1. 1 Empowerment Course Presenters: Melba Mensch Course Facilitator Dr Mary Ho CMO and Course Facilitator Dr. Tuan Quach Diabetes Specialist Rosalie Arnold Diabetes Educator and Guest Speaker

2. 22 The beginning In 1992 conducted a survey of first 100 patients who attended the Diabetes Education and Stabilization Centre which started in September 1975. Survey question: What knowledge and skills do you want to develop to assist you to better manage your diabetes?

3. 3 Results of Survey To become actively engaged in diabetes management- learn how to adjust own insulin To develop skills in making healthy food choices To develop skills in cooking To feel better about having diabetes Activities versus lectures 3

4. 44 1993 A new model Diabetes self management/empowerment Based on –- work of Dr. Bob Anderson, U. of Michigan, Michigan, US »-adult learning theory »- stages of change »-DCCT – basal/bolus

5. 55 Evidence for intensive insulin therapy USA - Diabetes Control and Complication Trial (DCCT) 10 year study of 14,400 type 1 patients age18- 39 Designed to answer two questions 1. if people treated their diabetes intensively would their blood glucose control improve 2. if their control improved would they lower their risk of developing diabetes-related complications

6. 66 DCCT Divided into two groups 1.Conventional therapy 1 or 2 injections per day 2.Intensive insulin therapy (IIT) 3 injections per day or pumps and testing at least 4 x/day 1.Insulin- learned to adjust their own doses 2.Diet- carbohydrate counting in grams or exchanges, or counted calories, or used observation to identify the amount of insulin for a set meal.

7. 77 DCCT results Intensive Insulin Therapy Group Eye disease reduction by 76% Decreasing the development of -early kidney problems by 35% -more advanced kidney disease by 56% Nerve damage was reduced by 60% Medical nutrition therapy reduced HbA1c by 1% Adverse effects –more severe hypos 3 x increase –average 10 pound weight gain during 10 years

8. 88 Around the world UK DAFNE type 1 Flexible eating and insulin dose adjustments HbA1c decrease pre 9.4% to 8.4% at 6 months DAFNE Study Group Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. BMJ,325 Oct. 25, 2002.

9. 9 Insulin effect HS What is the best management? Mimicking nature: basal–bolus insulin concept Fasting period

10. 10 Best Practice for individuals with type 1 diabetes Intensive Insulin Therapy Multi injections or pump therapy Flexible eating plan with carbohydrate/insulin dose adjustment

11. 11 Empowerment Course Goals: To become an active partner in self management of diabetes To develop a proactive approach to carbohydrate/insulin dose management To develop confidence in adjustment of insulin doses to achieve diabetes self management goals To set short and long term diabetes self management goals To seek medical services and support as needed

12. 12 The course Who is it for? Individuals with type 1 diabetes and their support persons How often? once a month How many days? Four days 9am to 4 pm Where? Newcastle Community Health Centre

13. 13 The staff Endocrinology- Dr. Quach Co Facilitators- – Dr. Mary Ho Career Medical Officer –Melba Mensch Dietitian/Diabetes Educator –Guest Speaker- – Rosalie Arnold, Cred. Diabetes Educator 13

14. 14 Who should attend the Empowerment Course ? Referral criteria Individuals with Type 1 Diabetes To commence or already on intensive insulin therapy- multiple daily injections or insulin pump Individuals with problems eg. Hypoglycemia unawareness, poor control

15. 15 Requirements for attending  need to be able to read and write  basic numeracy  normal cognition  willing to participate in a group environment

16. 16 Type 1 Empowerment Course What knowledge and skills do the patients need for successful intensive insulin therapy? Learning about Insulin action day to day management About home glucose monitoring New equipment When to test Interpreting results Calculating insulin doses Identifying carbohydrate foods and carbohydrate exchanges Counting carbohydrates at lunch time Super market tour Label reading Calculating carbohydrate content of recipe Eating out and alcohol Managing exercise Reducing insulin? Increasing food?

17. 17 About daily living with diabetes Hypoglycaemia management Over coming fear of hypo Managing hypo unawareness Driving safely

18. 18 The “15” Rule for Treating a “HYPO” For prompt and effective “hypo” treatment pack your “hypo kit” and keep it with you at all times and consider keeping one in your car. Test blood glucose If level is 4 mmol/L or less- Treat with 15 grams of high GI food/drink (ie rapidly absorbed) a) Five Jellybeans b) 1/3 bottle Lucozade c) Glucose tablets (take number according to package) Wait 15 minutes and retest BGL If still 4 mmol/L or less-treat again with 15 grams high GI carbohydrate If greater than 4 mmol/L have 15 grams ie 1 exchange of Low GI food If unconscious do not give liquids or solids, call the ambulance or give Glucagon (Glucagen Hypo Kit tm ) 18

19. About managing stress Hyperglycemia DKA Illness 19

20. 20 About problem solving & learning about support services Active learning activities Australian Diabetes Council NDSS

21. 21 then …. Putting it all together Diabetes Self-management Setting Targets and Goals Developing self confidence Taking action to reduce complications LEADS to the Road to Empowerment