The Cystic Fibrosis Foundation Education Committee is happy to introduce the CF-Related Diabetes
(CFRD) Teaching Flip Chart. This educational tool was developed by Michelle Nosky, R.N., M.S., C.R.N.P., C.D.E., Nurse
Coordinator and Diabetes Educator at the Johns Hopkins Adult CF Program, and is specifically designed to introduce the
basic concepts of CFRD physiology and management. It is provided in Microsoft Power Point format but is most
effectively utilized by printing out each slide on a separate page (ideally in color) and placing them in a binder with plastic
page covers. It may also be helpful to use tabs to divide the flip chart into its subsections for easy reference.
Once assembled, the flip chart provides a wonderful format for a CF team member providing diabetes education to sit with
a patient and introduce the key concepts of CFRD physiology and management. The individual teaching slides allow the
caregiver to easily tailor the educational program for each patient no matter where they are in the diabetes continuum. This
may mean spending more time in the introduction section for individuals being evaluated for impaired glucose tolerance, or
jumping to the treatment section for those with CFRD with fasting hyperglycemia. Centers wishing to emphasize
particular aspects of diabetes education can modify the slides provided or add new slides to the flip chart to make it unique
to their center. Most centers have utilized the flip chart for initial one-on-one CFRD teaching, and then provided patients
with the outstanding manual Managing Cystic Fibrosis Related Diabetes (CFRD): An Instruction Guide for Patients &
Families by Hardin, Brunzell, Schissel, Schindler & Moran.
As new information and management techniques are developed for CFRD we will update the flip chart. We encourage you
to make suggestions for improvement in the flip chart and provide tips for its effective use. These can be forwarded to
Leslie Hazle at the Cystic Fibrosis Foundation (lhazle@cff.org). Our hope is that this flip chart will assist you in providing
outstanding CFRD care and teaching for the patients and families at your center.
The Cystic Fibrosis Foundation Education Committee
March, 2003
Cystic Fibrosis Related Diabetes
Teaching Guide
Developed by:
Michelle Nosky, MS, CRNP, CDE
Johns Hopkins Adult Cystic Fibrosis Program
Baltimore, MD
Introduction
How Does the Body Use Food?
When you eat, the food is digested into glucose (sugar).
A hormone called insulin helps your body use the
glucose for energy. Insulin acts as a key that opens the
door of each cell in the body to let the glucose inside.
Food
Glucose
Metabolized
Blood
Travels
Body Cells
Insulin carries into
What is Insulin?
Insulin is a hormone produced in the Beta cells of the pancreas.
The pancreas is a small organ that sits behind the stomach.
What happens without insulin?
• Body cannot turn carbohydrates into energy
• Extra glucose builds up in the blood and spills
over into the urine
• Losing glucose in the urine causes
frequent urination and thirst
What happens without insulin?
• Protein breaks down and muscle is lost
• Loss of muscle affects breathing
because lung function depends on
good muscle strength
• Body’s fat stores are depleted and
weight loss occurs
CF and Blood Glucose
Why is Less Insulin Made in
People with CF?
•CF causes damage to the pancreas (which is why
enzymes are needed for meals)
•Pancreas contains beta cells that make insulin
•If enough beta cells are damaged, the body can’t
make enough insulin to use the food that is eaten
•Decreased amounts of insulin higher blood
glucose levels food can’t be used by the body
Insulin, Glucoses, & Exacerbations
• Body needs more insulin when sick
• With infections, stress or when on steroids body is more resistant to the insulin
• Weight loss can occur rapidly because of
low insulin levels and high glucose levels
• People who usually have normal blood glucoses
may have high blood glucoses when sick
Why is Glucose Control
Important For People With CF?
• Decline in lung function and nutritional
status is associated with high glucoses
• Insulin therapy can improve weight and
pulmonary function
Are sicker patients at higher risk of
getting diabetes or does diabetes
make you more sick?
Tests for CF Related Diabetes
(CFRD)
Blood Glucose
•Fasting –Does your body make enough
“background” insulin?
•After meals – Can your body make enough
insulin to use the food you eat?
•Can be checked in the lab or with a meter at
home
Tests for CFRD
Glucose Tolerance Test
•Shows us what your blood glucose does after
a large amount of carbohydrate
•Similar to what happens to your blood
glucose after you eat a meal
•Does your body make enough insulin to use
the food that you eat?
Tests in CFRD
Hemoglobin A1C
•Picture of the “average” blood glucose over
past 3 months
•Amount of glucose that is “stuck” to the red
blood cells
•Gives a picture of overall glucose control
(average of highs, normals and lows)
Blood Glucose Testing
• Normal glucose levels 70-110mg/dl
• Monitor to evaluate need for treatment
- or • To adjust amount of insulin needed
– to cover food
– during illness or with steroids
– prevent high and low blood glucoses
Hyperglycemia - High Glucose
• Blood glucose >126
• Goal: Keep glucose as normal as possible
• Symptoms:
– thirst
– hunger
– frequent urination
Hyperglycemia - High Glucose
• Causes:
– not enough insulin
– infection
– steroids
• Side Effects
– damage to blood vessels (eyes, kidneys)
– easier to get and harder to fight off infections
– weight loss
Types of Diabetes
Types of Diabetes
• Type 1 (Insulin Dependent Diabetes Mellitus, Juvenile diabetes)
–
–
–
–
destruction of cells that make insulin
pancreas doesn’t make any insulin
ketoacidosis without insulin
insulin, exercise
• Type 2 (Non-insulin Dependent Diabetes, Adult Onset Diabetes)
– insulin resistance
– older, overweight
– pills and/or insulin, diet, weight loss, exercise
Types of Diabetes
• CF Related Diabetes (CFRD)
– different than other types of diabetes
– 15-50% of adults with CF have diabetes
– damage to the pancreas beta cells that make
insulin = insulin deficiency
– insulin resistance with infection
– associated with pancreatic insufficiency
– can make lung function worse
– can make nutritional status worse
Types of Diabetes
• Gestational Diabetes
–
–
–
–
More common in women with CF than without
Onset may be earlier in pregnancy with CF
Insulin should be started at first sign of diabetes
Well-controlled blood glucoses are needed for
healthy pregnancy (for both mom and baby)
– If already have CFRD, will need close monitoring
and insulin dose adjustments throughout pregnancy
CF Related Diabetes
• Depending on how much insulin your body is
making, you may fall into one of three CFRD
categories:
– Impaired Glucose Tolerance
– CFRD without fasting hyperglycemia
– CFRD with fasting hyperglycemia
• Your health (lung function, weight) and your
blood glucose levels help determine if you need to
take insulin
• CFRD can be chronic (all the time) or intermittent
(with illness, steroids)
CF Related Diabetes
• Impaired Glucose Tolerance
– fasting normal (<126)
– after meals high (140-200)
• CFRD without fasting hyperglycemia
– fasting normal (<126)
– after meals high (>200)
– may require insulin
• CFRD with fasting hyperglycemia
– fasting high (>126)
– requires insulin
CFRD Treatment
• Diet: Carbohydrate monitoring – shouldn’t
limit calories, fat, protein, or salt
• Medicine: Oral medications are now being
used, including Metformin.(updated 8/2007)
• Insulin is primary treatment (one or more may apply
to you)
– Daily, long acting and/or short acting
– With high CHO meals/snacks only
– During an exacerbation or when on steroids
Nutrition and Diet
CFRD and Nutrition
• Myth of “Diabetic Diet” – especially not
true in CFRD
• Need to maintain fat, protein and calories
• Carbohydrate (starch, sugar) is the main
nutrient that increases blood glucose levels
• A rise in glucose level is seen the
most after eating
CFRD and Nutrition
• Carbohydrates
– Needed for calories and energy
– Starches and sugar : Fruits, Breads, Rice, etc.
– Causes increase in blood glucose levels without enough
insulin
• Fat, Protein
– Needed in high amounts in CF diet
– Does not raise blood glucose very much
– Fat may slow absorption of carbohydrates
• Many food are combinations:
– Pizza (carbohydrate protein and fat)
– Ice Cream (carbohydrate, protein and fat)
CFRD and Nutrition
• All foods with carbohydrate raise blood glucose to
about the same degree
• Adjust insulin to food intake
• Match carbohydrates to peaks in long-acting
insulin, or match short acting insulin to amount of
carbohydrates eaten
• May need to have less high-sugar
foods or drinks (juice, soda)
• Work with team on insulin
adjustments for shakes/supplements
CFRD and Nutrition
Nutrition Facts/Food Labels
• Lists the carbohydrate content for
each serving
• Look carefully at serving size (are
you eating ½ cup or 3 cups?)
• Look at grams of Total
Carbohydrates
• Do not look at Sugars or % Daily
Value for carbohydrates
CFRD Treatment
Medication for CFRD
• Need to be treated with insulin
• Insulin can only be given by injection
• Pills have been shown to work, due to
insulin resistance that occurs with CFRD
(updated 8/2007)
• When body doesn’t make enough of it’s
own insulin, you need to give extra insulin
Types of Insulin
• Short Acting
– Regular (peaks 2-3 hours)
– Humalog, NovoLog (peaks ½ - 1½ hours)
• Intermediate Acting
– NPH (peaks 6-8 hours)
• Long Acting
– Ultralente (peaks 10-13 hours)
– Lantus (last 24 hours, no peak)
Insulin for CFRD
“Background insulin” - your body may make
this or it may need to be from insulin injection
Meal coverage/Carbohydrate counting – the
amount of insulin your body needs to use what you
eat and drink; normal pancreas produces insulin
every time you eat
Correction/Sliding scale - extra insulin to
bring your glucose to normal range when it’s high
Insulin for CFRD
How many shots?
• Multiple injections (4)
– better blood glucose control
– more flexibility
• 2 injections/day
–
–
–
–
not as good blood sugar control
less flexibility with meals
eat too much = high blood glucose
eat too little/skip meal = low blood glucose
Insulin for CFRD
Insulin Effect
Rapid Acting Insulin (Humalog or NovoLog)
Background insulin made by body or Glargine (Lantus) injection
Breakfast
Lunch
Dinner
Overnight
Insulin Effect
Intermediate acting insulin (NPH) and Rapid Acting (Humalog or NovoLog)
Breakfast
Lunch
Dinner
Overnight
Insulin Injection
•
•
•
•
Insulin can only be given by injection
Needle length
Syringes
Insulin pens
©Lilly
Insulin Injection
©Lilly
Stomach has the most even insulin absorption
Insulin for CFRD
Insulin Pump
• Basal rate - background insulin
• Boluses - to cover food
• Short acting insulin only
©Medtronic MiniMed
Hypoglycemia - Low Glucose
• Blood glucose <70
• Symptoms:
–
–
–
–
–
–
confusion
numbness (mouth, face)
blurry vision
irritability
shaking
sweating
Hypoglycemia - Low Glucose
• Causes:
– too much insulin
– not enough food
– too much exercise
• Treatment:
– fast acting carbohydrate (glucose tablets, sugar,
juice, soda, candy) (12-15g of carbohydrates)
– If on long acting insulin, follow with snack
Glucagon
• Hormone that raises the blood glucose level
• Given by injection for severe hypoglycemia
• Use: when glucose is so low you can’t eat
or drink, administered by someone else
• Mix liquid and powder together
• Inject into fat or muscle
Miscellaneous
CFRD and Exercise
•Exercise helps your body use insulin better
•Will need more food or less insulin for exercise
•Exercise is important in both CF and CFRD
•Preserves and increases muscle tone
•Increases lung efficiency
Complications from CFRD
•CF Complications: infection, decline in lung
function, weight loss
•Kidney damage (important for transplant)
•Delayed healing, especially of feet
•Eye damage, can lead to blindness
•Nerve damage
But The Good News is ….
…with control of blood glucoses
you can prevent or delay the
onset of these
complications
and improve
your overall
health
When You Are Sick…
• Treat the underlying illness (call your doctor or
nurse to discuss)
• Prevent dehydration (high blood glucose can make
you dehydrated)
• You won’t need meal coverage insulin if you
aren’t eating, but probably will need background
insulin
• Your body may need more insulin to cover the
extra stress of the infection
• When on steroids, you’ll need to monitor glucoses
more and will probably need more insulin
Daily Management
• Not something else!/I can’t do anymore!
• Juggling daily pulmonary
treatments, nutrition, and diabetes care
• Customize treatment to your life
• Share your concerns
• End benefit=better health
Credits/Resources
• All images are from Microsoft word online
clip art unless otherwise noted
(http://dgl.microsofe.com/?cag=1)
• Eli Lilly and Company - www.lilly.com
• Medtronic MiniMed - www.appliedmedical.co.uk/MiniMed/508.htm