MedStar Pathway to Diabetes Control Demonstration Project Principal Investigator: Michelle Magee, MD Sub-Investigators: John Reyes-Castano, MD, Gretchen Youssef, MS, RD, CDE, Carine Nassar MS, RD, CDE, Nawar Shara PhD. OBJECTIVE The MedStar Diabetes Institute (MDI), in partnership with key MedStar Health system diabetes stakeholders, seeks to implement an evidence-based innovative integrated care pathway for MedStar patients with uncontrolled diabetes which will demonstrate improvement in diabetes care outcomes. I- Introduction A. Making the case for glycemic control in preventing diabetes morbidity and complications: the evidence is unequivocal. Diabetes Mellitus (DM) is a high cost, complex, chronic medical condition. Large scale clinical trials have definitively demonstrated that targeted control of blood glucose (BG) reduces type 2 diabetes complications 1-3 . Diabetes self-management education (DSME) has also been shown to improve outcomes for those living with the disease 4-9 . Methodology to facilitate effective and timely delivery of evidence-based medication management and DSME for type 2 diabetes is needed. Implementation of targeted glycemic control initiatives across the continuum of acute and chronic care delivery settings presents a challenge to health care delivery systems, including MedStar Health, and is an evolving area of investigation. B. Best practice guidelines for diabetes management are well-established in the literature. Nationally, best practice guidelines are in place for outpatient type 2 diabetes management 10 and medication management algorithms have been published 11-13. These tools have helped to improve attainment of diabetes care benchmark indicators, including A1C nationally with most recent NHANES data showing that 55.7% of those with diabetes now attain an A1C of <7%.) 14 . While a recent report shows that diabetes complication rates in the United States are declining 15 a substantial percentage of patients with diabetes do not receive guideline recommended surveillance testing to assess glycemic control and diabetes complications status and/or remain above glycemic control targets placing them at increased risk for the development and progression of diabetes- related complications.
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MedStar Pathway to Diabetes Control Demonstration Project
Principal Investigator: Michelle Magee, MD
Sub-Investigators: John Reyes-Castano, MD, Gretchen Youssef, MS, RD, CDE, Carine
Nassar MS, RD, CDE, Nawar Shara PhD.
OBJECTIVE
The MedStar Diabetes Institute (MDI), in partnership with key MedStar Health system
diabetes stakeholders, seeks to implement an evidence-based innovative integrated care
pathway for MedStar patients with uncontrolled diabetes which will demonstrate
improvement in diabetes care outcomes.
I- Introduction
A. Making the case for glycemic control in preventing diabetes morbidity and
complications: the evidence is unequivocal.
Diabetes Mellitus (DM) is a high cost, complex, chronic medical condition. Large scale
clinical trials have definitively demonstrated that targeted control of blood glucose (BG)
reduces type 2 diabetes complications1-3
. Diabetes self-management education (DSME)
has also been shown to improve outcomes for those living with the disease4-9
.
Methodology to facilitate effective and timely delivery of evidence-based medication
management and DSME for type 2 diabetes is needed. Implementation of targeted
glycemic control initiatives across the continuum of acute and chronic care delivery
settings presents a challenge to health care delivery systems, including MedStar Health,
and is an evolving area of investigation.
B. Best practice guidelines for diabetes management are well-established in the
literature.
Nationally, best practice guidelines are in place for outpatient type 2 diabetes
management10
and medication management algorithms have been published11-13.
These
tools have helped to improve attainment of diabetes care benchmark indicators,
including A1C nationally with most recent NHANES data showing that 55.7% of those
with diabetes now attain an A1C of <7%.)14
. While a recent report shows that diabetes
complication rates in the United States are declining15
a substantial percentage of patients
with diabetes do not receive guideline recommended surveillance testing to assess
glycemic control and diabetes complications status and/or remain above glycemic control
targets placing them at increased risk for the development and progression of diabetes-
related complications.
C. Attainment of diabetes-related NCQA/HEDIS measures within the MedStar
Health Ambulatory Care Practices
As of 2013, there were 13,309 patients with diabetes being treated in 43 MedStar Health
Ambulatory practices. Of these: 2,153 (16.2%) had very poorly controlled diabetes with
an A1C >9% and 7,863 (58.5%) did not meet the national benchmark of an A1C <7%.
Rates of meeting NCQA and HEDIS measures for diabetes care among these practices
are summarized below on Table 1.
Table 1. 2013 MedStar Ambulatory Practices (n=43)
Diabetes-related Performance Data
MSH
Ambulatory
Diabetes Patients (n) 13309
HbA1C Control greater than 9.0 % (Goal 15% or Less) 16.18%
HbA1C Control less than 7.0 % (Goal 40% or More) 41.51%
LDL-C Control greater than or = 130 mg/dl (Goal 37% or Less) 11.44%
LDL-C Control less than 100 mg/dl (Goal 36% or More) 53.77%
Nephropathy Assessment (Goal 80% or More) 90.92%
Blood Presssure Control greater than or = 140/90 mm Hg (Goal
35% or Less) 26.22%
Blood Pressure less than 130/80 mm Hg (Goal 25% or More) 39.09%
Smoking Status and Cessation Advice or Treatment
(Goal 80% or More) 93.05%
Eye Examination (Goal 60% or More) 36.13%
Foot Examination (Goal 80% or More) 71.64%
Confidential data provided by MedStar Medical Group.
There is a need for strategies to support patients and providers in reducing the percentage
of patients with A1C >9% and to increase the percentage receiving eye examinations and
foot examinations in MedStar Ambulatory practices. In addition, in the long-term, as the
system’s percentage attainment of A1C < 7% is well below the most recently reported
NHANES average, as a system we should strive to meet or exceed that target as part of a
system-wide effort to deliver high quality care to our patients living with this prototype
chronic, complex medical condition.
D. Emergency Department visits and hospitalizations with uncontrolled diabetes
present an opportunity to identify and engage MedStar practices’ patients in a
glycemic management care delivery program.
In 2012, there were 18,800 unique patient admissions to MedStar Hospitals and 24,480
Emergency Department (ED) admissions for patients with diabetes (Explorys 2012 data).
These acute care encounters offer an opportunity to identify and engage patients with
uncontrolled diabetes in a quality improvement care delivery system.
E. Barriers to improvement in glycemic management: vercoming clinical inertia in
medication management and diabetes self-management education.
Among the many patient, provider and system variables which contribute to lack of
further improvement in overall progress to glycemic control in diabetes, clinical inertia in
advancement of the anti-hyperglycemic medication regimen remains common16-17
and
despite evidence that DSME reduces ED visits, A1C and hospital admissions18-20
fewer
than 55% of all diabetes patients in the United States receive any DSME during the
course of their illness21-23
. The MedStar Pathway to Diabetes Control will address each of
these barriers in an effort to support both patient and provider in improving glycemic
control. We will specifically undertake timely advancement of the diabetes medication
management regimen and delivery of concise, focused DSME among high risk, high cost
type 2 diabets patients with A1C > 9% enrolled in the program.
F. Economic implications of uncontrolled diabetes
The economic costs of diabetes in the U.S. are high and continue to rise. Persons with
diabetes have medical expenditures that are 2.3 times higher than those without diabetes.
The annual medical expenditures average $13,700 per diabetes patient, of which about
$7,900 is attributed to diabetes24
. . About 43% of all diabetes-related expenditures can be
attributed to inpatient stays. In addition to the medical costs associated with DM, there
are costs associated with decreased productivity and increased absenteeism. Persons with
diabetes have 2-10 more days of absenteeism from work per year than those without
diabetes. Uncontrolled diabetes contributes both to absenteeism and to decreased
productivity in the workplace. As the rates of diabetes continue to increase in the U.S.,
these economic implications will continue to impact MedStar Health as a healthcare
provider, as a medical home for patients enrolled in MedStar managed care plans,
including MedStar Family Choice, and as an employer providing insurance to employees
and their families. Efficient and effective management of diabetes and diabetes-related
illness will contribute to the success MedStar’s transition to being a national leader in the
provision of value-based care.
The MedStar Diabetes Institute (MDI), in collaboration with partners across the MedStar
Health system seeks to implement an innovative integrated care pathway for high risk,
high cost MedStar patients with uncontrolled diabetes in order to demonstrate
improvement in care outcomes and reduce costs.
II- MDI-generated Evidence for Best Practices for Uncontrolled Diabetes Clinical Care
and Diabetes Self-Management Education Relevant to this Project
MDI has completed several studies, that have informed the development of best practices
for diabetes clinical care and education delivery. These results have been reported at
national meetings, received awards, and been published in peer-review journals.
Following in a summary of those studies that will be relevant to the current project:
A. STEP-Diabetes, American Diabetes Association (ADA) Core Research Award:
This study assessed the impact of a care delivery intervention focused on glycemic management
for adults with type 2 diabetes (T2DM) presenting to the emergency department (ED) of the
MedStar Washington Hospital Center with uncontrolled hyperglycemia.
A 4 week randomized controlled trial provided algorithm-based antihyperglycemic medications
management; survival skills diabetes self-management education (DSME); and navigation to
primary care for adults presenting to the ED with BG>200mg/dL. Medications were titrated and
DSME content delivered by endocrinologist-supervised certified diabetes educators at each visit.
Controls received standard ED care. One hundred and one patients were enrolled and
randomized and 78 completed the week 4 visit.
In both the intervention (INT) and control (CON) groups mean BG decreased (403+132
to 192+ 93 mg/dL and 412 +120 to 259+124mg/dL, respectively), p< 0.001 but the post-
BG was significantly lower only for the INT, p<0.01. A1C went down within each
group, (11.8+ 2.4 to 10.5+1.9% , p < 0.001 for INT, and 11.5+2.0 to 11.1+2.1% ,p=0.012
for CON). Absolute reduction in A1C was -0.9% greater in the INT than the CON group
(p=0.01). The ADA recommended BG level of <180 mg/dl was reached by 65% of
intervention and 29% of control subjects, p=0.002. Hypoglycemia rates between groups
did not differ and no severe hypoglycemia was reported.
Diabetes Fasting BG > 126 mg/dL (positive result should be confirmed with repeat test another day)
OR Casual plasma glucose > 200 mg/dL with symptoms of hyperglycemia
OR A1C>6.5%
OR -2-hour 75 gm OGTT > 200 mg/d
No Prior Anti-hyperglycemic Agent Therapy*
BG (mg/dL) Action
126-139
(fasting)
Follow-up BG with MD within 2 weeks. BG is not completely normal. Possible pre-diabetes or
diabetes.
140-199
(random)
Follow-up BG with MD within 2 weeks. Sooner if symptoms of hyperglycemia. Probable diagnosis
of diabetes or pre-diabetes.
> 200mg Inform patient of diabetes diagnosis.
200-250 Start metformin 500mg po bid, unless contraindicated;
If metformin contraindicated DPP-4i OR GLP-1A OR SGLT2i (OR low dose SU)
251-300 START Metformin 500 mg po bid unless contraindicated.
PLUS DPP-4i OR GLP-1A OR SGLT2i (OR starting dose SU)
OR basal or premix insulin: one dose daily
301-400 Correction dose of rapid-acting insulin
Metformin 500 mg po bid
PLUS Basal insulin or premix 1-2 times daily OR GLP-1a
>400 Correction dose of rapid-acting insulin analog (see algorithm.)
START Metformin 500 mg po bid.
PLUS Basal insulin or premix 1-2 times daily
Pre-existing Diabetes on Oral Anti-hyperglycemic Agents*
BG
(mg/dL
)
One agent
2-3 oral agents
On metformin
On
sulfonylurea Other oral agent
80-139 No change. Follow up with MD.
140-
199
< 1000 mg daily: to
1000 mg twice daily:
Add DPP-4i OR
SGLT2i (OR SU)
Add metformin
OR DPP-4i
OR SGLT2i
OR uptitrate SU
Add metformin
OR DPP-4i
OR SLGT2i
Titrate one or more agents to higher or
maximal dose(s)
OR add third oral agent
OR add GLP-1a
200-
300
If not already on metformin, add 500 mg po bid, unless contraindicted
Titrate to higher or maximal dose AND/OR add second oral agent
OR add basal insulin OR GLP-1a
If not already on metformin, add 500 mg po
bid
START Basal insulinOR GLP-1A.
Continue SGLT-2i and/or DPP-4i when
starting insulin as actions synergistic.
Discontinue DPP-4i if start GLP-1a as actions
redundant.
Stop SU as increased risk for hypoglycemia
with insulin and GLP-1a
301-
400
Correction dose of insulin. (See CD algorithm)
If not already on Metformin, add 500 mg po bid, unless
contraindicated
START Basal or premix insulin 1-2 times/day OR GLP-1a
Continue SGLT2-i
Continue DPP-4i , unless starting GLP-1a, then stop DPP-4i
STOP SU
> 400 Correction dose of rapid-acting insulin analog (see CD algorithm.) ).
Metformin 500 mg po bid if not already taking.
PLUS Basal insulin or premix insulin
When a choice of two or more agents is possible based upon the algorithm, the options and potential benefits and risks of each should be discussed with the patient whom
should be invited to participate in the decision as to which agent will be used preferentially in the next treatment step to help promote medication adherence.
MedStar Hypoglycemia Treatment Algorithm.
For symptoms of low blood sugar (hungry, shaky, dizziness, sweating, palpitations),
and/or if realize is not thinking clearly, or for FSBG less than 70 mg/dL:
1) Treat for low blood sugar, then check a fingerstick blood sugar reading:
a. Give one 15 gram serving of carbohydrate such as:
1) 4 oz. of unsweetened apple or orange juice (avoid orange juice in
renal disease)
2) 4 oz. of regular soda
3) 8 oz. of milk (skim or 1% preferred)
4) 3-4 glucose tablets
b. If patient cannot take PO and/or is unconscious and family member or
caregiver has been trained in use of glucagon, give1 mg Glucagon IM,
place in side-lying position
c. Call 911 after glucagon is given
d. Check fingerstick blood sugar as soon as treatment has been given and
record value
2) If hypoglycemia was because a meal was delayed or skipped, eat that meal, or if a
meal is not due, eat a snack. A snack is something such as: half sandwich or
snack bar or 6 cheese/peanut butter crackers.
3) Recheck FSBG every 15 minutes until reading is greater than or equal to 100
mg/dL, and again one hour later to be sure it is not low again.
a. If taking insulin and If low blood sugar was due to extra physical activity,
eating less than usual or to taking extra insulin, resume your usual doses
once hypoglycemia resolved.
b. If taking insulin and you do not know why your blood sugar got so low
and/or you have more than one blood sugar under 70mg/dL in two days,
call for recommendations about your insulin doses.
c. If on oral hypoglycemics, do not resume previous therapy until after
discussion with provider to evaluate current orders.
4) If the patient has a severe hypoglycemic reaction, he/she should call his/her
doctor or go to the emergency room to obtain recommendations for what to do
with doses of diabetes medications
Hard stops for Allied Health Professional use of algorithm
Consult team Endocrinologist in the presence of any of the following:
Recurrent severe hypoglycemia (BG </= 40mg/dL on two consecutive days or 3
days in one week) in spite of reduction(s) in insulin dose per hypoglycemia
management guidelines.
Recurrent hypoglycemia (BG < 70mg/dL) in spite of two reductions in insulin
dose per algorithm
ED visit or hospitalization for severe hypoglycemia in patient being treated using
pathway algorithm
2-3 increases in insulin dose per algorithm without BG improvement
BG > 400 or patient continues to be symtomatic in spite of 2-3 increases in insulin
dose per algorithm
A serious or severe or medically significant adverse reaction to any DM
medication prescribed per the algorithm.
o Serious adverse reaction will be defined as any unfavorable and unintended
sign, symptom, or disease temporally associated with the use of medications
prescribed using the algorithm that may or may not be considered related to
the medical treatment or procedure and which are medically significant but
not immediately life-threatening.
o Severe adverse reaction will be defined as any unfavorable and unintended
sign, symptom, or disease temporally associated with the use of medications
prescribed using the algorithm that results in a life threatening circumstance,
an ED visit or hospitalization; death; or is disabling or limits self care ADL.
Dosing: Byetta®/exenatide twice daily with breakfast and dinner;
Bydureon/exenatide extended release once weekly; Victoza®/onglyza once daily.
Choice of GLP-1a agent(s) is determined by provider formulary.
Up to 25% nonresponders, therefore, If no response in 6-12 weeks, GLP-1a should be
discontinued.
Appendix B
INSULIN START Dosing Guidelines for Type 2 Diabetes
Type of Insulin Starting Dose Timing of dose(s) Comments
Basal Insulin 0.2units/kg/day *see comment section for special situations
one dose daily at same time of the day* (B, D, or hs)
Large doses, ( >50 units/day) split into 2 doses/day Detemir may not last for 24 hours and need to be split into 2 doses/day √ Special situations
A dose of 0.3 or 0.4 units/kg/day may be considered if marked
symptomatic hyperglycemia, BMI > 30 and no obvious lifestyle
intervention which might significantly impact BG levels present (
such as drinking sugared sweetened beverages).
Use 0.1units/kg/day if ESRD/CKD stage 4 or the elderly/frail
patient.
NPH may require bedtime snack to prevent nocturnal
hypoglycemia
glargine or detemir
NPH Split dose- Before breakfast, and dinner or bedtime*
Premixed Insulin 70/30, 75/25
0.2units/kg/day Split dose before breakfast and dinner
Can start with one dose before largest meal of the day.* Emphasize consistent CHO intake at each meal. Use for pts requiring a simple regimen if anticipate will need meal insulin. Also see √ special situations under basal insulin above. May require bedtime snack to prevent nocturnal hypoglycemia if pm dose.
Mealtime/prandial Aspart, lispro, glulisine
0.1 units/kg/meal Right before –or- right after meal*
Can start with single dose with the largest meal of the day, and then add to each remaining meal as needed.
* to promote adherence to the insulin dosing regimen, discuss timing preference with the patient
INSULIN ADJUSTMENT Guidelines
METHODS for making insulin dose adjustments, select one of:
BG-based dose adjustment algorithm
Titrate insulin* dose(s) 1-2 times per week based on blood glucose patterns during the preceding 2-7 days.
For BG: Change responsible insulin dose:
<80 mg/dl decrease 1-3 units
80-120 mg/dl no change
121-200 mg/dl increase 1-3 units
>200 mg/dl increase by 3-5 units
*Applies to all types of insulin
% of prior dose
If clinical judgment suggests that a greater incremental change in insulin dose is required to correct BG, then the dose of the responsible insulin can be adjusted by 10-20% in order to effect a clinically meaningful change, eg. If patient has insulin resistance and is on high dose(s) of insulin, and/or BGs running particularly high.
PATTERN MANAGEMENT
BASAL – glargine or detemir
If no response to basal insulin dose of 0.2 units/kg/day, double basal insulin dose to 0.4 units/kg/day. This is often necessary in presence of marked hyperglycemia (BG >300-400), BMI > 30 and no obvious lifestyle intervention which might significantly impact BG levels, eg elimination of sweetened beverages.
CHECK FSBG as: Fasting and before dinner
Titrate basal insulin until fasting and pre-meal BGs at goal
Then, if A1C still high and/or post-meal BGs above target, start another agent: GLP-1 analog; prandial insulin; or an insulin mix.
BASAL – NPH
Adjust morning NPH dose based on pre- dinner BG values Adjust bedtime NPH dose based on next day fasting BG values**.
Fasting and before dinner
Premixed Insulin- 70/30, 75/25
Start with one shot of premix insulin with largest meal of the day, usually dinner. Add second dose of premix insulin once single daily dose optimized. Adjust morning dose of premix insulin based on pre- lunch and/or pre- dinner BG values Adjust dinner dose based on bedtime and/or next day fasting BG values Note that premix insulin may not control post-lunch BG if meal large. Lower CHO content of lunch or add a third (smaller) dose of premix to lunch.
Fasting and vary pre- lunch, dinner or bedtime
**Suspect nocturnal hypoglycemia if fasting BG pattern is erratic (highs and lows), history of insomnia, night sweats, nightmares, in which case- decrease basal insulin glargine or detemir, or the PM NPH or premix insulin dose by 10-20%. Rapid acting insulin dosed with a late dinner can also cause nocturnal
hypoglycemia. Can confirm nocturnal hypoglycemia by checking 2-3am FSBG.
PATTERN MANAGEMENT, cont’d
Rapid-acting
PRANDIAL-
Aspart,
lispro,
glulisine
Pre-lunch BG is elevated adjust breakfast rapid-acting insulin dose
Pre-dinner BG is elevated, adjust lunch rapid-acting insulin dose
Bedtime BG is elevated, adjust dinner rapid-acting insulin dose
OR
Use the adjustment algorithm shown in the table below:
Mealtime dose
of insulin
Pattern of mealtime blood glucose
values below target*
Pattern of mealtime blood glucose
values above target†
< 10 units Decrease by 1 unit Increase by 1 unit
11-19 units Decrease by 2 units Increase by 2 units
> 20 units Decrease by 3 units Increase by 3 units
*If more than one-half of the mealtime blood glucose values for the week were below target. †If more
than one-half of the mealtime blood glucose values for the week were above target.
OR
Base meal insulin adjustments on BG change from pre- to post-meal:
If post-meal BG is more than 40 mg/dL higher than pre-meal BG increase meal insulin
dose by 1-3 units.
If there is a pre- to post-meal drop in BG of concern, decrease the pre-meal insulin dose
by 1-3 units. This is important as pre-meal BGs approach target values to help prevent
hypoglycemia. OR
Carbohydrate Counting Method
If patient counts CHO choices/grams of carbohydrate or is on consistent CHO diet
Start at one unit of prandial insulin per 15 grams of CHO or per 1 CHO Choice
CHECK FSBG as: Before next meal (or 120 minutes after meal)
Select method for adjusting rapid-acting insulin based on patient and clinical care team preference.
For further information on BG pattern management, see resource binder for chapter on pattern management from Magee reference.
Correction Dose Insulin Algorithm
Use rapid-acting insulin analog (lispro, aspart or glulisine) when hyperglycemia is present as an
add-on dose to usual daily insulin regimen .
Low Dose: < 40 units of
insulin/day, weight < 70 kg
Medium Dose: 40-100
units of insulin/day, weight
70-125 kg
High Dose: > 100 units of
insulin/day, weight > 125 kg
BG (mg/dL) Insulin Dose BG
(mg/dL)
Insulin Dose BG
(mg/dL)
Insulin Dose
150-199 1 unit 150-199 1 unit 150-199 2 units
200-249 2 units 200-249 3 units 200-249 4 units
250-299 3 units 250-299 5 units 250-299 7 units
300-349 4 units 300-349 7 units 300-349 10 units
> 349 5 units > 349 8 units > 349 12 units
Appendix C
MedStar Health Diabetes Survival Skills
KNOW Your Diabetes Numbers:
Target blood sugar (glucose) for MOST people with diabetes should be:
In the morning before eating (fasting) and before meals: 80 to 140
2 hours after eating: under 180
What blood sugar is too LOW (also called hypoglycemia)?
Less than 70
What blood sugar is too HIGH (also called hyperglycemia)?
Over 180: Discuss with your doctor at your next visit
Over 300: for 2 or more readings over 12-24 hours: Call your doctor at his/her
office
Over 500, “HI” or “HHH” on your meter: Call your doctor right away or go to
the emergency room
When to check your blood sugar:
Always check: Every day when you wake up in the morning, and at least one
more time during the day
If you take pills for your diabetes: check before breakfast and two hours after your
biggest meal of the day, usually this will be 2 hours after dinner.
If you take insulin for your diabetes: check before each meal and bedtime.
Your doctor may ask you to check your blood sugar at other times as well
Check any time you feel like your sugar might be too high or too low
How do you feel if your blood sugar is LOW (hypoglycemia)?
Sweaty
Shaky
Fast heartbeat
Dizzy
Headache
Not thinking clearly
Hungry
Tired
Blurry vision
Confused
Moody or angry
How to treat low blood sugar (hypoglycemia):
1. First eat 15 grams of carbohydrate, such as:
o ½ cup of juice
o ½ cup of regular (NOT diet) soda
o 1 cup of milk (skim is best)
o 1 tablespoon of honey, jelly, syrup, or sugar
o 1 small tube of gel mate cake frosting
o 3-4 glucose tablets of tube of glucose gel
2. Test your blood sugar again in 15 minutes
o If sugar is not over 70, eat another 15 grams of carbohydrate
o Repeat step1 and 2 until your blood sugar is greater than 70.
3. Eat a sandwich, cheese and cracker or peanut butter and crackers or the missed
meal to prevent your blood sugar from getting low again.
How do you feel if your sugar is HIGH (hyperglycemia)?
Increased urination
Increased thirst
Tired
Blurred vision
Dry skin/dry mouth
What to do if you think you have high blood sugar:
Check your blood sugar as soon as you can
Eating: What to do until you get a meal plan or see a dietitian:
Here are some tips to help keep your blood sugar under control before you learn more
about diet and diabetes.
Eat 3 meals a day
Eat your main meals 4-5 hours apart
Do not skip meals
Eat less food
Do not eat seconds
Do not snack between meals
Do not drink fruit juice, regular sodas or sweet tea
Drink calorie-free liquids such as diet soda, Crystal-Lite®, unsweetened tea,
coffee or water
Stay away from foods that are high in sugar, such as cake, pie, doughnuts,
sweetened cereal, honey, jam and jelly.
Do not add sugar to your food; instead use
sugar substitutes like Equal®, Sweet ‘n Low® or Splenda®
When to call your doctor or go to the emergency room:
Blood sugar is higher than 300 mg/dL two or more times over 12-24 hours
More than two low blood sugars (less than 70 mg/dL) in one day
Vomiting or diarrhea for more than 6 hours
Moderate or large urine ketones (if you have Type 1 Diabetes)
Other medical problem that requires immediate attention
Appendix D
Diabetes Knowledge Test
Please answer the following questions checking the best answer.
If you do not know the answer check “Do not know”.
1. A person with diabetes should test his or her blood sugar at home at least:
a. One to two times per day
b. Once a week
c. Once a month
d. Do not know
2. Checking blood sugar at home:
a. Provides me with information on my diabetes control
b. Helps me understand the effect of physical activity and food on my
blood sugar
c. Both a and b.
d. Do not know
3 A good blood sugar in the morning before you eat anything is:
a. 80-140
b. less than 150
c. less than 200
d. Do not know
4. The highest a blood glucose should be 2 hours after a meal or at any other time
of the day is
a. 120
b. 180
c. 250
d. Do not know
5. The A1C blood test gives you your average blood glucose in the past 3 months.
The A1C target or goal for most people with diabetes is less than:
a. 7
b. 8
c. 9
d. Do not know
6. High blood sugar may make you:
a. Feel shaky and nervous
b. Feel full of energy
c. Have increased urination, thirst and hunger
d. Do not know
7. One cause of high blood sugar is:
a. Exercising more than usual
b. Illness and infection
c. Skipping meals
d. Do not know
8. Your blood sugar is greater than 300 for two or more tests in one day. You should :
a. Call your doctor
b. Go to bed
c. Stop taking diabetes medication
d. Do not know
9. It is Saturday morning and your meter reads “ High” and you feel sick. You
should:
a. Call your doctor on Monday to schedule an appointment
b. Wait until your next scheduled appointment with your doctor in one
month
c. Go to the hospital emergency room
d. Do not know
10. Low blood sugar may make you feel:
a. Shaky and nervous
b. Full of energy
c. Itchy
d. Do not know
11. Low blood sugar can be caused by
a. a cold or infection
b. skipping a meal
c. eating a large meal
d. Do not know
12. Your blood sugar is 62, you
a. lie down and rest
b. drink ½ cup of juice and check your blood sugar again in 15
minutes
c. take a shot of insulin
d. Do not know
13.Low blood sugar should not be treated with:
a. ½ cup of diet soda
b. 1 cup skim milk
c. 1 tablespoon of jelly, syrup, sugar or honey
d. Do not know
14. Fruit juice, soda and sweet tea makes blood sugar:
a. go down
b. go up
c. stay the same
d. Do not know
15. Foods high in carbohydrates such as bread, potatoes, fruit , and milk make blood
sugar:
a. go down
b. go up
c. stay the same
d. Do not know
16. It is recommended the person with diabetes”
a) Eats 3 meals per day and eat less food
b) Drink plenty of natural fruit juice and fruit shakes
c) Avoids all foods that contain carbohydrates
d) Do not know
Answer question 17_ only if you take pills for diabetes.
17. Store diabetes pills:
a. At room temperature in a dry place away from the sunlight
b. On the window sill
c. In the medicine cabinet
d. Do not know
Answer question _18 only if you take insulin using a vial and syringe.
18. Insulin vials that are open and in use should be stored :
a. In the freezer b. At room temperature or in the refrigerator c. On top of the refrigerator d. Do not know
Answer question _19 only if you take insulin using an insulin pen.
19. Insulin vials or insulin pens that are open and in use should be stored :
a. In the freezer b. At room temperature away from the sunlight c. In the refrigerator d. Do not know
Appendix E
8. How often do you have difficulty remembering to take all your medication(s)?