Diabetes in Emergency Situations Introduction and housekeeping About DPC Presented by MaryAnn Nicolay, BA, DTR. Health Educator

Program objective: How to help people with diabetes in emergency situations Learning objectives: Understand basic diabetes management Discuss emergency needs as related to basic diabetes management Use tools for determining medication and SBGM needs Handouts Pre and post surveys Info about DPC and camp Basic free lit kit + insulin, medications and high/low blood sugar sheets Monitoring and medication flow charts

What is diabetes? Diabetes is a disease that affects the way your body uses the food you eat for energy. Diabetes happens when: Your body does not make any insulin, Your body does not make enough insulin, or Your body does not use the insulin it makes the right way There is no cure for diabetes, however, it can be managed. Diabetes is diagnosed through a blood test. After the age of 45, a blood glucose test every 3 years or yearly if there are symptoms or risk factors present

Risk Factors for developing diabetes Being over 45 years old Having blood relatives with diabetes Being over weight Being a person of color Not exercising Having high cholesterol or heart disease Having high blood pressure Having diabetes when pregnant Having a baby that weighed over 9 pounds

Symptoms of Diabetes Increased hunger Being very thirsty Frequent urination Being very tired Slow healing wounds Changes in vision Tingling or numbness in hands or feet Unexplained weight loss For some people, these symptoms of diabetes can be very subtle and go unnoticed or be attributed to something else. For people with diabetes, these symptoms can be experienced when blood sugars are elevated or not under good control

Types of Diabetes Type 1 diabetes Type 2 diabetes Gestational diabetes Diabetes is a chronic illness…that means there is no cure, however, it can be managed. Type 1 diabetes usually develops before the age of 30 but can happen at any age. We tend to see it in children. The body no longer produces insulin, so insulin injections are needed along with healthy eating, exercise and monitoring blood sugar. Type 2 diabetes usually develops in adulthood, but we are seeing it in children also. Type 2 diabetes is the most common type of diabetes. The body is still producing insulin, however not enough is being produced or what is produced is not being used effectively in the body. Management of type 2 diabetes includes healthy eating, exercise, medications in needed and monitoring blood sugar. Gestational diabetes occurs during pregnancy and is the only type of diabetes that can go away. Usually (but not always) mom’s blood sugar will normalize after the baby is born. Gestational diabetes is managed through healthy eating, exercise, medications if needed, and monitoring blood glucose.

Diabetes Management Plan Healthy Food Choices Checking Blood Sugar Physical Activity Diabetes Medication Diabetes, regardless of the type, is managed by: Making healthy food choices Being physically active Checking blood sugar Taking diabetes medicine or insulin if needed

Healthy Food Choices There is no “diabetes diet” General Guidelines Eat 3 meals each day Eat at about the same time each day Do not skip meals Watch the fat! Watch your portion size Learn to read and use food labels

Healthy Food Choices in Emergencies Meals every 4-5 hours Between meal snacks Carbs at each meal Fruit, starches / grains, vegetables, milk / yogurt Serve sugar-free beverages Serve heart-healthy foods What are some of the foods you have served in the past? Let’s see if they fit or what suggestions can be made to make them fit better. If people do not eat, they may experience hypoglycemia.

Meal Ideas   Breakfast Cold cereal/milk, toast, yogurt, fruit, yogurt, bagel w/cream cheese, Snack Lunch Deli meat sandwich, soup, salad, fruit, Grilled chicken salad w/low fat dressing, roll or crackers, fruit Dinner Baked chicken, mashed potatoes, green beans, roll w/ margarine, fruit cup Fruit, 100 calorie snack packs, graham crackers, peanut butter w/crackers, yogurt, sandwich, ½ cup ice cream, pudding, cheese and crackers, cottage cheese w/fruit, pretzels

Beverage Ideas Beverages   Beverages Milk, sugar-free beverages like coffee or tea w/sugar substitutes, water, crystal light, sugar-free soda pop

Physical Activity Lowers blood sugar Lowers blood pressure Lowers cholesterol Helps you sleep Enhances your mood Helps burn fat Helps build muscle Strengthens bones There are a lot of reasons to be physically active including lower blood sugar levels! It is recommended that we start slowly and work up to 150 minutes per week.

Physical Activity in Emergencies Depending on the nature of the disaster, there may be a change in regular activity Increase in activity due to repairing damage Hypoglycemia (low blood sugar) Decrease in activity due to being away from routine Hyperglycemia (high blood sugar) Excessive exercise when blood sugar is over 250mg/dl may cause blood sugar to elevate Things to think about when it comes to diabetes, physical activity and disasters.

Checking Blood Glucose Tells what your blood glucose number is NOW Is used to make changes in how you manage diabetes How food and activity affects your blood glucose How well diabetes medicines are working Effects of stress or illness People with diabetes should be checking their blood sugar. Checking blood sugar tells what the blood sugar number is NOW. The results can help you and your doctor know how well your diabetes is doing and if you need to make changes in how your are managing it. Testing should not be discontinued during an emergency situation. It is just as important to test now because of the stresses of the situation (erratic eating, possible problems with medications, stress). Pass out and review the blood glucose testing supplies flow chart

Blood Glucose Monitors & Test Strips

Diabetes Medications People with diabetes may need to take pills and/or insulin to help manage their diabetes Taking pills and/or insulin does not mean your diabetes is worse than someone else. It means that this is the best way to way to manage your diabetes.

Diabetes Medications in Emergencies People with diabetes may or may not be taking diabetes medications Oral medications do not require special storage Insulin or other injectable medications require special storage and equipment Syringes Pen needles Alcohol swaps Pump supplies Sharps container Pass out and review medication flow sheet. Note names of some diabetes medications and insulin on back of flow chart. Many have similar sounding names which makes it easily confusing.

Insulin Pumps and Pens

Stress and Diabetes Coping skills may be inadequate for situation Decreased sleep Increased worry Damage to property “Where will I go?” Loss, grief, fear, anger, frustration Change in priorities Preoccupation with survival or clean up Stress can raise blood glucose. People with diabetes should test more often, drink sugar-free beverages or water when blood sugar is elevated, seek counseling of some sort if needed.

Low Blood Sugar Blood glucose of less then 70mg/dl Feeling weak or tired Being hungry Feeling sweaty, having chills or cold hands Feeling shaky, anxious or confused Having a fast heart beat, dizziness, or headache Having blurry vision or numb lips Passing out or having seizures Some people with diabetes, especially those taking insulin and certain oral medications, may develop low blood sugar or hypoglycemia. A blood sugar below 70 is considered low and should be treated. Symptoms include: Feeling weak or tired Being hungry Feeling sweaty, having chills or cold hands Feeling shaky, anxious or confused Having a fast heart beat, dizziness, or headache Having blurry vision or numb lips Passing out or having seizures Symptoms can be mild to severe. Causes of low blood sugar include: Skipping meals or snacks Not eating at the right time Not eating enough food Drinking too much alcohol Unplanned or increased physical activity Taking too much diabetes pills or insulin or not taking it at the right time Increased stress (physical or emotional)

Treating Low Blood Sugar Follow the Rule of 15 15 grams of quick acting carbohydrate Wait 15 minutes Re-test blood glucose If glucose still below 70mg/dl, retreat Low blood sugar can get bad fast, so it needs to be treated. To treat low blood sugar, follow the Rule of 15 Eat or drink 15 grams of carbohydrate Wait 15 minutes Test your blood sugar. If it is below 70 mg/dl, repeat these steps. Examples of 15 grams of carbohydrate are: ½ cup of juice (any kind or REGULAR soda pop) 4 glucose tablets 2 teaspoons of jam or jelly 6-8 lifesaver candies, chewed up 1 tablespoon of sugar dissolved in water Do not treat low blood sugar with diet soda pop. This will not raise your blood sugar. Do not treat low blood sugar with chocolate candy. This will not raise your blood sugar quickly enough.

15 grams of carbohydrate ½ cup of juice (any kind or REGULAR soda pop) 4 glucose tablets 2 teaspoons of jam or jelly 6-8 lifesaver candies, chewed up 1 tablespoon of sugar dissolved in water Do not treat low blood sugar with diet soda pop. This will not raise your blood sugar. Do not treat low blood sugar with chocolate candy. This will not raise your blood sugar quickly enough.

Other Things to Consider in Emergencies Problems with feet Poly-pharmacy Where to get meds Other medical conditions Heart BP Vision Prosthetic devices Dialysis For people with diabetes, problems with feet can get bad fast. Cuts, bruises or open wounds on feet need immediate attention. Check feet daily, keep them clean and dry, do not go barefoot. It is not uncommon for people with diabetes to have other health issues (heart disease, hypertension) and be taking more than one type of medication. Low vision may be an issue for people with diabetes, especially older people with diabetes Prosthetic devices and dialysis are not as common but you should be aware that they are possibilities. There are power point presentations of these topics on the CCBOH website.

When to call for help Refer to a hospital, clinic or ER when: Hypoglycemia that does not respond to treatment Consecutive blood glucose readings greater than 250 mg/dl Blood glucose reading greater than 250 mg/dl along with vomiting, rapid breathing, fruit breath, stomach ache

Emergency or Disaster Situations Situation: Person with diabetes had been stockpiling insulin in refrigerator from when she had health insurance. Her power went out for 5 days during hurricane Sandy. She was able to remain in her home, but her main concern was how to keep unopened insulin cold (between 36-46 degrees) so it would not be destroyed. Her options included: Store someplace until power came on (which is what she did) Keep in refrigerator and monitor temperature. When temp. goes above 46 degrees, transfer to freezer compartment and continue to monitor temperature. Check temperature of garage. Move to garage if temp stays between 36-46 degrees. Monitor temperature. These options require having a refrigerator/freezer thermometer (which most people do not have). Do not put on ice or in a cooler with ice. You do not want the insulin to freeze! Monitor “look” of insulin (see insulin handout). Some insulin should be cloudy; others should be clear. If the look of the insulin changes, do not use. If insulin becomes stringy or develops crystals, do not use. If staying in an emergency shelter, make room for unopened insulin to be stored. If staying in a hotel, make accommodations for unopened insulin.