Set short- and long-term goals weight control, exercise, food plan, medications, monitoring Determine SMBG and HbA1c targetsRecord current medications Address lifestyle changes such as a
Trang 1Check all that apply
7
9 At which point are patients referred for diabetes education?
Who provides diabetes education?
Newly Diagnosed type 1 Newly Diagnosed type 2 Type 1 Continuing Education Type 2 Continuing Education Impaired Glucose Tolerance Inpatient
Gestational Diabetes
At Onset of Complications Pre-conception Counseling Other
SECTION FOUR: DIABETES EDUCATION SERVICES
1 Do you have a diabetes education curriculum in place in your facility? Yes No.
1 If yes, please describe or attach summary.
2 What diabetes patient education materials do you use?: ADA Drug Co IDC
1 IHS In House Ministry of Health Other
Figure A.1 (continued)
Trang 2SECTION FIVE: SYSTEM ASSESSMENT
1 Is there a diabetes committee or team? Yes No
Will this committee/team be responsible for the implementation of SDM?
2 How will you evaluate success of the SDM program?
a) What process/outcome inidcators will you use?
b) How often will you measure outcomes? _
3 Are you currently auditing diabetes care?
Trang 3What strengths does your community bring to the diabetes program?
Do you have the following processes to enhance your diabetes care in place?
How will you involve/inform others of the SDM program, its content and implementation process
9
Diabetes Flowsheet on chart Case Reviews/Grand Rounds Diabetes Support Group(s)
Patient Satisfaction Survey Rapid HbA1c available at time
of patient visit Foot Care Clinic
Community Awareness Program
Figure A.1 (continued)
Trang 48 What questions do you have to assist you with the Site Preparation or training for SDM?
Trang 51 Site Name
2 Abstraction Date:(mm/dd/yy)
3 Abstractor Name: _
4 Abstractor Title: _
5 Patient Gender: 1 Female 2 Male
6 Patient Date of Birth:(mm/dd/yy)
7 Pre-Diabetes:
Type of glucose abnormality diagnosed
1 Impaired Glucose Tolerance
2 Impaired Fasting Glucose
12 Visit Date: (mm/dd/yy) _
13 Blood Pressure Date: (mm/dd/yy) _
14 Most Recent Blood Pressure Systolic _ :
15 Most Recent Blood Pressure Diastolic _ :
16 Most Recent HbA 1c Date:(mm/dd/yy)
17 Most Recent HbA 1c Value: _
18 HbA 1c Lab Normal Range:
19 Total Serum Cholesterol Date: (mm/dd/yy) _
20 Total Serum Cholesterol Value:
21 LDL Date: (mm/dd/yy) _
22 LDL Value: _
SDM Patient Chart Audit Form
Figure A.2 SDM patient chart audit form
Trang 623 HDL Date: (mm/dd/yy) _
24 HDL Value:
25 Serum Triglyceride Value: (mm/dd/yy) _
26 Serum Triglyceride Value: _
27 Gross Protein Present :
34 Foot Exam Date: (mm/dd/yy) _
35 Tobacco Status Documented:
1 Not documented
3 Previous tobacco user
2 Yes, documented in chart
36 If smoker, was referral for Tobacco Cessation made?:
0 Not documented
1 Yes
37 Retinal Exam Date: (mm/dd/yy) _
38 Metabolic syndrome: is patient diagnosed with any type of Metabolic Syndrome in addition
to the above diabetes types?
Figure A.2 (continued)
Trang 7Set short- and long-term goals (weight control, exercise, food plan, medications, monitoring) Determine SMBG and HbA1c targets
Record current medications Address lifestyle changes such as activity level and smoking cessation Educate about preventive care (foot, eye, dental)
Plan contraception and pregnancy with women of childbearing age Refer patient to registered dietitian for nutrition recommendations (exercise plan) and instruction Refer patient to diabetes educator for self-management training, BG and urine ketone monitoring and record-keeping instructions
Plan follow-up schedule with patient Refer patient for special services as necessary
Medical History
Symptoms/laboratory tests at diagnosis Previous and current diabetes therapy and control (SMBG and HbA1c) Weight history/especially previous diets
Nutrition and exercise pattern assessment Medications: assess those that may affect BG (b -blockers, steroids, thiazides) Growth and development in children and adolescents
Acute or chronic complications including hypoglycemia/hyperglycemia; neuropathy; sexual dysfunction; retinopathy; nephropathy; foot problems; cardiovascular disease; gastrointestinal symptoms
Prior or current infections including skin, dental, genitourinary History of other conditions, including endocrine and eating disorders Smoking and/or alcohol use
Lifestyle, cultural, psychosocial, abuse, occupational, and economic issues Previous education about diabetes
Determine body mass index (BMI weight/height 2 kg/m 2 )
BP (sitting and standing) Examinations: funduscopic; dental; thyroid; cardiovascular; abdominal; neuro/vascular; feet; insulin injection sites
Growth and development in children (plot on growth charts) Sexual maturation in children
Fasting (preferred) or casual plasma glucose, if there is a question as to the validity of SMBG results
or for meter quality assuarance Hemoglobin A1c (HbA1c) Fasting lipid profile within 6 months of diagnosis Urinalysis (urine culture if sediment)
Urine microalbumin (timed or random albumin/creatinine ratio) if dip stick negative for proteinuria; after 5 years of duration in postpubertal type 1; at diagnosis and then annually in type 2
Serum creatinine in adults; in children if proteinuria present Thyroid functions in all type 1, in type 2 when thyroid disease is suspected Other lab assessments as indicated by history (chem profile, CBC) EKG (adults)
Trang 8Follow-up Visit
Every 1–2 months during adjust phase; every 3–4 months during maintain phase
Interim History
Note current stage (food plan, oral agent, etc., particularly self-adjustment of insulin/oral agent)
Review current medications and illnesses
Review SMBG and HbA1c targets
Discuss episodes of hypoglycemia/hyperglycemia (frequency, cause, severity, symptoms, treatment)
Address presence of intercurrent illness/ketonuria
Assess nutrition; exercise; lifestyle changes; psychosocial issues; complications
Evaluate patient’s adherence issues
Assess sexual activity beginning with puberty
Birth control/pregnancy planning for women of childbearing age
Review record book
Assess frequency of monitoring; SMBG ranges; patterns of hypoglycemia/hyperglycemia; validate
meter accuracy annually; response to exercise; illness
If memory meter used, compare with record book or download into computer for analysis
Determine body mass index (BMI weight/height 2 kg/m 2 )
BP (sitting and standing)
Examinations: funduscopic; dental; thyroid; cardiac; abdominal; neuro/vascular; feet; injection sites
for patients on insulin
Growth and development in children (plot on growth charts)
Sexual maturation in children
Examine previous abnormal findings
Fasting (preferred) or casual plasma glucose, if there is a question as to the validity of SMBG results
or for meter quality assurance
HbA1c
•
•
Management Plan
Refer patient to diabetes educator and/or regisitered dietitian for review of self-management and/or
medical nutrition therapy as indicated
Consult with specialists as indicated (ophthalmologist, nephrologist, neurologist, podiatrist)
Yearly Check-Up
•
•
Complete eye examination with dilation by ophthalmologist: annually after 5 years duration in
post-pubertal type 1; at diagnosis and then annually in type 2
Lipid profile: every 5 years if normal; annually if abnormal
Albuminuria: each visit
Urine microalbumin (time or random albumin/creatinine ratio) if dip stick negative for proteinuria:
after 5 years duration in postpubertal type 1; at diagnosis and then annually in type 2
Thyroid: age 18 if growth problems, enlarged thyroid, or symptoms; age 18 if suspected problem s
EKG: all adults
Foot examination (pulses, nerves and inspection)
Trang 929 28 27 27 26 25 24 23 23 22 22 21 20 20 19 19 18
30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19
31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 19
32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20
33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21
34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21
35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22
36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23
37 36 35 34 33 32 31 30 29 28 27 26 26 25 24 24 23
38 37 36 35 33 32 31 31 30 29 28 27 26 26 25 24 24
39 38 37 35 34 33 32 31 30 30 29 28 27 26 26 25 24
40 39 37 36 35 34 33 32 31 30 29 29 28 27 26 25 25
41 40 38 37 36 35 34 33 32 31 30 29 28 28 27 26 26
42 41 39 38 37 36 35 34 33 32 31 30 29 28 28 27 26
43 42 40 39 38 37 36 34 33 32 32 31 30 29 28 27 27
44 43 41 40 39 37 36 35 34 33 32 31 31 30 29 28 27
45 43 42 41 39 38 37 36 35 34 33 32 31 30 30 29 28
46 44 43 42 40 39 38 37 36 35 34 33 32 31 30 29 29
47 45 44 43 41 40 39 38 36 35 34 33 33 32 31 30 29
48 46 45 43 42 41 40 38 37 36 35 34 33 32 31 31 30
49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30
50 48 47 45 44 42 41 40 39 38 37 36 35 34 33 32 31
51 49 48 46 45 43 42 41 40 38 37 36 35 34 33 32 32
52 50 48 47 45 44 43 42 40 39 38 37 36 35 34 33 32
53 51 49 48 46 45 44 42 41 40 39 38 36 36 35 34 33
54 52 50 49 47 46 44 43 42 41 39 38 37 36 35 34 33
55 53 51 50 48 47 45 44 43 41 40 39 38 37 36 35 34
56 54 52 50 49 47 46 45 43 42 41 40 39 38 37 36 35
57 55 53 51 50 48 47 45 44 43 42 40 39 38 37 36 35
58 56 54 52 51 49 48 46 45 44 42 41 40 39 38 37 36
59 57 55 53 51 50 48 47 46 44 43 42 41 40 39 37 37
60 58 56 54 52 51 49 48 46 45 44 43 41 40 39 38 37
Patients with BMI 25 kg/m 2
have a higher risk of adverse effects on health BMI is defined as body weight (kg) divided by height squared (m2) (BMI kg/m 2
)
1 meter 39.37 inches, 1 kilogram 2.2 pounds
Figure A.5 BMI chart
Trang 10Patient experiencing hypoglycemia
BG 70 mg/dL (3.9 mmol/L) with symptoms
Is patient unconscious or having a seizure?
NO
Is patient confused or combative,
requiring assistance in treatment?
Patient usually able to self-treat
Assess cause and determine level of
hypo-glycemia; identify individual symptoms; discuss
preventive measures and review annually with
patient and significant others
Sypmtoms
Mild: shaking; sweating; tachycardia; dizziness;
hunger; blurred vision; irritability Moderate: confusion; tiredness; yawning; poor coordination; headache; double vision;
Treatment for Severe Hypoglycemia
Subcutaneous or IM glucagon: ½ cc (0.5 mg) for age 5; 1 cc (1.0 mg) for age 5
If glucagon not available, call 911 for emergency assistance; health professionals may administer 50% D/W; 5–25 cc IV
Follow-up
Assess cause of hypoglycemia; make appropriate adjustments in treatment plan; report episode to clinician
Treatment for Moderate Hypoglycemia
Fruit juice or glucose gel (30 g)
If patient refuses or is unable to swallow, administer subcutaneous or IM glucagon
Treatment for Mild to Moderate Hypoglycemia
NO
YES YES
Figure A.6 Hypoglycemia/Treatment DecisionPath
Trang 11Do not delay meals or snacks Eat extra food or adjust insulin for planned exercise
Be aware of warning signs and treat promptly Always carry food to treat hypoglycemia Anticipate schedule changes
Always eat carbohydrates when consuming alcohol
Make sure friends, co-workers, teachers, and room-mates are aware of causes, symptoms and treatment
Have glucagon available for severe hypoglycemia; review instructions periodically; check expiration dates
For Nocturnal Hypoglycemia with Insulin Therapy
Measure BG before evening snack; if
100 mg/dL (5.6 mmol/L) may increase snack Measure BG at 3 AM; if less than target may need to adjust insulin, time of administration,
or stage of therapy Adjust SMBG targets if persistent nocturnal hypoglycemia
Recommendations
Review SMBG targets and adjust higher (100–160 mg/dL [5.6–8.9 mmol/L]) if necessary
Treat earliest symptoms immediately SMBG at least 4 times/day Treat any BG 70 mg/dL (3.9 mmol/L) in adults; 80 mg/dL (4.4 mmol/L) in children/ elderly; 60 mg/dL (3.3 mmol/L) in pregnancy
Patient previously treated for hypoglycemia
Assess potential cause; consider time of day and
activity when hypoglycemia occurred (occurs
most often before meals, during or after exercise,
and at peak times of insulin action)
Begin preventive measures based on cause
Assess Hypoglycemia Unawareness
Experienced most by type 1 patients; may occur
if BG levels are maintained at or below normal
glucose levels, or with increasing duration of
diabetes; SMBG target may need to be adjusted
higher
Rare in type 2 unless on b-blockers or with
autonomic neuropathy
Rare in gestational diabetes
Occurs over time, due in part to loss in ability
Trang 12Type of diabetes (diagnosis data)
Diabetes treatment regimen (medications,
medical nutrition therapy)
Medical history (HTN, lipids, complications)
HbA1c/ketones/SMBG data
SMBG/HbA1c targets
Prescription for BG testing, if needed
Diabetes education indicated
Obtain Referral Data
Readiness to learn/barriers to learning
Lifestyle (work, school, food and exercise
Achieve self-management knowledge/skills/
behavior (SMBG, medications, nutrition,
exercise)
•
•
Plan
Teach initial education topics
Establish 3 behavior change goals with patient
(exercise, nutrition, medications, monitoring)
•
•
Move to Diabetes Education/Follow-Up
Document and communicate education delivered
and behavior change goals in writing to referral
Behavior Change Goals
Goals must be specific, reasonable, and measurable
Establish a time frame and evaluation points Document goals for the patient record and give copy to patient
Encourage rewards for progress
Trang 13Follow-up diabetes education indicated
Obtain Referral Data
Type of diabetes (diagnosis data)
Diabetes treatment regimen (medications,
medical nutrition therapy)
Medical history (HTN, lipids, complications)
HbA1c/ketones/SMBG data
Summarize progress; document and
communicate in writing to referral source
Follow-Up
Education: annual visits
Diabetes Complications and Treatment
CVD: antihypertensives Dyslipidemia: lipid-lowering agents Retinopathy: laser therapy Nephropathy: nutritional interventions Neuropathy: pharmacologic agents Foot Problems: ulcer treatment
Diabetes Education Goals
SMBG/HbA1c in target Achieve self-management knowledge/skills/ behavior (SMBG, medications, nutrition, exercise)
•
•
Consider addressing adherence issues, updating education plan, or setting new behavior change goals; document and communicate education delivered and new goals in writing to referral source
Education: within 3 months
Figure A.9 Diabetes Education/Follow-up DecisionPath
Trang 14Initial Visit
Follow-up Visits
General Information
Diabetes pathophysiology (definition and causes of
hyperglycemia, type 1 vs type 2)
Interaction of food/exercise/medication
Insulin resistance/obesity (type 2)
Target goals (SMBG, HbA1c, weight)
Medication administration/adjustment
SMBG technique/record-keeping
Daily schedule (testing, medication, meals, snacks)
Hypoglycemia signs (dizziness, sweating, confusion,
loss of consciousness)
Hyperglycemia signs (fatigue, acetonic, polyuria,
polydipsia, polyphagia)
Prevention/treatment of hypoglycemia/hyperglycemia
Emergency phone numbers
Patient education materials
Insulin storage Syringe/lancet disposal Hypoglycemia/glucagon use Urine ketone monitoring (type 1) Medical identification
Add for Insulin Pump Users
Pump operation and care Site care (change site every 24–48 hours) Use of algorithm for bolus/basal ratio Record-keeping
New topics based on assessment
Review first-visit topics/re-educate as needed
Check SMBG skills/meter accuracy
Precautions when driving
Illness management
Benefits/responsibilities of self-care
Added for Insulin Users
Pattern control Compensatory/anticipatory insulin adjustments Hypoglycemia unawareness
Review injection technique Travel/schedule changes and effect on insulin
Added for Insulin Pump Users
Review hypoglycemia signs (dizziness, sweating, confusion, loss of consciousness)
Unexplained hyperglycemia (causes, recognition, treatment)
Exercise (insulin adjustments, pump care) Problem-solving skills
Add as Needed
Foot/skin/dental care Recognition of complications (numbness, persistent ulcers, blurry vision, frequent urination)
Healthy lifestyle (weight management, exercise, tobacco and alcohol use, stress management) Travel/schedule changes
Sexuality (impotence, contraception, pregnancy planning)
Psychological adjustments Community diabetes resources
Trang 15Nutrition intervention indicated
Obtain Referral Data
Type of diabetes (diagnosis data)
Diabetes treatment regimen (medications,
medical nutrition therapy)
Medical history (HTN, lipids, complications)
HbA1c/ketones/SMBG data
Weight goals/eating disorders
Psychosocial issues (denial, anxiety,
Achieve desirable body weight (adults)
Normal growth and development (children)
Consistent carbohydrate intake
Establish adequate calories for growth and
development/reasonable body weight
Set meal/snack times
Integrate insulin regimen with medical
nutrition therapy (insulin users)
Set consistent carbohydrate intake
Encourage regular exercise
Establish adequate calories for pregnancy/
lactation/recovery from illness
Move to Nutrition Education/Follow-Up
Document and communicate medical nutrition
therapy and education delivered in writing to
referral source
Follow-Up
Nutrition: within 1 month
Diabetes Complications and Treatment
CVD: antihypertensives Dyslipidemia: lipid-lowering agents Retinopathy: laser therapy Nephropathy: nutritional interventions Neuropathy: pharmacologic agents Foot Problems: ulcer treatment
Medical Nutrition Therapy Guidelines
Total fat 30% total calories; less if obese and high LDL
Saturated fat 10% total calories; 7% with high LDL
Cholesterol 300 mg/day Sodium 2400 mg/day Protein reduced to 0.8 g/kg/day (~10% total calories) if macroalbuminuria
Calories decreased by 10–20% if BMI
Inactive women/obese adults/inactive adults
age 55: weight (lb) 10 kcal
Children/Method 1
First year: 1000 kcal/year Ages 1–10: add 100 kcal/year Age 11–15: boys add 200 kcal/year; girls add
100 kcal/year Age 15: Boys add for activity (23 kcal/lb very active, 18 kcal/lb normal, 16 kcal lb inactive); girls calculate as adult
Children/Method 2
First year: 1000 kcal Ages 1–3: add 40 kcal/inch Age 3: Boys 125 kcal age; girls 100 kcal age; add up to 20% kcal for activity
Figure A.11 Nutrition Education/Initial DecisionPath
Trang 16Follow-up nutrition education indicated
Obtain Referral Data
Type of diabetes (diagnosis data)
Diabetes treatment regimen (medications,
medical nutrition therapy)
Medical history (HTN, lipids, complications)
HbA1c/ketones/SMBG data
Nutrition adequacy/carbohydrate intake
Height/weight/BMI, see BMI Chart
Growth and development (children)
Progress toward weight goal
SMBG records
Progress toward BG/HbA1c goals
Incidence of hypoglycemia/hyperglycemia
Work/school/sports schedules
Exercise (times, duration, types)
Psychosocial issues (denial, anxiety,
Is any additional education needed?
Summarize progress; document and
communicate in writing to referral source
Follow-Up
Nutrition: annual visits
Diabetes Complications and Treatment
CVD: antihypertensives Dyslipidemia: lipid-lowering agents Retinopathy: laser therapy Nephropathy: nutritional interventions Neuropathy: pharmacologic agents Foot Problems: ulcer treatment
Nutrition Education Goals
SMBG/HbA1c in target Achieve desirable body weight (adults) Normal growth and development (children) Consistent carbohydrate intake
Trang 17Food components (carbohydrate, protein, fat)
Effect of food on BG levels (carbohydrates have
greatest effect)
Portion control (average servings, measuring,
estimating)
Realistic weight goals (achievable, maintainable)
Guidelines for fat intake
Guidelines for exercise
Guidelines for treatment of hypoglycemia
Individualize medical nutrition therapy
Synchronization of insulin with food Consistency in timing of meals and snacks Prevention and treatment of hypoglycemia (food or beverage choices and amounts)
Adjusting food intake/insulin for exercise
Review first visit topics and short-term goals
Carbohydrate counting
Nutrition management during short-term illness
Food nutrition labels/healthy food choices
Use of food with higher sugar content
Reset short-term goals
Food related questions/problem-solving
Pattern control for adjusting insulin/food Anticipatory insulin adjustments for changes in basic medical nutrition therapy
Travel/schedule changes; effect on insulin Review SMBG/food and insulin adjustments Food/insulin adjustments for short-term illness
Sources of carbohydrate/protein/fat; effects on BG/other health factors (blood lipids, CHD)
SMBG to problem solve/identify patterns related to food intake
Adjusting meal times or delayed meals Travel/schedule changes
Holidays/special occasions; restaurant/fast food choices Alcohol guidelines/effect on BG
Recipes/menu ideas/cookbooks Dietetic foods/sweeteners Exchanges and equivalencies Behavior modification/problem-solving tips Vitamin/mineral/nutritional supplements
Trang 18Method of meal planning that takes into account only
carbohydrate content of foods
May be used in people with type 1 diabetes, type 2
diabetes, and in pre-gestational and gestational diabetes
Individualize carbohydrate intake for each patient
15 g carbohydrate 1 carbohydrate choice
1 carbohydrate choice is provided in one serving of
food from the starch, fruit, or milk food exchange lists
“Simple” and “complex” carbohydrate absorption rates
are similar
Emphasize total carbohydrate content of foods, rather
than the source
Carbohydrate is the first and primary nutrient that
affects BG levels
Consistency of carbohydrate intake will promote
consistency in BG control
Serves as a guideline for how much carbohydrate to
consume at meals and snacks
Provides flexibility in food choices
Sugar (sucrose) affects BG levels in a similar way
as other carbohydrate foods Sugar and foods high in sugar must be counted into the food plan or substituted for other carbohydrate Foods that are high in sugar are often high in fat and low in nutrients, making them a source of “empty calories”
Sugar and foods high in sugar should not be aged, rather worked into the food plan appropriately
encour-Potential for weight gain if too many foods high
in fat are consumed Nutritional inadequacy of the diet if the food plan
is not well balanced with a variety of foods
May be be used to teach people how to make adjustments
in regular or rapid-acting insulin for adding or
subtracting food from their usual food plan
Normally 1 unit bolus insulin for each 15 g of
carbohydrate (or 1 carbohydrate choice)
Add 1 unit of short-acting insulin to cover 1 extra
carbohydrate choice to be eaten at that meal
Subtract 1 unit of short-acting insulin from usual dose if
1 less carbohydrate choice is to be eaten at that meal
Frequent monitoring and diligent record keeping are
For All Patients
Considerations
Additional Considerations
Figure A.14 Carbohydrate counting
Trang 19Carbohydrate Servings (15 g carbohydrate; 60–90 calories)
Starch Group
Bagel or English muffin
Bread, slice or roll
Hamburger or hot dog bun
Lima beans, cooked
Squash, winter, cooked
Taco shells, 6" across
Tortilla, 6" across
Waffles, 4½" across
Fruit Group
Banana Berries or melon Canned fruit in juice or water Dried fruit
Fresh fruit Fruit juice Grapes or cherries Raisins
Milk Group
Milk, skim or low-fat Yogurt, low-fat, artificially sweetened (6–8 oz) Yogurt, plain, low-fat (6–8 oz)
Meat and Meat Substitutes Servings (7 g protein; 5 g fat; 50–100 calories)
Meats
Beef, lamb, pork, seafood, ham, veal
Poultry with skin removed
Meats should be baked, broiled, roasted, or grilled
Average serving size is 3 oz
Meat Substitutes
Cottage cheese Cheese Egg Peanut butter Tuna or salmon packed in water
¼ cup
1 oz 1
Sour cream Sunflower seeds
½ cup
3 squares
1 half or 1 oz cup 1 2
½ cup cup
3 cups 1
½ cup
½ cup
1 cup 2 1 1
Excerpted from My Food Plan
© 2003 International Diabetes Center
Figure A.15 Food choices
Trang 20Exercise assessment indicated
Obtain Referral Data
Obtain Medical Clearance
Obtain Fitness Clearance
Start Exercise/Plan
Type of diabetes
Diabetes treatment regimen (medications,
medical nutrition therapy)
Medical history (HTN, lipids, complications)
HbA1c/ketones
SMBG/HbA1c targets
Avoid strenuous exercise if BP 180/100
mmHg; if active proliferative retinopathy or
recent laser therapy; if recent foot disease or no
feeling in extremities (neuropathy)
If HbA1c 6 percentage points above upper
limit of normal, measure change in BG during
test exercise
Perform stress EKG if pre-existing CHD; over
age 40; or over age 30 with 10 years duration
Fitness clearance obtained?
Does patient understand the role
of exercise in diabetes? Educate patient about benefits of exercise
Refer to exercise specialist to improve fitness for exercise
If micro- or macro-vascular disease, refer accordingly
If BG control problem, adjust medical nutrition therapy and/or medication to optimize control, then reassess for exercise