GUIDELINES FOR DIABETES CARE: DABETES SELF-MANAGEMENT EDUCATION
Diabetes self-management education (DSME) is critical to successful re for all people with type 1 and type 2 diabetes. National standards for DSME are regularly updated by the American Diabetes Association d are reviewed and approved by key organizations with involvement diabetes care.
The 10 national standards for DSME are comprehensive and fully de-ibed in the Clinical Practice Recommendations of the American Diabetes Association. The ADA has a recognition program for hospitals, nics, and other health care sites that develop programs in accord with ;se guidelines. Reimbursement for DSME from Medicare is linked to  ADA recognition. The 10 standards can be summarized as follows: . Documentation of organizational structure, mission and goals, and recognition of quality DSME as an integral component of diabetes
• Definition of target population, its educational needs, and necessary resources.
•Oversight by a representative advisory body, including planning, ongoing review of outcomes, and consideration of community concerns.
• Designation of a qualified coordinator.
• Interaction of the patient with diabetes with a multifaceted education instructional team, which should include at least a registered dietician and a registered nurse who are certified diabetes educators (or eligible to become a CDE).
•Regular continuing education for the instructors.
• A written curriculum, with criteria for successful learning outcomes.
• Individualized assessment, development of an educational plan, and reassessment of participants.
• Documentation of step 8 in a confidential education record. Development of a continuous quality improvement process. care.
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DIABETES: TAKING ORAL HYPOGLYCEMIC DRUGS
If you are taking oral hypoglycemic pills and your blood or urine glucose levels become very high, consider increasing your dose. Naturally, whether you can do this, depends on whether you are already on the maximum dose or not. If you are not on the maximum dose, try taking another half pill a day or another whole pill if this does not take you over the maximum.
One of the problems of being on pills is that they may not be absorbed if you have diarrhea or vomiting. Even if they are, they may not be sufficient to overcome the increased insulin resistance that can result from infection and other illnesses. If you have diarrhea and vomiting or if you cannot bring your blood glucose level down yourself, or if you feel very ill, contact your doctor immediately. Sometimes it may be necessary to have insulin injections to control your blood glucose level during a time of illness. This does not necessarily mean that the insulin will need to be continued when you have recovered.
Loss of glucose control on oral hypoglycemics
Many people with the form of diabetes that starts during middle age and the later years (maturity onset type) can control their blood glucose on diet and oral hypoglycemic treatment. Most people whose diabetes begins under the age of thirty years need insulin treatment but a few with maturity onset diabetes of youth (MODY) can be treated successfully with oral agents.
Control of your weight through diet is especially important in maturity onset diabetes because obesity increases the body’s resistance to the action of insulin. However, if insulin production fails, whether in maturity onset diabetes or MODY, insulin injections will be needed for glucose control. This is not a disaster.
Geoffrey, who is now fifty-eight years old and a production manager, had been taking chlorpropamide since his diabetes was diagnosed five years previously, gradually, increasing the dose to the maximum of 500 mg daily.
Despite sticking carefully to his diet and remaining at the ideal weight for his age and height, his glucose levels began to rise. His doctor added metformin treatment and the dose of this was increased to its maximum, but to no avail. Geoffrey’s blood glucose levels continued to rise and he began to feel thirsty and had to get up to urinate several times each night. He felt tired and listless. I told him that he now needed insulin treatment but Geoffrey had a horror of injections and was convinced that he would never be able either to give his own insulin or allow anyone else to give it to him.
‘I would sooner die than go on to insulin,’ he said.
Nothing I said could persuade him to change his mind. Over the succeeding weeks he became increasingly ill, was drinking large quantities of fluids daily, started to lose weight and was irritable with his wife and family. He developed an embarrassing soreness around his penis, a fungal condition called thrush, which men and women with diabetes can develop with poor glucose control. This was treated but it recurred. At each clinic visit I tried to persuade Geoffrey to change his mind about insulin treatment but he remained adamant. Then finally one day he came into the clinic in tears. He could no longer do his job properly, he felt awful and was badly depressed. His wife, who came with him, was very worried about him. I got out an insulin syringe and needle and demonstrated on myself how simple it is to insert the needle under the skin. After thirty minutes’ persuasion by me and his wife, Geoffrey stuck the needle into his arm.
‘It doesn’t hurt,’ he said, astonished.
He is now on twice daily insulin injections with good glucose control, is back at work and says he feels marvelous. He wishes he had tried insulin sooner.
Call for help
Even the best informed and most efficient people have occasional Problems. It is not an admission of defeat to call for help -just common sense. Doctors greatly prefer being called when they can help prevent a problem from getting worse than when a disaster has occurred. Contact your doctor sooner rather than later.
Problems with glucose control
•   Hypoglycemia is preventable. Learn your warning signs – and learn from your mistakes.
•   Measure blood glucose levels frequently when you are ill.
•   Plan what to do if you become ill before it happens.
•   Take more insulin if your blood glucose level rises.
•   Check for ketones if your blood glucose level rises or you cannot eat.
•   Never stop taking your insulin.
•   Do not be afraid to call for help.
*29/102/5*

DIABETES: TAKING ORAL HYPOGLYCEMIC DRUGS
If you are taking oral hypoglycemic pills and your blood or urine glucose levels become very high, consider increasing your dose. Naturally, whether you can do this, depends on whether you are already on the maximum dose or not. If you are not on the maximum dose, try taking another half pill a day or another whole pill if this does not take you over the maximum.One of the problems of being on pills is that they may not be absorbed if you have diarrhea or vomiting. Even if they are, they may not be sufficient to overcome the increased insulin resistance that can result from infection and other illnesses. If you have diarrhea and vomiting or if you cannot bring your blood glucose level down yourself, or if you feel very ill, contact your doctor immediately. Sometimes it may be necessary to have insulin injections to control your blood glucose level during a time of illness. This does not necessarily mean that the insulin will need to be continued when you have recovered.
Loss of glucose control on oral hypoglycemicsMany people with the form of diabetes that starts during middle age and the later years (maturity onset type) can control their blood glucose on diet and oral hypoglycemic treatment. Most people whose diabetes begins under the age of thirty years need insulin treatment but a few with maturity onset diabetes of youth (MODY) can be treated successfully with oral agents.Control of your weight through diet is especially important in maturity onset diabetes because obesity increases the body’s resistance to the action of insulin. However, if insulin production fails, whether in maturity onset diabetes or MODY, insulin injections will be needed for glucose control. This is not a disaster.Geoffrey, who is now fifty-eight years old and a production manager, had been taking chlorpropamide since his diabetes was diagnosed five years previously, gradually, increasing the dose to the maximum of 500 mg daily.    Despite sticking carefully to his diet and remaining at the ideal weight for his age and height, his glucose levels began to rise. His doctor added metformin treatment and the dose of this was increased to its maximum, but to no avail. Geoffrey’s blood glucose levels continued to rise and he began to feel thirsty and had to get up to urinate several times each night. He felt tired and listless. I told him that he now needed insulin treatment but Geoffrey had a horror of injections and was convinced that he would never be able either to give his own insulin or allow anyone else to give it to him.’I would sooner die than go on to insulin,’ he said.Nothing I said could persuade him to change his mind. Over the succeeding weeks he became increasingly ill, was drinking large quantities of fluids daily, started to lose weight and was irritable with his wife and family. He developed an embarrassing soreness around his penis, a fungal condition called thrush, which men and women with diabetes can develop with poor glucose control. This was treated but it recurred. At each clinic visit I tried to persuade Geoffrey to change his mind about insulin treatment but he remained adamant. Then finally one day he came into the clinic in tears. He could no longer do his job properly, he felt awful and was badly depressed. His wife, who came with him, was very worried about him. I got out an insulin syringe and needle and demonstrated on myself how simple it is to insert the needle under the skin. After thirty minutes’ persuasion by me and his wife, Geoffrey stuck the needle into his arm.’It doesn’t hurt,’ he said, astonished.He is now on twice daily insulin injections with good glucose control, is back at work and says he feels marvelous. He wishes he had tried insulin sooner.
Call for helpEven the best informed and most efficient people have occasional Problems. It is not an admission of defeat to call for help -just common sense. Doctors greatly prefer being called when they can help prevent a problem from getting worse than when a disaster has occurred. Contact your doctor sooner rather than later.
Problems with glucose control•   Hypoglycemia is preventable. Learn your warning signs – and learn from your mistakes.•   Measure blood glucose levels frequently when you are ill.•   Plan what to do if you become ill before it happens.•   Take more insulin if your blood glucose level rises.•   Check for ketones if your blood glucose level rises or you cannot eat.•   Never stop taking your insulin.•   Do not be afraid to call for help.
*29/102/5*

WHAT’S HOT IN DIABETES: TYPE 2 DIABETES
A critical issue in type 2 diabetes is the steady increase in prevalence over the past decade, particularly in developed countries. There has been an alarming increase in numbers of obese individuals and the choice of a sedentary lifestyle. It is now clear that type 2 diabetes is caused by a combination of insulin resistance and progressive insulin deficiency, and therapy must be directed at both defects. Exciting studies have now demonstrated that intensive lifestyle changes, including a regular exercise conditioning program and modest weight reduction (5-10%), will delay the onset of type 2 diabetes in those with impaired glucose tolerance. Specific methods to accomplish this, as was done in the research trials, are now widely promoted. Translation to the real world will be difficult.
One of the most exciting developments in diabetes is the general acceptance by the medical community that a metabolic syndrome (previously called Syndrome X or the Insulin Resistance Syndrome) usually precedes and accompanies clinical diabetes. This syndrome has the essential components of impaired glucose tolerance (or frank diabetes), centripetal obesity, hypertension, elevated plasma triglyceride, and low plasma HDL cholesterol levels in variable combinations. Other vascular risk factors may be present, such as microalbuminuria and decreased fibrinolytic activity. A focus on prevention of future cardiovascular events in these people who often have “mild” diabetes has dramatically changed our therapeutic strategies, very early in the course of diabetes mellitus.
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WHAT’S HOT IN DIABETES: TYPE 2 DIABETESA critical issue in type 2 diabetes is the steady increase in prevalence over the past decade, particularly in developed countries. There has been an alarming increase in numbers of obese individuals and the choice of a sedentary lifestyle. It is now clear that type 2 diabetes is caused by a combination of insulin resistance and progressive insulin deficiency, and therapy must be directed at both defects. Exciting studies have now demonstrated that intensive lifestyle changes, including a regular exercise conditioning program and modest weight reduction (5-10%), will delay the onset of type 2 diabetes in those with impaired glucose tolerance. Specific methods to accomplish this, as was done in the research trials, are now widely promoted. Translation to the real world will be difficult.One of the most exciting developments in diabetes is the general acceptance by the medical community that a metabolic syndrome (previously called Syndrome X or the Insulin Resistance Syndrome) usually precedes and accompanies clinical diabetes. This syndrome has the essential components of impaired glucose tolerance (or frank diabetes), centripetal obesity, hypertension, elevated plasma triglyceride, and low plasma HDL cholesterol levels in variable combinations. Other vascular risk factors may be present, such as microalbuminuria and decreased fibrinolytic activity. A focus on prevention of future cardiovascular events in these people who often have “mild” diabetes has dramatically changed our therapeutic strategies, very early in the course of diabetes mellitus.*4\357\8*

WHAT’S WRONG WITH TODAY’S DIET?

Today’s Western diet is the product of industrialisation based on inventions ranging from Jethro Tull’s seed drill (in 1701) to the high speed steel roller mills for milling cereals (in the nineteenth century) and advances in processing food to give it a longer shelf life. The benefits are many. We have a plentiful, relatively cheap, palatable (some would say too palatable) and safe food supply. Gone are the days of monotonous fare, gaps in the food supply, weevil-infested and adulterated food. Long gone are widespread vitamin deficiencies such as scurvy and pellagra. Today’s food manufacturers work hard to bring us irresistible products that meet the demands of both gourmands and health conscious consumers.

Many of the new foods are still based on our staple cereals—wheat, maize, oats—but the original grain has been ground down to produce fine flours with small particle size that produces the best quality breads, cakes, biscuits, breakfast cereals and extruded snack foods.

Cereal chemists and bakers know that the finest particle size flour produces the most palatable and shelf-stable end product. But this striving for excellence in one area has resulted in unforeseen problems in another. Today’s staple carbohydrate foods, including ordinary bread, are quickly digested and absorbed. The resulting effect on blood sugar levels has created a problem for many of us.

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DIABETIC COMPLICATIONS

‘Complications’ refer to things that can go wrong during the course of diabetes, either as a consequence of diabetes itself or its treatment. Thus, ketoacidosis is a complication of diabetes but hypoglycemia is a complication of insulin treatment. Complications may occur as part of the course of diabetes, but treatment may affect the severity of the complications or when they develop. Some complications, such as social and psychological problems arising in the course of diabetes, may be due partly to diabetes itself and partly to its treatment.

Most people think of impairment of vision, kidney function, blood circulation or nerve function as the principal complications of diabetes. These are sometimes called ‘late complications’ because they occur (if at all) many years after the onset of diabetes.

There is however a number of complications that can occur during the early stages of diabetes. These include hypoglycemia, psychological stress, growth impairment, pregnancy problems and cataracts.

Whereas most of the early complications are correctable and reversible, many of the late complications are not. It is for this reason that complications of later life are the main source of worry for family and friends of the person with diabetes. Prevention of complications is one of the main tasks for physicians caring for diabetes. Young people sometimes don’t seem quite as concerned about the long term affects of diabetes. Perhaps this is because they, very sensibly, think there is no point in worrying about an uncertain future, and perhaps because there are higher priorities in their lives at the moment than becoming too involved with strict diabetic control. It is not usually helpful or fair to threaten young people with the prospects of complications if they do not take better care of their diabetes. It would however be a mistake to suppose that young people don’t care.

It is perhaps important to have some understanding of the risk of complications. We can often recognize their early development and do something to minimize the risks of them progressing to the point where they cause trouble or impair health.

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