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‘ The aim of education is for people with diabetes to improve their knowledge and skills, enabling them to take increasing control of their own condition and integrate self manag ement into their daily lives’ *NICE
Background
In 2004 two major pieces of work were beginning in Leicester; the development of a care pathway for type 1 diabetes and the creation of a patient held handbook for people with diabetes. Feedback from our Dose Adjustment For Normal Eating (DAFNE) courses and anecdotal evidence from the team revealed differences in the information and education given to people with type 1 diabetes early on in their diagnosis. This highlighted the need for a more equitable service and the idea of a structured education course was proposed.
We developed our original mission statement to capture what we set out to achieve;
Mission statement
Our vision is to improve outcomes for people with Type 1 diabetes through high quality structured education which begins at diagnosis and is an integral part of our service.
In order to become empowered the person with diabetes should be offered the opportunity to acquire skills and knowledge from diagnosis. Our group aims to offer a foundation to self-management.
In order to achieve this we adopt the principles of empowerment and derived responsibilities of health care professionals described in DESMOND. We have a an evolving curriculum which was developed following service user consultation.
* NICE. Guidance on the use of patient education models for diabetes. A Technology Appraisal 60. (2003). Available from
[http://www.nice.org.uk/nicemedia/pdf/60Patienteducationmodelsfullguidance.pdf]
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In developing this curriculum we have drawn on our years of experience delivering national structured education programs and working with people with diabetes to improve their health outcomes and quality of life. We worked with local service users to develop the content of the curriculum and continue to use feedback and evaluation from the courses to improve the program.
Delivering this structured education from diagnosis has helped us to embed structured education into our routine care. Following a foundation course participants are encouraged to attend further structured group education.
The curriculum has evolved over the years and this current format represents a comprehensive curriculum the can be used to develop lesson plans and deliver a program that can be locally adapted and quality assured.
Trained Educators
In Leicester we run a variety of other national and local education programs including; DESMOND, DAFNE and insulin management groups.
While the content of the groups is different they have very similar principles and values. They aim to meet the Department of Health guidelines on structured education;
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Patient centred philosophy
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A structured curriculum
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Trained educators
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Be quality assured
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Be audited.*
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*taken from A joint Department of Health, National Diabetes Support Team and Diabetes UK initiative How to Assess Structured Diabetes
Education: An improvement toolkit for commissioners and local diabetes communities (Aug 2006) available from; http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4138035.pdf
Locally we use educators who have experience of delivering DAFNE courses to deliver the foundation program. This means that they are already competent and quality assured to deliver education according to DAFNE’s robust, audited standards.
Experienced
DAFNE educator
Observe
Foundation course
Reflect on observations
Review with experienced foundation educator and develop lesson plans
Deliver foundation with experienced educator and receive feedback
Review and develop delivery of sessions and lesson plans
Deliver foundation course, receive feedback
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Once training has been completed educators are encouraged to continue to review their sessions and give and receive feedback from fellow educators. Each course is also evaluated by the participants.
The educator teams meets regularly to discuss feedback and up-date the curriculum.
Content and layout
The current format of the curriculum is designed to be comprehensive in its content and give suggestions regarding teaching style.
Each session begins with a list of aims which are the learning outcomes that participants have the opportunity to achieve by the end of the session.
Suggested resources are listed followed by a brief introduction to the session.
Delivery style
The style of delivery of the sessions should be patient focused using adult learning principles. Open questions are used to work through the majority of the aims and examples are given throughout. Examples of the dialogue for educators are highlighted by prompts such as “ask” and “explain”. Actions for educators are also included such as “collect responses” and “collect onto flip char t”.
We have included “Educator notes” which are suggestions for strategies to use when facilitating some of the sessions.
Individual lesson plans
This curriculum is not designed to be used as a script; we recommend that individual educators produce their own lesson plans for each session based on the curriculum. The curriculum can be used to standardise the lesson plans so that they have the same content.
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Individual lesson plans should take account of the educators’ personal style of teaching, local differences (e.g. food choices) and cultural considerations of participants etc. Lesson plans should also use a variety of teaching strategies and be as interactive as possible allowing time for group discussion and practise.
A key aim of the foundation group is to help people to build confidence and self-efficacy. It is important to remember that as a group with newly diagnosed type 1diabetes they may have limited experience and knowledge, educators will need to facilitate sessions carefully and be sensitive to individuals.
Resources
The resources used for foundation are:
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Depression self assessment (attached)
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Flip chart and pens
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What is diabetes posters (produced by DAFNE)
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Food models
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Adjusting your insulin work sheet (example attached)
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Food plate photographs (produced by DAFNE)
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Relevant locally approved patient information literature e.g. FRIO, DUK foot care, travel, driving etc
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Quiz (example attached)
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Useful websites (attached)
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Evaluation (attached)
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Examples of referral forms and participant informat ion letter’s are included in the appendices.
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Publications
At the time of print the following paper is being peer reviewed for Practical Diabetes International:
Title; Leicester foundation Group; Successful implementation of structured group education for people with newly diagnosed type 1 diabetes.
Poster presentation DUK 2011 “ using structured education to build confidence to self manage in those newly diagnosed with type 1 diabetes
”. H Bird, J Fairfield, S Phillips, J Troughton, R Pidcock,
D Kitchener, C Byard, C Wilkes, J Henson
Diabetes Care, University Hospitals of Leicester NHS trust
Diabetes Research, University of Leicester
Preparing for DAFNE from diagnosis-structured education for people with newly diagnosed diabetes. Available on www.dafneonline.co.uk
Workshop delivered by Jane Fairfield and Sarah Phillips University Hospitals Leicester. Presented at 2011 National DAFNE collaborative conference.
Contact us
Sarah Phillips senior specialist Dietitian sarah.phillips@uhl-tr.nhs.uk
Jane Fairfield diabetes specialist nurse jane.fairfield@uhl-tr.nhs.uk
Hannah Berkeley senior specialist Dietitian Hannah.berkeley@uhl-tr.nhs.uk
Rebecca Pidcock senior specialist Dietitian Rebecca.pidcock@uhl-tr.nhs.uk
Diabetes Care, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW
Tel 01162 584919
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Foundation Group Session 1
Prepare the room
There should be enough chairs around a central table for participants, their guests and the 2 educators. You may need to think about whether you have observers and where they will be sitting. You need to make sure that everybody will be able to see the resources you will use so position the flip chart at the front of the room and think about where you will put up posters and do activities. Place participant packs on the table with accompanying pens.
1.0 Introduction and expectations
Aims of the session
 To know who the educators are
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To know where the housekeeping facilities are.
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To know the duration and start –if applicable and finish time of the session/ sessions.
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To know when breaks are and where to get refreshments if available.
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To understand the overall aims of the session/sessions
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To have information on the contents of the programme.
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To be introduced to the participant packs
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Know that they are group sessions and that they should try to participate as much as possible.
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To get to know others in the group
 Discuss their aims, expectations and goals for attending the session/ sessions
Resources required
 Flip chart (could prepare beforehand: Aims of the session, Names/when diagnosed, Symptoms, Burning Q’s/topic to be covered).
 Flip chart pens
 Patient information leaflet
 Pens
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Welcome the group to the session
Introduce the educators and any observers you may have
Explain where the toilets, fire escapes, refreshments are.
Explain that the sessions are run over 2 half days (or one full day where applicable). Make sure everybody is aware of the session timings and check that everyone is able to stay and attend the second session-where applicable.
Explain the overall aims of the sessions are;
 to provide a foundation to self-management,
 to provide an opportunity to acquire a basic knowledge of what diabetes is and the principles of management,
 to raise awareness of treatment options,
 to meet others and share experiences which may include discussing some feelings and symptoms.
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To answer any questions you may have
(You may want to write this on a flip chart)
Explain -the sessions began in 2004 when we were developing a care pathway for people with type 1 diabetes.
Through interviewing both patients and staff and looking at research and guidelines, we found that there was a gap in our service.
We found…..
Information and education provided by staff varied,
There would be different practises with review appointments
People with diabetes (PWD) wanted to meet others in the same situation who they could relate to
From this information the foundation group was developed. We have continued to develop the content of the course , through participant feedback. We would like to invite you to contribute to the future development and improvement of the course by providing your feedback and comments at the end.
Explain There is a programme for the sessions which you will see on the first page of your patient packs in front of you. This can be relatively flexible. So if we spend more time on one topic area because it suits the group, we can give you literature on the sessions which we then spend
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less time on. If there is something which is not on the curriculum that you would like to cover, please let us know and we will do our best to include this.
Give people chance to have a look through the contents
Explain that the rest of the pack is a summary of each of the sessions and that we will be referring to this throughout the sessions. They are yours to keep.
Explain
The sessions will be very interactive, so please participate as much as you feel comfortable to do so.
We do ask that confidentiality is maintained in the group, as personal feelings, thoughts and experiences can sometimes be shared.
If there is a problem or concern which relates to an individual person, we may ask you to come to discuss it with us at the end or at an individual appointment.
Explain We would like to start the session by introducing ourselves and in a moment we would like to invite you to introduce yourselves and your experiences so far with diabetes .
Educators to introduce themselves and share some of their background in diabetes. .
Ask Can we go around the group so you can introduce yourself, please use the name you would like us to refer to you as during the session.
Please explain how you were diagnoses and what symptoms you had?
Educator notes; ask for a volunteer to start, then go around the group one by one, being sure to ask open questions and listen actively e.g How did you find out you had diabetes? How did you feel when you were told you had diabetes? What symptoms did you have? How long have you had diabetes for now? Be sensitive to those who may not wish to say very much at this stage.
(Collect the symptoms that they experienced onto a flip chart- we will be using this in the next session)
Try to facilitate sharing and open up the discussion using prompts such as “did anyone else feel like that?” Try to identify feelings e.g. “Frank said he felt shocked-did anyone else feel shocked?”
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Thank them for their contributions
Explain that we would like to know what you would like to get out of the session
Ask Does anybody have any burning questions or specific topics they would like to have covered?
Collect the answers on a flip chart and explain that we will come back to this at the end of the second session to ensure we have met your requirements.
Once again thank you for your contributions.
2.0 What is diabetes?
Aims of the session
 Establish that they all have type 1 diabetes.
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Discuss and describe the very basic physiology of glucose metabolism and what happens in type 1 diabetes.
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Be able to relate the symptoms at diagnosis to what was happening in the body
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Understand that there are 2 main types of diabetes and discuss the key differences.
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Understand that insulin replacement via injections or pump is the main treatment for type 1 diabetes.
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Understand the consequences of not taking insulin.
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State the normal range for blood glucose (BG) levels.
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Discuss the advantages of trying to keep BG within the normal range.
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Describe safe injection technique
 Discuss monitoring and recording results.
Resources required
 Flip chart and flip chart pens
 Patient packs
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 Pens
 Flip chart of symptoms generated earlier
 Posters/ magnetic board
 Patient information leaflets

An insulin pen, needles and cartridge, penmate
 blood glucose meter
Introduction
Explain that we are going to spend some time discussing what diabetes is and how symptoms develop at diagnosis
Ask Would anyone like to describe what they understand diabetes to be?
Discuss responses-use prompts to encourage other’s to add to the discussion
Illicit that it is high sugar levels caused by a lack of insulin
Explain that another name for sugar is glucose which is what we will calling it throughout the sessions
Ask Does everyone have glucose in their blood?
Yes everybody has glucose in their blood all of the time with and without diabetes
Ask Why do we need glucose?
For energy, our brains only source of energy is glucose and our muscles need glucose to work
Ask Where do we get glucose from?
We get it from carbohydrate foods in our diet but we will do more on this later
Explain First we will look at what was happening in the body before type 1 diabetes:
Work through posters/ diagrams you draw/ novo magnetic board:
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Ask So what happens when we eat carbohydrate eg bread?
Include responses
Explain; It goes to the stomach and works through the gut where it is digested, It gets broken down into glucose in the gut.
Where does the glucose move to from the gut?
Glucose then enters the blood stream which is what causes blood glucose levels to rise.
Ask Does anyone know what happens next?
Include responses
Explain The blood vessels are like a road system and the blood acts like a delivery van, and carries the glucose all around the body to cells which need energy.
On the way it drops some sugar at the liver which is a Warehouse for glucose
The glucose arrives at the cells but the cell door is locked. We need a key to open the cell door.
Ask What do you think is the key to open the cell door? insulin
Ask Does anybody know where insulin is produced?
Include responses
Explain; It is in the beta cells of the pancreas. As blood glucose rises, the beta cells automatically release insulin (keys) into the blood stream which unlock the cell doors and allow glucose to enter.
Once the glucose has entered the cell doors close behind.
Ask So what happens in type 1 diabetes?
There is no insulin (keys) being produced.
Ask So what happens to the level of glucose in the blood?
It rises
Ask Does anyone know why there is no insulin being produced in type 1 diabetes?
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Include responses
Explain; Type 1 diabetes is an autoimmune condition which means the body is recognising some cells as foreign bodies so it breaks them down (in type 1 diabetes it is the beta cells which are destroyed). This means that there is a complete lack of insulin.
Ask could anything have been done to prevent this from happening?
No
Explain that lots of research is done to try to establish why this happens and look at ways to prevent it but at the moment type 1 diabetes cannot be prevented.
Ask So what happens to the glucose levels in the blood if there is no insulin being produced?
They are high
Ask Can anybody remember what their glucose level was when they were first diagnosed?
Gain answers from the group and record on flip chart- Illicit that they were all high.
Explain We have already collected some of the symptoms you had at diagnosis so we can go through these in more detail:
Passing more urine (going to the loo more)- Polyurea
Drinking more-Polydipsia
Tiredness/lack of concentration
Weight loss
Ketones-in the urine
Coma
Thrush/infections
Blurred vision
Polyurea-passing lots of urine
Ask How does your body try to reduce blood glucose levels when there is no insulin available?
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Include responses
In the urine. When blood glucose is high the kidneys try to get rid of the extra glucose in the urine, because glucose levels are so high at diagnosis you need to pass a lot of urine - polyurea
Ask Is it normal to have glucose in your urine?
No. Normally we do not get rid of glucose in urine. This only happens if glucose levels are >10mmol.
Ask What can happen when you are passing lots of urine? Prompt How might it make you feel?
You become dehydrated, You feel very thirsty, hence you drink more fluids- polydipsia.
Ask When the cells of your body were unable to access glucose from the blood for energy, how might that have made you feel?
Tired, lethargic, bad tempered, hungry, weak etc
Ask What other source of energy do our bodies have? Prompt It is our stored energy!
Fat and muscle
Ask So why do you think you lost weight?
Yes that’s right, because you couldn’t use your glucose for energy you were breaking down your body’s other energy stores, your fat and muscle stores.
Ask Does anyone know what product is produced by the breakdown of fat?
Ketones
Ask Has anyone ever heard of ketones?
Ask What do you know about ketones?
Include responses
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Ketones are poisonous to the body when they build up. Normally if someone without diabetes does not eat for a while, they have a few ketones but insulin and fluids will keep them at safe levels.
In type 1 diabetes due to lack of insulin, the levels of ketones can build up.
Ask Does anyone know the signs that ketones are building up in the body?
High glucose levels, drinking more, passing more urine, stomach pains and vomiting, shortness of breath, pear drop/acetone breath, coma
(diabetic ketoacidosis DKA). If they continue to build up, they can be life threatening! (although in most cases it is picked up before it gets to this stage).
Ask Was anyone told that they had ketones at diagnosis?
What did the doctors do to get rid of ketones?
You were given insulin and some of you may have also had fluids.
Educator notes; Review the physiology so far ( a member or members of the group may be able to do this with prompts) Explain; the cells of the body need glucose for energy. Glucose comes from the carbohydrate food we eat. When carbohydrate is digested, it breaks down into glucose which is released into the blood. As blood glucose levels rise the body automatically produces insulin from the beta cells of the pancreas. Insulin allows the glucose to move into the cells where it can be turned into energy. In type 1 diabetes insulin can no longer be produced automatically so the level of glucose in the blood rises. The body breaks down fat and muscle stores to provide energy to the cells. This produces lots of ketones which are toxic to the body in large amounts. Without treatment this can be life threatening.
Ask So how important is it that you always take some insulin?
VERY!
Now you are on insulin, you are unlikely to have a build up of ketones, unless you stop taking it. The other time ketones can occur is during illness which we will discuss later.
Ask Why did you have blurred vision?
When blood glucose levels are high, it can change the shape of the lens in the eye and make vision distorted. As glucose levels come down to normal range, usually vision will improve again. (This is different to long term damage which can happen to your eyes over many years)
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Ask Why is it harder to get rid of infections when blood glucose is high and when first diagnosed with diabetes?
Explain; The bugs which cause infections can thrive in sugary environments, it acts as a fuel/ food for them, and this is why it is harder to get rid of infections with high glucose levels.
Ask- does anybody have any questions on what we have covered so far?
Explain What has been discussed so far is what happens in type 1 diabetes
Ask Have you heard of any other types of diabetes?
Type 2 diabetes (you could discuss gestational diabetes if it comes up in discussion with the group)
Ask What is the difference between type 1 and type 2 diabetes?
Draw this table on a flip chart fill it in as the group volunteer the answers.
Type 1 diabetes Type 2 diabetes
No insulin production
Diagnosed within weeks
Treated with insulin
? cause ?virus
Percentage of PWD15%
Some insulin production but insulin does not work very well
Can take many years to be diagnosed
Treated with diet, tablets, insulin and lifestyle
Lifestyle, family history, ethnicity, obesity, drugs e.g. steroids
Percentage of PWD 85%
In summary the difference between type 1 and type 2 is that in type 2 diabetes some insulin is produced but it is not working well. In type 1 diabetes there is no insulin production so insulin injections are required to control glucose levels.
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Ask Has anybody heard of the honeymoon period?
Discuss responses
Ask does anyone know why this happens?
Collect responses.
Explain- When you start injecting insulin, it gives the last few remaining beta cells a rest, and for a while they keep producing insulin.
During this time you can be very sensitive to your injected insulin and your requirements are likely to fall.
Due to the (autoimmune) nature of diabetes, eventually the last few beta cells will stop working and injected insulin requirements increase.
This phase can last from weeks to months and not everybody will experience this.
Ask So why do we need to keep glucose levels under control?
Collect responses
Explain; To stop symptoms at diagnosis from returning and to make you feel better in the short term. Also to stop long term complications
(we will discuss this further in session 2).
Ask What would the blood glucose level of someone without diabetes be?
The target is 4-7mmol
Ask What BG levels are you all aiming for?
Collect ranges
Explain that by eventually aiming for BG levels between 4-7mmol/l this helps us to feel well and reduce the risk of long-term complications of diabetes.
Ask And to re-cap what do we need to keep blood glucose levels BG levels in target?
Insulin
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Explain Insulin can only be given by injection (or with an insulin pump). Unfortunately at the moment there is no way to give insulin as a tablet. For most people starting to give themselves daily insulin injections is a daunting part of living with diabetes . So lets spent some time discussing injected insulin:
Ask How do you give your insulin?
Discuss responses
Ask What process do you go through?
(you could do this holding an insulin pen and ask them to shout out the steps they would take)
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Check date and type of insulin and general appearance of the cartridge/ pen.
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If it is cloudy or a mixed insulin then you will need to roll the pen 20 times.
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Put a needle on pen
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Dial up and press a 2 unit air shot
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Dial your insulin dose
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Place needle into the skin at a 90 degree angle (may need a gentle pinch if you have very little fat stores and 8mm needles)
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Dispense the insulin and hold the needle in the skin for the count of 10
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Remove from skin
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Replace outer cap on needle and remove from pen
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Dispose of needle in a sharps bins
Ask Where do you give your injection?
Abdomen, thighs, bottom -demonstrate the areas
It is important to rotate injection sites and that if you are on more than 1 type of insulin, to give it in separate areas.
Ask Do you always inject the same spot?
Collect answers
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Ask What can happen if you always give your injections in the same place?
Over time the area might become less sensitive which is why it can be tempting to keep injecting there but this can cause the tissue under the skin to change
Ask Do you know why it is important to rotate your injection sites?
These changes to the tissue can take some time to develop. Over time fat deposits build up in these areas and this can affect the way your insulin is absorbed. This is known as lypohypertrophy.
Ask How do you feel about actually giving your injections? Prompt does anyone dread doing it or hesitate for some time before injecting the needle?
Re-assure that it is common to feel anxious about injecting to begin with but after a couple of weeks if it is still difficult this should be
addressed
If anybody is anxious about it? In your own words discuss options e.g. counselling etc.
Ask Where do you store your insulin?
Collect answers
The insulin you are using can be kept at room temp for 28days.
Other insulin pens or cartridges must be stored in the fridge
Ask does it matter where in the fridge you keep it?
Explain that insulin is a natural protein and if it gets frozen or over heated this will change how well the insulin will work.
Ask So how do you know how well the insulin is working for you?
Collect answers and confirm that monitoring is the only accurate way to know what the BG level is, especially if it is around the target range of 4-7mmol/l
Ask How do you monitor BG levels?
Collect responses
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Ask does everyone have their meter with them? Can you get them out and think through the stages of how to do a test
Collect steps to achieving an accurate BG test
 Wash hands in warm water and dry thoroughly
 Get finger pricker (lancet) ready
 Put a strip in the machine
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Use the side of the fingers to get blood
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Do not squeeze the finger too hard to get the blood out, you may dilute the sample with plasma
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Apply the blood to the strip and await the result
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Make sure you change the needle after each test that you do and dispose of it in a sharps bin
Ask the group to discuss their meters, go around the table and ask participants to discuss the following (if it is a larger group this can be done in pairs or three’s
How do you operate your meter?
what do you like about it?
what do you dislike about it?
Facilitate discussion around the different types of meters. You might want to bring up alternative site testing, those which plug into computers, USB etc
Explain- after that session- if anybody wants to swap pen devices or meters, we can write to your GP to arrange this.
Ask Does anybody have any questions relating to the session we have just done?
Comfort/refreshment break
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5.0 Food and diabetes
Aims of the session
 Know why food/diet is an important consideration for People with diabetes (PWD)

Understand what foods affect Blood Glucose (BG) levels following digestion
 Be able to identify foods containing carbohydrate (CHO)

Understand that different foods containing the same amount of CHO will require the same amount of insulin/have the same affect on
BG levels.

Be able to identify CHO containing foods from a plate of food and understand that different portions will require different amounts of insulin.

Discuss the use of 10g CHO portions and their role in insulin dose adjustment
Resources required

Flip chart

Flip chart pens

Patient information leaflets

Carbohydrate portion information
 Pens

Food models
 Plate photographs/plates of meals (using food models) made up
Introduction
In this session we will explore food, diet and its affect on blood glucose level. Once we start to understand how different foods affect blood glucose we can use this to improve blood glucose control, either by adjusting quick acting insulin to match the meal we are about to eat or by adjusting the portion of certain foods that we choose.
Ask Why is diet important?
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Discuss responses
Diet is important for giving us the correct balance of nutrients but also for many other reasons. Most of us enjoy food and eating occasions.
We associate food with celebrations and socialising. If we feel our choices are restricted it can affect our quality of life. So the aim of this session is to enable you to have some freedom to make your own choices around your dietary intake and still manage your BG levels
Ask What food groups do you know?
Use prompts e.g. what types of food give us energy? What types of food might we try to eat less of? etc
Can you give examples for each food group?
(list on flip chart)
Carbohydrate (sugar and starch)
Protein
Fats
Dairy
Fruit and vegetables
Ask So which of the foods groups has an effect on glucose levels?
Discuss responses
Explain it is the CHO foods. There are 2 types of CHO - sugar and starch. Starchy foods are like beads of sugar on a piece of string which is broken down when these foods are digested.
Ask So what about a fish finger? Which category would that go into?
Discuss responses
Explain; many foods contain combinations of fat, protein and CHO so sometimes foods fall into more than 1 category. Other examples are yoghurt, milk, sausage roll and pizza.
We have identified that it is CHO foods which affect BG levels…. Do you think that means you shouldn’t eat them?
Discuss responses
Explain; CHO foods are very important to ensure we have enough energy and are an important part of a n enjoyable, healthy balanced diet.
We just need to think about how these foods work in combination with insulin treatment.
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Task- Using food models, separate CHO containing foods from non-CHO containing foods i.e. those that affect BG and those that do not.
Ask Do all these foods affect you BG in the same way?
Discuss responses
Educator notes; Glycaemic index or GI will often be mentioned at this stage, try to avoid lengthy discussion of this. Instead focus on rapid acting CHO which make good hypo treatments and foods that have a very small affect such as pulses and sweet corn.
Compare an orange to orange juice.
Ask which would work more quickly?
Collect responses
Orange juice
Ask Why is the orange juice faster?
Collect responses
Explain; Because it is in solution it gets absorbed very quickly and it is also concentrated in natural sugar because it takes 2-3 oranges to make a small glass/ carton of juice.
Ask What would orange juice or other sugary drinks be good for treating?
Collect responses
Hypos.
Drinks like these are sometimes hard to match with your insulin- do you know why?
Discuss responses
Explain; Because they start to increase BG within a few minutes which is faster than insulin can work. Insulin may then continue to work after the affect of the sugary drink has worn off which could lead to a hypo.
Ask What might slow down the absorption of the juice or sugary drinks?
Discuss responses
Explain Having them with a meal or snack
Ask if you want a drink which doesn’t affect blood glucose- what would be a good alternative to these?
Collect responses
Examples; Diet, zero, max, no added sugar pop/squash, sugar free flavoured water, water, sweetener in tea and coffee, low calorie hot chocolate.
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Ask What about beans, pulses and lentils? What effect would they have on your blood glucose levels?
Discuss responses
Explain These foods release glucose into the blood stream very slowly. The on BG is often so small that there is no need to give insulin.
Ask what might happen if you try to cover these with insulin?
Discuss responses
Explain the insulin might work before the CHO gets into your system.
Other examples of slow release foods are nuts, cherries and grapefruit
Explain How quickly or slowly Glucose is released into the bloodstream after eating a carbohydrate containing food is called glycaemic index or GI. Very fast foods are high GI e.g. fruit juice and very slow release foods are low GI e.g. beans, cherries. Both of these can be difficult to match with insulin. Everything else is in between and can normally be matched with insulin.
Ask Do you think it is only the rate glucose is released from food that is important?
Discuss responses
Task ; Using food models of different sized portions e.g. French stick compared to a slice of bread; ask the group to consider which will have more of an affect on blood glucose explain that the amount of CHO will have a much bigger effect on BG levels than GI.
TaskLooking at these snacks which do you think will have the biggest effect on your glucose levels?
(using a plate of 1 cp snacks e.g. apple, sausage roll, grapes 60g, mini cake, multipack crisps, biscuit/kitkat).
They all have the same amount of CHO so will all have the same effect on BG levels. Sometimes this can be surprising as people assume the snacks which are sweeter will have a bigger effect on blood glucose.
Explain one way to know how much carbohydrate is in food is to look at portions of carbohydrate.
Introduce the 10g carbohydrate portions list .
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This list is a means of knowing how different foods will affect BG levels. The booklet tells you how many portions of CHO or CP’s there are in different foods. The higher the portion of CHO in the food, the bigger the effect it will have on BG levels. Each portion is equivalent to
10g of CHO so you can use food labels to help you to calculate it.
Work through an example from this book
If you normally have a cup of cornflakes for breakfast but then you decide to have a cup of muesli for a change, what is the difference in
CHO?
Cornflakes 2.5cps
Muesli 7cps.
What do you think will happen if you have the muesli?
BG levels will be higher
What are your options to control your BG levels?
You could try a smaller bowl of muesli/ increase insulin/ have it on an active morning.
Can you see how you could use this book to help you make decisions around managing your BG?
Discuss responses
Explain You may also use it to help you to work out the CHO in your snacks. We know that 1 portion of CHO will have a small effect on your
BG levels so you can use this book to identify 1 portion snacks.
Ask So how do you think you could use food packets to estimate CHO portions?
Discuss responses
Look at total CHO per serving which you are eating, not the ‘of which sugars’. To turn the grams into portions, you divide the grams by 10.
Explain Some of you who are on a basal bolus insulin regimen-that is quick acting insulin at mealtimes and a longer acting insulin once or twice per day-may be using this book to CHO count already . Is anybody doing this? If so do you want to explain how it works?
Discuss responses
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Explain If you are on a basal bolus regime, you can start using this book to estimate portions and use your quick acting insulin to match the portions. with 1 unit to quick acting insulin for 1 portion of CHO. However we have to be careful that this is not too much when someone is in the honeymoon phase.
There is a course called Dose Adjustment For Normal Eating (DAFNE) which you can do once you have been diagnosed for 12 months (to ensure that you are not still in the honeymoon phase). The course is centred around calculating portions of CHO and adjusting insulin to what you choose to eat. You need to be on the basal bolus insulin regime to attend.
We have had great results both locally, nationally and worldwide from the DAFNE course. People feel there is a huge improvement to quality of life and there is also some improvement to HbA1c.
So you can use this CHO portions book in a number of different ways.
Explain the next activity is designed to give you some practice at using the CHO portion book to estimate CHO..
Using the plates we have on the table. Think about where the CHO is and using you books to help you, try to rank them in order of high to low CHO content.
Notes to educators-You may want to choose the following
Fish and chips
Spaghetti bolognaise
Curry
Banana split
New potatoes and stew
Crumpets
Omelette and salad
In your own words facilitate discussions around each of the plates you have chosen e.g. Omelette and salad- What would you need to consider on a mixed insulin? On a basal bolus insulin? On a basal insulin?
E.g. Compare crumpets and casserole with new potatoes- Try to get people to think about where the CHO is rather than just looking at the size of the total meal.
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Compare spaghetti bolognaise to a take-away Indian meal, there is more CHO in the spaghetti bolognaise- try not to think about whether the food is healthy or not, look at where the CHO is for BG levels. What could you do to make them have the same effect on BG levels?
Reinforce that healthy eating is important generally.
Ask-suppose you would like to have a dessert
Ask the group to calculate the CHO in a dessert chosen from the food models and consider their options.
 For a mixed insulin, basal insulin or basal bolus insulin.
 Think about adjusting activity

Think about portions- could you have a smaller version, or have a smaller amount of carbs at the meal time to allow for the carbohydrate in the dessert?
Discuss the pros and cons of different insulin regimens for allowing dietary freedom and more flexible dose adjustment. Invite participants to reflect on their own insulin regimen.
28

3.0 Insulin action and dose adjustment
Aims of the session
 To discuss and understand the profile of insulin secretion in someone without diabetes.

To understand that there are different types of insulin and insulin regimens and learn about their actions
 To adopt a methodical/problem solving approach to adjusting insulin.

To identify consequences of options e.g increasing snacks may lead to weight gain.

To practice using a problem solving approach on case studies and real life examples from the group

To discuss feelings about and consider adjusting their own doses.
Resources required

Flip chart

Flip chart pens

Patient information leaflets

Adjusting your insulin worksheet

Pens
 Posters

Introduction
Explain Before you had diabetes your pancreas would have produced insulin automatically according to your BG level-as we discussed at the beginning. Now you are injecting insulin. This insulin is manufactured to act like the body’s natural insulin. This means that to get good blood glucose control we need to learn about how insulin works. This session aims to help you to understand how insulin works and the principles of how to adjust it.
Ask Before you had diabetes did your body make different types of insulin?
Discuss answers
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Explain Insulin is produced automatically in different amounts according to BG level but it is all the same type. In diabetes different insulin types are manufactured to work like human insulin.
Explain the profile of insulin secretion in someone without diabetes / draw a diagram to demonstrate this.
Ask which insulin’s are you using?
collect answers on the flip chart.
Divide the insulin’s into groups according to the table below. Ask the group if they know what the action of their insulin is e.g. rapid, long acting.
Introduce the insulin actions tables using a volunteer work through a typical day producing an insulin profile of their insulin and when they inject it.
Ask the group to identify their insulin and draw the profile of their insulin(s) on the graph including the onset, peak and duration (use worksheet)
Ask how does your insulin compare to the pre diabetes picture (can ask as a group if a few people are on the same insulin)
Encourage discussion amongst the group.
Rapid acting analogue insulin e.g. novorapid/ humalog
Onset
5-15mins
Peak
50mins
Duration
2-4 hours
Quick acting insulin e.g. humalin S/ actrapid
Intermediate acting insulin e.g. humalin I/
30 mins
2 hours
2-4 hours
4-6 hours
Upto 8 hours
8-14 hours
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insulatard
Long acting analogue insulins e.g. lantus/ levemir
2 hours No peak 18-24 hours
Ask Apart from insulin, what else has an effect on glucose levels?
Activity levels, quantity of food, snacks, heat, illness, alcohol
These are all things we need to bear in mind when looking at blood glucose levels
Explain So when we look at glucose levels, we need to use a problem solving approach bearing all of these things in mind.
(refer to work sheet).
Explain that we use a step by step approach to improve blood glucose using these problem solving questions.
 Which BG test is out of target?
 Is there a pattern?

What could be the cause?

What are the options?

What are the consequence’s of your chosen options?

Reflect on and evaluate your actions

Discuss the advantages and disadvantages of this approach
Explain so now we are going to put this approach into practise and use the example on the problem solving page.
Facilitate discussions around the case studies. Remember to encourage dose adjustment within local protocols or PGD’s this is usually around 10-20%.
31

Educator note
Make sure that when you discuss insulin dose adjustment that you talk through each of the individuals own insulin regimes and the options they would have e.g. go for a walk, have an extra snack, have a smaller portion of carbohydrate, change insulin dose etc. If participants are on different regimens they will begin to compare their options-encourage this. This is an opportunity for participants to begin to evaluate different regimens. Some may question why they are on a different regimen to others, try to facilitate this discussion so that participants begin to explore their options.
Ask- have a look at the other examples in the book and apply the problem solving approach, based on the insulin you are taking .
Encourage the group to discuss what they would do in each scenario.
Ask each person/ group to think about the pro’s and con’s of their insulin regime
Ask participants to bring their own BG record next time if they would like to work through a personal example with the group
Ask participants how they feel about adjusting their own insulin, discuss the pro’s and con’s of self adjustment
Explain At the start of the next session we will look at real blood glucose levels using the problem solving approach if one or two people would like to volunteer their results. We will discuss your experiences of using the approach over the past 2 weeks.
Remind the group that in order to be safe and to know how effective the changes have been they must monitor regularly especially
before driving.
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4.0 Hypoglycaemia
Aims of the session
 Understand what hypoglycaemia is
 Know the signs and symptoms
 Understand the causes

Discuss correct treatment of hypos and the advantages of correctly treating them.

Discuss fears/concerns about hypos

Understand the true risk of unconscious hypos and the role of the liver.
Resources required

Flip chart

Flip chart pens

Packs

Pens

Food models to demonstrate hypo treatments
 ? Glucagon kit
 Patient information sheet on hypoglycaemia
Explain that we have spent a lot of time so far discussing high blood glucose levels. With insulin treatment there is a chance that BG levels will sometimes go too low. This session is about how to reduce the risk of hypoglycaemia and when it does occur, how to recognise and treat it effectively.
Ask What is hypoglycaemia?
Collect responses
Low blood glucose levels. This term is often shortened to ‘hypo’
Ask Has anyone had a hypo?
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Discuss responses, encourage the group to share feelings.
Identify feelings e.g. “Frank says he felt frightened-did anyone else find having a hypo frightening?” Facilitate discussion; ask; do those who have had a hypo feel reassured now they know what to expect?
Ask Do you worry about hypos?
Collect and discuss responses
What worry’s you most about hypos
Discuss responses.
Educator note Use this session to explore any anxiety regarding hypo, try to address fears as they come up rather than “park” them for later.
A common worry regarding hypo’s are nocturnal hypos. People and their supporters may worry about going to sleep and not and not waking up. Use the discussion to allay fears around hypos. Explain that about 10% of people with type 1 diabetes have sever hypos that they are unable to treat themselves, this very rarely leads them to die in their sleep. In instances where this has happened it often involves another factor such as excessive alcohol consumption.
Stress that good diabetes control reduces the risk of severe hypos.
Ask What symptoms did you have or what have you heard of?
Collect the symptoms people may have experienced or heard of on the flip chart.

Sweaty

Shaky

Hungry

Pale

Weak

Tingling

Dizzy
 Not making sense
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 Aggressive
Ask although these symptoms can be unpleasant ,why do you think they are important?
Discuss early warnings of hypos and being able to treat them effectively without help from someone else.
Ask what might happen if you did not treat a hypo as soon as you noticed these symptoms?
Collect answers
Explain that the body can adjust to having low BG levels a lot of the time and eventually the person will not get the early warnings of a hypo. This increases the risk of more severe hypos and the likelihood that they will need someone to help them treat it.
Explain that by treating hypos quickly and effectively participants can maintain these early warnings and therefore their personal independence and safety.
Ask What BG level is classed as a hypo?
<4mmol
Ask Why do hypo’s happen?
Collect on a flip chart

Too much insulin

Eaten less carbohydrate than expected

Unplanned increased activity

Lumpy injection sites

Alcohol
 Heat
Ask What would your options be to reduce the risks of the above causing hypos?
 If you have taken too much insulin you need to monitor closely and eat more carbohydrate foods/ sip on sugary drinks
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 If you have eaten less carbohydrate and given your insulin, you could sip sugary drinks, monitor blood glucose levels and consider a snack.
 Take extra carbs for activity if unplanned, if planned you may want to lower your insulin
 Rotate injection sites regularly

Take precautions with alcohol by lowering insulin or have a carbohydrate based snack

Lower insulin if you are going to be in high temperatures or take extra snacks
Ask What do you think would happen if you had a hypo while you were sleeping?
Explain that the liver will release glucose from its stores to bring glucose levels back up and that eventually your insulin will run out.
Discuss Sometimes you can sleep through hypos in the night. You might find that BG readings are in range before bed and erratic in the mornings if this is the case.
Ask How would you check for this?
3am testing
Ask What do people use/ or what have you been told to use to treat hypos?
Document on flip chart
OR could use food models i.e. biscuit/bread/full sugar drink/diet drink/chocolate/chapatti/milk/fruit/dextrose tablets and ask group to split into 2 groups those that ‘would be most effective to treat a hypo’ and those that ‘are not the most effective to treat a hypo’
Explain that the most effective treatments are.
150ml-200mlof ordinary cola
120ml Lucozade
150-200ml fruit juice
6 dextrose tablets
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2 heaped teaspoons of sugar in warm water
2 marshmallows
3-4 jelly babies
Collect on flip chart and direct to the page in packs
Why do you think the amount of hypo treatment you give is important?
Collect answers, Discuss not over treating to cause re-bound high BG levels
Explain that biscuits, bread, chocolate, milk etc. will work eventually but they take longer to digest and get into the blood stream than the examples above. Therefore to feel better the most quickly the best treatments are the ones above.
Ask Once you have treated you hypo with something quick acting, what would you do next?
Once you have treated your hypo, if it is over an hour until your next meal is due then you may need a carbohydrate based snack to ensure you blood glucose levels do not fall again. E.g. fruit, bread, biscuit, cereal bar.
If you are eating within an hour you may not need to do anything
Explain If your family, friends find you have gone unconscious or are unable to swallow whilst hypo then you should not be treated with the items above. There would be a risk of choking.
A family member could use a glucagon injection or they should phone for an ambulance. (may want to show the group a demo glucagon injection kit)
Ask When might hypos be particularly dangerous to you and other people?
When driving.
Ask What should your glucose levels be before you drive?
5.5mmol
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Ask What should you do if you are hypo while driving?
Pull over immediately in a safe place. Take keys out of ignition and move into the passenger seat if it is safe to do so.
Treat your hypo with quick acting carbohydrate, followed by longer acting carbohydrate and wait 45-50mins before driving again.
If you are having regular hypos and lose your awareness then you should not be driving
The law regarding hypos and driving has changed recently. If you have 2 hypos (not related to driving) where you have needed assistance within a year then you may have your license confiscated for up to a year. At this early stage you will have very good early warning symptoms of hypo so should be able to treat your hypos yourself. Treating hypos quickly using the suggested treatment will help you to maintain these early warnings of a hypo
Ask What might stop you from recognising hypos?
If you have repeated hypos then you will start to feel normal at that glucose level. The danger is that if you do not feel the signs then you have less time to treat a hypo before you need help to do so . not sure whether to include this part highlighted in red. Don’t want to frighten people but I think they need to know (RP think we should keep this in!)
Ask Do you think that having mild (a hypo you can treat yourself) hypos is normal part of having diabetes?
Yes, most people who have well controlled blood glucose levels can expect around 1-2 mild hypos/week.
Summarise and ask if there are any questions
End of session 1 summary;
Thank the group for attending the first session and for working so hard. Confirm the date, time and venue of the second session (if it is being delivered in 2 sessions). Remind the group that the information given out is theirs to take home but ask them to bring them to the next session. Keep flipchart of ‘important issues’ to revisit next week.
38

Tell the group at the start of the next session we will look at real blood glucose levels using the problem solving approach if one or two people would like to volunteer their results. We will discuss how you have gotten on using the approach over the past 2 weeks.
39

Foundation group Session 2
6.0 Welcome back, reflections and dose adjustment
Prepare the room as session 1
Session aims (you may want to write this on a flipchart)
 Reflect on past week and last session, have the opportunity to go through their personal dose adjustment examples with the group.
 Apply a problem solving approach to their personal examples.

Draw on knowledge of onset peak and duration of action of insulin.

Apply CHO portion information from last session if appropriate to example.
Resources required

Flip chart

Flip chart pens

Patient BG results

Adjusting your insulin worksheet

Insulin action charts
Welcome back, introduce educators again and go through program for this session, refer to participants expectations if appropriate
Explain that we will start by seeing how everyone has got on from last time
Ask Has anybody done anything differently since last time? Has it gone well, not so well? (wait for someone in the group to volunteer and go around until everybody who wants to has had a chance to contribute)
Ask Does anybody want to share their BG levels with the group?
40

If a couple of people volunteer their results, write the past 3 days up on a flip chart and with the group go through the problem solving approach reminding the group of the approach used in the dose adjustment session in part 1. Ask the group to consider insulin actions and other factors which may influence BG levels e.g. activity, heat, alcohol.
Use this session to answer any dietary questions which have arisen after the session last time.
41

7.0 Annual review
Aims of the session
 Understand that an annual review (AR) is recommended and why it is important.
 Know what happens in the AR-what is tested and why.
 Know that complications can be prevented with good BG control and healthy lifestyle.

Understand some of the terms used look at some of the equipment used.

Have the opportunity to discuss fears and concerns about complications.

Understand that they can have a role in ensuring that they get everything checked at least yearly
Resources required

Flip chart

Flip chart pens

Patient information leaflets and pens- refer to where your results are kept

Retinal screening chart

Equipment for checking feet
Introduction
As part of the routine care of your diabetes everyone should be offered an annual review appointment. This appointment helps to reduce the risk of developing problems or “complications” that can be caused by diabetes over time if it is not well managed. The annual review appointment includes tests which screen for the very early signs of complications. This session aims to help you to get the most out of your appointments by understanding what’s involved and why.
Ask Why do you think it is called an annual review (AR)
Discuss responses
Explain It is a yearly check up, to make sure that there are no early signs of diabetes complications. Not all of the tests may be done at one appointment for instance eye screening should be done yearly but may be done my a mobile screening unit that comes to your local GP practice.
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Ask Have you heard of any possible complications of diabetes?
Write on a flip chart splitting the complications under 2 headings
Microvascular
Eyes, kidneys, nerves and feet
Macrovascular
Heart, vessels, stroke
You may need to prompt people or give some of the answers if you do not get the full list.
Explain, the complications are under 2 headings. Microvascular means it affects your small blood vessels and macrovascular means it affects your large blood vessels.
We haven’t generated this list to depress or scare you, it’s so that we can explain what we check for, how we do it and what you can do to prevent the complications.
These problems are not inevitable and there is a lot you can do to prevent them. Attending your AR is just one of the things you can do.
So let’s take a closer look at each of these
Eyes
Ask How can diabetes affect your eyes?
When BG levels have run at a high level for a considerable amount of time, it can damage the delicate blood vessels in the back of the eye
(retina). The body will try to compensate for this by growing new vessels around the damaged area. Although this is a very clever way for your body to ensure it has a blood supply, the new vessels can be leaky and prone to bleeding, which may affect your eyesight.
You may wish to draw a picture to demonstrate or use example eye photographs
Ask What is the medical name for it?
Retinopathy
Ask How do we check for it?
Eye photographs yearly at your GP, you may not be able to detect early changes without this. The eye screening programme has helped to reduce the levels of blindness caused by diabetes.
43

Has anyone had this done yet? They will usually ask you not to drive to your appointment because they use special drops to dilate your eyes which can make you sensitive to light for a while afterwards.
Ask How do we treat it?
If there is sign of damage, treatment is to laser the affected area in the eye to stop the bleeding.
Ask How can you prevent it?
Controlling BG and blood pressure (BP)
Kidneys
Ask How can diabetes affect your kidneys?
Your kidneys are like a sieve that filters out waste products from the body and keep in the good stuff. When BG levels are high it was causes the kidneys to start leaking out things we want to keep in our body such as protein.
Ask What is the medical name for it?
Nephropathy
Ask How do we check for it?
You will have a blood test from your arm which will check 2 things- eGFR (>90) to check how your kidneys are filtering and createnine to see how well they are clearing the waste products (60-120)
We also dip the urine to look for protein.
In the very early stages of kidney damage we may start leaking microscopic bits of protein called microalbuminurea. To pick this up your urine sample is sent off to labs for analysis.
If this is picked up and treated the damage can be holted or even reversed.
Ask How do we treat it?
Early damage to your kidneys is treated with medication and improving BG levels.
Ask How can you prevent it?
Control BG & BP
44

Nerves
Ask How can diabetes affect your nerves?
High blood sugar can damage the sheaths on the outside of your nerves causing you to have heightened sensation or to lose sensation, this typically occurs in feet initially. This can lead to either painful feet- particularly at night with heightened sensation or unknown damage happening to feet with loss of sensation.
Ask What is the medical name for it?
Neuropathy
Ask How do we check for it?
Tuning forks- the vibrations on your feet help to check the sensation
Monofilament- this is a piece of plastic used to touch your feet to check sensation
Neurothesiometer- this is a machine which vibrates on your feet and you have to say when you can feel it. Its used to check sensation.
Ask How do we treat it?
With medication if it is painful and by improving BG levels to prevent further damage.
Ask How can you prevent it?

Control BG levels

Check feet daily
If you have signs of damage to your feet

Wear well fitting shoes

Do not walk bear foot

Check the temperature of water before baths

Do not treat own verrucas, corns etc
Your feet can also be affected by poor circulation so you will also have your pulses checked in your feet.
Ask Have you heard of any other parts of the body that nerve damage affects?
When the nerves and small blood vessels are damaged from exposure to high BG levels this can sometimes prevent men from gaining an erection. There are a lot of options to treat this problem, so speak to your doctor if you have any concerns, erectile problems are fairly common in men without diabetes too so if you are concerned remember it may not be related to disbetes.
45

? mention gastroparesis here
Large blood vessels
Ask How can diabetes affect your heart?
Collect responses
Having diabetes can increase your risk of heart disease and stroke
Ask What is the medical name for it?
Vascular disease
Ask How do we check for it?
Measure BP, cholesterol, ask if you smoke, check weight, height, bodymass index (BMI)
Ask How do we treat it?
Give lifestyle advice and medication to control risk factors
Ask How can you prevent it?
Discuss responses
Control BP
Control cholesterol
Stop smoking
Control BG levels
There is a recurring pattern for how to reduce risk of complications
 control BG levels
 control BP
 control cholesterol
 stop smoking
Let’s take a look at how we can achieve all of these:
Controlling BG levels
We have talked about how you can make changes to control your BG
46

Ask What is the long term measurement we use to see what blood glucose levels have been like?
HbA1c- Is a measure of the amount of glucose which has stuck to the red blood cells over a period of 8-12 weeks. The higher the levels of glucose, the more glucose sticks to red blood cells, which would lead to a higher HbA1c. This is a different test to your day to day finger prick tests you do at home.
Ask What is the target for HbA1c?
7% or 53 mmol/mol
Ask what are the day to day results we aim for?
4-7mmol
How to control BP
Ask What is blood pressure?
It is the pressure on the vessel walls when the heart is contracting and relaxing.
Ask What level should this be?
Equal or less than
130 systolic
80 diastolic
Ask How do we measure BP?
Cuff
Ask How can you help to control your blood pressure?
Less salt, more activity, control weight, take medication, oily fish, have fruit and vegetables in your diet.
How to control cholesterol
Ask Does everyone know what cholesterol is?
Discuss responses
Explain Cholesterol is a type of fat in our body. There are different types of cholesterol, both good and bad.
The bad cholesterol- LDL (L for lousy)- is what sticks to the side of vessels and causes them to clog up. You may wish to draw a diagram
47

The good cholesterol HDL (H for healthy) - is what helps to smooth/condition the vessel walls to flatten them and stop jagged edges which can be prone to breaking off.
Ask What level should
Total cholesterol be? <4mmol
HDL cholesterol be? >1
LDL cholesterol be? <2
Ask How do we measure cholesterol?
Blood test- there is no way of knowing that cholesterol is raised without this.
Ask how can you control cholesterol?
Eat less saturated fat, control weight, fruit and vegetables, more activity, choose healthy fats.
Stopping smoking
Ask What does smoking do to your vessels?
It causes the furring up process to speed up so increases risk of micro and macro vascular disease.
Ask What can you do to help you to stop smoking?
Contact STOP smoking service in Leicester
NRT e.g. gum, patches
Medication e.g. champix
Support from family and friends
So alongside coming to your AR, there are things that you can do with your lifestyle to prevent complications of diabetes. We hope that you feel more informed and empowered to prevent these complications.
48

There is another condition which is not a complication of diabetes but is related to living with a long-term condition, does anyone know what that could be?
Collect responses
Explain
Depression, The is a questionnaire that we have given you called the depression score. It would be worth completing this if you haven’t already, it is a simple self-assessment tool. If it shows that you are at risk of depression then you should speak to your GP about this. There are lots of options to help to improve depression such as medication, counselling and exercise schemes.
Summary
We have included this session in our foundation course to emphasise that many of the complications of diabetes can be prevented. By working towards good diabetes control and a healthy lifestyles from the beginning you can significantly reduce your risk. When we were developing this course people with diabetes helped us to decide what we should include. Most people felt that it was important to cover this topic.
Ask Does anyone have any questions or concerns?
Comfort break.
49

8.0 Physical activity
Session aims
 To discuss and understand how activity can have an impact on BG levels
 To know how to see the effects of activity on BG levels
 To know how to manage BG levels to prevent hypoglycaemia during and after activity

Know that if glucose levels are >13mmol to check for ketones and take appropriate action.
Resources required

Flipchart

Flip chart pen

Patient information leaflets

Pens
Introduction
We have just been looking at how to prevent complications. We briefly discussed healthy diet and lifestyle, in this session we will consider physical activity and sports and how this affects diabetes control in a bit more detail.
Ask Has anybody tried any physical activity or exercise since their diagnosis of diabetes?
Collect answers and discuss. Try to elicit concerns they have about returning to activity.
Explain that the PWD should be able to continue with activity
Ask What do we mean by activity?
Collect answers on the flip chart
Activity is any form of movement that uses energy and increases our heart rates e.g. house work, sex, gardening/walking.
Ask What happened to your glucose levels when you did activity?
Collect responses
Explain Some of you may have found that your glucose levels fall during activity. This is because the muscles need more energy so take up more glucose when exercising, also more sensitive to your injected insulin.
Ask How did you know how activity affected glucose?
Discuss responses
50

Through monitoring. Activity can affect everyone differently so when trying a new activity it is recommended that you monitor pre and post activity.
Ask What else do you think you need to carry with you?
Hypo treatment.
Ask What are the options to prevent hypos from happening?
 Eat a CHO snack before – what are the consequences?
Might balance out the energy you burn from activity so may not lose weight.

Take small amounts of quick release CHO throughout- what are the consequences?
Need to remember to have these small burst of
CHO, also may hinder weight loss.

Reduce insulin- what are the consequences?
If activity is unplanned, cannot reduce insulin you have already taken. Which insulin would you reduce? How will this affect later in the day on your own insulin regimen?
Try to get some discussion around this.
Ask (if this has not already come up in conversation) Has anybody had a delayed hypo after activity? Why do you think this is?
Explain When doing long periods of activity, your body uses the reserves from its stores in the liver. After activity your body prioritises replacing these stores so BG levels can go low, especially within the first 2 hours after exercise but it can be for several hours afterwards.
What can you do to prevent it?
Reduce insulin after activity
Have a snack after activity
Discussion Sometimes your BG levels can go higher when doing activity.
Ask Any thoughts why this might happen?

May have had a very large snack pre meal and not burnt off glucose

May be a short burst of activity which uses adrenaline so can make glucose rise

Could be a time when insulin is running out.
Explain If glucose is above 13mmol check for ketones.
If you have ketones then do not do activity and seek advice (take some extra insulin)
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If it is close to a time when your insulin might be running out, what could you do? E.g. if it is 5pm and you decided to go to the gym straight from work and usually you take your long acting insulin with your evening meal.
If you see that your BG levels always rise, you could take a unit or 2 of fast acting insulin to bring it down before your exercise.
This is a very brief introduction to managing activity. If you need any further support, you can speak to your healthcare professional.
9.0 Alcohol
Aims of the session

To understand how alcohol can affect BG levels

Know the recommended maximum alcohol limits

To know how to prevent hypoglycaemia related to alcohol
Resources requires

Flip chart

Flip chart pens

Patient information leaflets

Pens

ID cards to hand out if needed
Introduction
Alcohol can affect blood glucose control, it is important to understand how alcohol affects blood glucose in order to drink safely.
Ask What effect do you think alcohol can have on the blood glucose levels?
Collect responses
Explain; Some alcoholic drinks contain sugar and which means they may cause an initial rise in BG levels. These include- alcopops, liquers, beer/lager, cider.
Other alcoholic drinks do not contain sugar so will not increase your BG levels initially e.g. wines and spirits
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Moderate to large amounts of any alcohol can increase the risk of hypoglycaemia because it interferes with the liver’s ability to release its stored glucose.
All of the time the liver is releasing some glucose into our blood to give us some energy. But alcohol is broken down by our body in the liver and because it is a toxin it will prioritise breaking this down at the expense of releasing glucose for energy. If you have had your normal amount of background insulin and there is less glucose for it to work on, then you could be at risk of hypos. This is particularly important over night as your long acting insulin overnight mainly works on the glucose released by the liver.
Ask what should you consider to manage your diabetes if you are going to have some alcohol?
Collect responses, produce a list on the flip chart.
Ask is drinking alcohol likely to increase the risk of hypos?
You might need to consider having extra CHO/and or reducing the long acting insulin whilst and after drinking alcohol.
Ask How will you know what works for you?
Collect responses
Monitoring BG levels, before, during, after
NB The liver gets rid of alcohol at the rate of approx 1 unit per hour, so 4 pints can take 8 hours or more for the liver to deal with!!!
This is important to realise when thinking about how to reduce the risk of hypos.
Ask Thinking about the times when we often choose to drink alcohol what other factors might we need to consider also?
Collect responses
Exercise- clubbing, sex, sport etc. These activities may also lower your BG levels so will also need to be taken into account when thinking about managing your diabetes. Try lowering you insulin or eating more CHO.
Because of the risk of hypoglycaemia we advise not to correct high BG levels when you have drunk alcohol. It may also be safer not to take insulin with CHO containing alcohol and correct high BG levels the next day if needed.
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Ask How do hypo symptoms compare to the affects of being drunk?
Collect responses
Explain Alcohol can also affect the ability to recognise a hypo and treat it. The symptoms of being drunk and hypo are similar so make sure that you carry some ID with you and it is a good idea to let someone you are with know that you have diabetes.
Ask What are the recommended daily limits for alcohol for adults?
Discuss responses
Government guidelines are:
-No more than 2 units per day for women (14 units per week)
-No more than 3 units per day for men (21 units per week)
1 unit =1 glass wine, ½ pint beer or cider, 1 measure of spirit (25ml)
Ask Do you think these recommendations are different for people with diabetes?
Discuss responses
Explain people with diabetes are able to drink alcohol and the same recommendations apply, you just need to take precautions to keep BG levels at safe levels.
Ask are there any questions?
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10.0 Travel and diabetes
Aims of the session
 To know the safe procedure for storing insulin on an aeroplane and whilst abroad
 To know what and how many supplies to take
 To be aware that insulin comes in different strengths in different countries

To know the effects of different climates, different activity levels and alcohol on BG levels

To be aware of considerations for different time zones
Resources required
Patient information leaflets
Flip charts
Flip chart pens
Pens
Introduction
It is important to plan ahead when travelling, it will require extra preparation. You may also need to consider different climates, food and activity levels.
Ask What experiences do people have of travelling with diabetes or what have people heard about travelling with diabetes?
Collect answers on a flip chart
Ask How much insulin and equipment should you take?
take twice as much insulin, pens and needles and monitoring equipment as you would normally need for your period away
Ask Where should you carry and store your insulin?
Collect answers
you should carry your insulin and equipment in your hand luggage as it may freeze in the airplanes hold
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if you have a travel companion you may decide to split your diabetes supplies between both of your hand luggage in case one bag gets lost
when travelling in a hot climate store your insulin in the fridge or in a cool bag/ frio pack. Your insulin in safe up to 4 weeks at ambient temperature
if using a car during your trip do not store it in the glove compartment
keep insulin out of direct sunlight
Give out info on frio packs or direct them to the website if necessary
Ask Do you think you would be able to get your insulin in another country ?
Discuss responses
Explain; In case you need to get hold of some insulin in the country you are travelling to, it is important to check the types and strengths of insulin available there i.e. concentration used in UK 100u/ml, Europe 40u/ml. The DUK website also has useful information on travel
Ask What else will you need to take?
Explain you may need a travel letter from your GP or Diabetes care team explaining you have diabetes and that you need to carry blood testing and injection equipment with you at all times when you are travelling
your medication list
wear identification jewellery or carry an ID card
Ask What will you need to consider if you are travelling across time zones?
you may need to adjust your insulin
you can speak to you diabetes team prior to your trip about making necessary adjustments
Remember-never stop taking your insulin.
Ask What about BG testing?
be prepared to test more frequently
consider the affect of heat, activity and diet on BG levels. You will need to adjust insulin or CHO intake accordingly
be prepared for illness, take ketone testing equipment with you and remember sick day rules.
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Ask What about hypos?
carry hypo treatments with you at all times
warmer climates can make your insulin be absorbed faster, which may lower your BG levels (colder climates insulin may be absorbed more slowly, which may raise you BG levels)
Ask What about diet?
no need to order a special diabetic meal on the flight, these sometimes contain less CHO
if on basal bolus regimen then can take quick acting insulin for the CHO you eat
if on a pre mixed insulin, take regular meals which are starchy CHO based
Ask What else would you consider?
inform your travel insurance that you have diabetes
get into good habits and wear well fitting shoes and don’t walk bare foot on hot sand or other surfaces
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11.0 Sick day rules
Aims of the session
 To know that illness can affect diabetes control

To know that they should never stop taking insulin even if not eating
 To know that they should monitor more frequently during illness

To know when they should contact their diabetes team or GP
Resources required
Literature on coping with illness/sick day rules
Flip charts
Flip chart pens
Pens
Ask Has anybody been unwell since their diagnosis of diabetes?
What happened to your BG levels?
Generate some discussion around this with the group and illicit that BG levels can increase during periods of illness.
If no-one has been ill ask the group what they think may happen to BG levels when they are ill?
Explain; during periods of illness you will often see a rise in your BG levels even if you are not eating much.
What is the single most important thing you should do during illness?
Collect responses
Explain Carry on taking your insulin!! Even if you are not eating well you will need insulin. Without insulin you could get seriously ill very quickly.
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If your BG levels are high, where will your body get its energy from?
Collect responses
Explain; you will start to break down you protein and fat stores
Remember back to the first session- what is a by product of breaking down fat?
Explain: Large amounts of ketones are poisonous to the body. To get rid of ketones you need to have more insulin and drink plenty of fluids. If your BG levels are >13mmol and you are ill then it is important that you recheck you BG and ketones every couple of hours (check everybody has some ketostix and that people know how to use them)
If you have ketones in your urine then phone for advice on the diabetes helpline, GP or NHS direct. It is important to get medical help.
If you have any signs of stomach cramps, vomiting, shortness of breath then you will need to seek medical advice urgently and may need to come into hospital.
If you are ill but do not have any ketones in your urine then you will need to keep a check on your BG levels every 4-6 hours and may need slightly more insulin depending on the results.
12.0 Quiz
Aims of this session

To collate all of the learning points from across the 2 sessions

To give a further opportunity to ask questions
Resources required

Quiz

Pens
Notes to educators, work through the quiz, try to do this in an interactive manner, reassure that it is not a test but an opportunity to reflect and review anything they are unsure about. Review topics highlighted by the quiz as appropriate.
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13.0 Drs questions and meeting expectations
Ask the doctor to address the questions which have arisen for him/her and ensure that people feel happy that their burning question was met.
14.0Summary and Signposting to further courses and support
This is the end of the foundation group sessions. If you would like to follow on from this there is a course called DAFNE which you can attend after having diabetes for 1 year. DAFNE stands for Dose Adjustment For Normal Eating. We would strongly encourage you to consider this. It is for people who are on a basal bolus insulin regime and it includes a lot more information around CHO counting and self adjustment of insulin doses. Give out DAFNE leaflets with relevant contact details
Ensure everybody has some follow up arranged with the DSN/ Dietitian/Doctor
Please ask the group to complete evaluation forms and address any 1:1 questions and concerns.
Thank the group for their contributions and say goodbye.
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