason to stop. It is never too late!
• Don’t fall/work on balance: As the years go on, many people notice balance isn’t what it used to be. Many people don’t know they can improve balance but it can get better by doing challenging balance exercises. This has been proven specifically in people with diabetes. If a person has fallen in the last year or loses balance easily, she/he is at high risk of falls so should see a physical therapist (PT) or participate in a community balance program. Over 90% of hip fractures and nearly half of spine fractures are due to a fall; almost all fractures in the wrist, shoulder and pelvis are due to a fall. So, if a person doesn’t fall, the risk of fracture is greatly decreased! A PWD might have many risks for falls including vision problems, lack of sensory input from the feet due to neuropathy, taking more than 4 medications, and variable blood pressure to name a few. A complete balance assessment should be performed by a healthcare provider for a person at high risk of falls.
• Stand tall: Many spine fractures can be prevented by keeping the spine in a good position without forward flexing. This means using the legs to lift so the back can stay straight and avoiding flexing movements such abdominal curl sit ups and toe touches. If a person has slouched posture and struggles to be in a good position, he/she can work with a physical or occupational therapist to improve it.
Diabetes educators can raise awareness of the possibility of osteoporosis and fracture in a PWD and can help with steps to decrease this risk through adjustments to the diabetes self-management plan and referrals to specialists as needed.
As a practicing optometrist I realized the connection between diabetes and what I do, and decided to enroll in the online Master of Science in Diabetes Education and Management program at Teachers College. During my interactions with classmates, I have learned that diabetes educators in all clinical backgrounds can help people with diabetes take care of their eyes and protect their vision.
Eyesight vs. Eye Health
The eye provides a unique opportunity to monitor microvascular changes. An annual dilated vision exam by an ophthalmologist or optometrist can screen for the occurrence of retinopathy. Early changes are usually reversible with lifestyle (nutrition and activity) and medication interventions. Even in advanced cases (usually treated by laser for retinopathy, intravitreal injections for macular edema or vitreoretinal surgery for more advanced conditions) timely intervention and treatment can prevent further vision loss or blindness. However it has been my experience that many patients (with or without diabetes) correlate eyesight with eye health. The two terms are not equal. A patient may mistakenly carry a false sense of security about eye health. Patients with proliferative retinopathy or macular edema can have excellent acuity (20/20 vision). Undiagnosed these underlying conditions will continue to worsen and by the time a patient notices vision changes fewer treatment options remain. Additionally the risk of vision loss and blindness increases due to the condition itself and/or the treatment required to stop its progression.
Images that compare the different stages of retinopathy to that of a normal retina can be informative. One study indicated that showing the patient their retinal images had a positive impact on patient attitudes toward eye care. However, discretion should be exercised. An educational intervention that uses fear as a motivator for change (in this case continuity of eye care) has been shown to have the opposite effect.
Another helpful tool that can educate your patients on the importance of regular eye care is the web-based Retina Risk calculator (www.retinarisk.com). This tool uses blood pressure (BP), A1C, and diabetes duration to calculate future risk of retinopathy for a specified number of years in the future. It is easy to use on office computers or tablets. The BP and A1C numbers can be adjusted to demonstrate the positive affect of improved self-management skills. This resource is free for the first month, and then has a charge.
Another option might be for your institution, health center or clinic to invest in a retinal camera. This works well in instances where patients are reluctant or unable to engage in yearly comprehensive eye exams due to lack of transportation, age/cognitive change and time constraints. Digital photos without dilation can be taken by non-eye specialists for later review by a qualified clinician/physician.
Loss of vision and blindness are devastating to the individual with diabetes. The few minutes a diabetes educator invests in communicating the importance of regular comprehensive exams may provide a patient with a lifetime of vision and improved quality of life.
Guest blog post by Dr. John McDonald, OD
First, I know I have written several blogs about current or recently approved medications. I have always been fascinated with the chemistry of medications, but more importantly how and why do we use certain medications for a specific disease state? On a regular basis, I am having a discussion with my providers at a rural health family medicine clinic – “Which one is better an ACE-inhibitor or ARB?” “Which one should I use among patients with diabetes who need additional blood pressure control?” As a pharmacist, I have looked for key factors for why a patient may be prescribed an ARB, such as documented allergy (i.e. cough), documented angioedema, or insurance. Either option – ACE-inhibitor or ARB – has become the standard of care for patients with diabetes.
When talking about the latest blood pressure guidelines – JNC VIII – calcium channel blockers (i.e. amlodipine), thiazide-type diuretic (i.e. hydrochlorothiazide) are recommended at the same level of ACE-inhibitors and ARBs as there is no superior evidence among these classes. However, patients with diabetes may benefit from either an ACE-inhibitor or ARB due to risk of cardiovascular events. A patient with diabetes is at a higher risk of heart failure, myocardial infarction, and stroke. Therefore, the benefit would definitely be gained with an ACE-inhibitor or ARB for these conditions. It is okay for patients with diabetes to be prescribed amlodipine or hydrochlorothiazide, but it would be better for a patient with diabetes who also has chronic kidney disease, albuminuria, heart failure, myocardial infarction and/or stroke. No matter what, it will take several agents to lower the patient’s blood pressure. I think about all the available combination products – small doses of several agents can lower a patient’s blood pressure. It is important to strive for a desired blood pressure goal (i.e. for diabetes, less than 140/90 mm Hg per the JNC VIII and ADA guidelines) rather than maximize doses, which could increase the risk of adverse events.
While writing about blood pressure management, it is important to counsel patients about:
For everyone’s review, here is a list of current ACE-inhibitors and ARB with brand names (combination products are not provided):
Every year I look at all the educational offerings for diabetes professionals throughout the country. There are more and more options to choose from with excellent speakers, locations, and continuing education hours. So why choose the AADE Annual Meeting?
Continuing education: For the individual new to a career in diabetes management and education, there are multiple educational sessions that will help to guide you. For those in the field for many years – Master Classes will update you on the newest medications, research progress on prevention, and updates on the newest technology to enhance the your ability to help education and provide management skills to patients with diabetes. Product Theaters are available to bring you up to date on the newest products on the market to not only help guide our patients but to also share the information with fellow providers at home.