The Cystic Fibrosis Foundation Education Committee is happy to introduce the CF-Related Diabetes (CFRD) Teaching Flip Chart. This educational tool was

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 ([email protected]). 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 CommitteeMarch, 2003

Cystic Fibrosis Related Diabetes Cystic Fibrosis Related Diabetes Teaching GuideTeaching Guide

Developed by: Michelle Nosky, MS, CRNP, CDE Johns Hopkins Adult Cystic Fibrosis Program Baltimore, MD

IntroductionIntroduction

How Does the Body Use Food?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 Blood Body Cells Metabolized Travels Insulin carries into

What is Insulin?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?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?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 GlucoseCF and Blood Glucose

Why is Less Insulin Made in Why is Less Insulin Made in People with CF?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, & ExacerbationsInsulin, 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 Why is Glucose Control Important For People With CF?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 DiabetesTests for CF Related Diabetes (CFRD)(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 CFRDTests 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 CFRDTests 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 TestingBlood 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 GlucoseHyperglycemia - High Glucose

• Blood glucose >126

• Goal: Keep glucose as normal as possible

• Symptoms: – thirst– hunger– frequent urination

Hyperglycemia - High GlucoseHyperglycemia - 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 DiabetesTypes 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


• 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


• 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 DiabetesCF 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 DiabetesCF 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 TreatmentCFRD 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 DietNutrition and Diet

CFRD and NutritionCFRD 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


• 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)


• 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


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 TreatmentCFRD Treatment

Medication for CFRDMedication 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 InsulinTypes 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 CFRDInsulin 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


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 CFRDInsulin for CFRDIn

suli

n E

ffec

t

Breakfast Lunch Dinner Overnight

Rapid Acting Insulin (Humalog or NovoLog)

Background insulin made by body or Glargine (Lantus) injection

Breakfast Lunch Dinner Overnight

Insu

lin

Eff

ect

Intermediate acting insulin (NPH) and Rapid Acting (Humalog or NovoLog)

Insulin InjectionInsulin Injection

• Insulin can only be given by injection

• Needle length

• Syringes

• Insulin pens

©Lilly

Insulin InjectionInsulin Injection

Stomach has the most even insulin absorption

©Lilly


Insulin Pump• Basal rate - background insulin

• Boluses - to cover food

• Short acting insulin only

©Medtronic MiniMed

Hypoglycemia - Low GlucoseHypoglycemia - Low Glucose

• Blood glucose <70

• Symptoms:– confusion – numbness (mouth, face)– blurry vision– irritability– shaking– sweating

Hypoglycemia - Low GlucoseHypoglycemia - 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

GlucagonGlucagon

• 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

MiscellaneousMiscellaneous

CFRD and ExerciseCFRD 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 CFRDComplications 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 ….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…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 ManagementDaily 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.applied-medical.co.uk/MiniMed/508.htm

Documents

The Cystic Fibrosis Foundation Education Committee is happy to introduce the CF-Related Diabetes (CFRD) Teaching Flip Chart. This educational tool was