Diabetes Awareness - Educational and Preventive Health Event Participant Guide
Introduction
Pharmacists are well-positioned to provide education and preventive health initiatives for the benefit of patients and the public.
This guide describes a Diabetes Awareness service that has been successfully prototyped by pharmacy students and pharmacists at the UBC Pharmacists Clinic. The clinical and procedural materials have been modified to enable any pharmacist to provide a similar service using equipment and materials routinely available in a community pharmacy.
The service includes the following components:
Education about blood sugars, diabetes and what it all means Measurement of weight, waist and, blood pressure and blood sugars Education about diabetes risk factors and a personalized risk assessment (CANRISK score) Interpretation of results with an individualized action plan for preventing or reducing diabetes risk Information on the structure and function of bones in the body Information on factors that affect bone health A bone fracture risk assessment Calculation of calcium and vitamin D intake and needs A personalized plan for optimal bone health
To ensure accountability and compliance with regulatory requirements, all health care services should be provided by licensed pharmacists, pharmacy students supervised by a licensed pharmacist or other regulated health care professionals.
NOTE - This guide does not cover logistic and business aspects of organizing a health event such as: advertising, where to hold the event, identifying participants, booking appointments, charging fees, liability issues, offering service to local businesses, etc.
About the Pharmacists Clinic The Pharmacists Clinic, located at the UBC Faculty of Pharmaceutical Sciences, is a university-affiliated, licensed, pharmacist-led patient care clinic with a mandate to:
Be a model of patient care best-practices Provide learning and skill development opportunities for health
August 16, 2017 Version 1October 2017 professionals and students Be a living lab that contributes service models, systems, processes, research and program evaluation for the health care community.
More information about the Clinic is available here: https://pharmsci.ubc.ca/pharmacists-clinic
Service Approach
Participants are typically scheduled at 15 minute intervals with the total appointment time being about 20 minutes, although this may vary.
Two options for service delivery are:
Participants receive service by moving through a series of stationsmove from station to station and receive part of the service at each station Participants receive all services from one person If enough pharmacists/students are available, 2 or 3 participants can receive service at the same time in parallel service streams.
Participants receive a Diabetes Awareness Passport where information about their health is recorded and they will take home. NOTE – the pharmacy needs to also keep a record of service provided. This can be done using an excel spreadsheet, taking a copy of the completed passport or using an electronic record.
The order of service is at your discretion, however, experience has shown that the following step-wise approach provides a logical flow.
Station* Step in Service Description (if used) Passport A Register participant in pharmacy record and give passport 1 Complete the “About Me” section (name, birth year, gender) BB Explain the role of glucose regulation in the body 1 Circle diabetes/pre-diabetes yes or no 2 Measure height, weight, waist circumference, and calculate BMI Complete the “Body mass” section 2 Complete “My BodyBody Mass” section 3 Complete the “My Body ShShape” section Describe the difference between Type 1 and 2 diabetes 3 Complete the “Body Shape” section 4 Complete the “My Lifestyle Habits” section
August 16, 2017 Version 1October 2017 C 5 Measure andR record blood pressure in the “My Blood Pressure” section 6 Review and RRrecoecord any mentioned pre- diabetes/diabetes symptoms in passportthe “My Symptoms” section 76 Review checklist in passportComplete the “My Diabetes Risk Ffactors” section 87 Circle the Calculate “My Diabetes (CANRISK) risk s Score” (Diabetes risk score) D 8 Go through and record a current list of medicationsComplete “Current Medications” section 9 Interpret results and establish “My Plan” with the patient 9 Pharmacists signs the copy of passport *If service offered in stations, Station A can be manned by an administrative person. Stations B and C can be manned by pharmacy students with pharmacist supervision. Station D is for the licensed pharmacist.
August 16, 2017 Version 1October 2017 Materials
In addition to this Guide, materials provided for use at a Diabetes Health Awareness event are:
Diabetes Awareness Health Passport Images (to print or load onto an iPad and have available at Station B) Clinical Resources (to have available at Stations C and D) Images (to print or load onto an iPad and have available at Station B) PDFs for patient education provided by Diabetes Canadathe Canadian Diabetes Association Recommended list of supplies to have on-hand
Preparatory Readings
1. Clinical people (pharmacists/students) who will be providing service in the Diabetes Awareness event are encouraged to read the following materials so they are familiar with the elements of fracture risk being measured and discussed:
1 – Glucose role, regulation and measurement: https://public.health.oregon.gov/DiseasesConditions/ChronicDisease/Diabetes/resourc ebank/Documents/Type_2.pdf
2 – Canadian diabetes statistics: https://www.diabetes.ca/getmedia/513a0f6c-b1c9-4e56-a77c-6a492bf7350f/diabetes- charter-backgrounder-national-english.pdf.aspx
3 – Screening and diagnosis of prediabetes and diabetes: http://guidelines.diabetes.ca/screeninganddiagnosis/refguide
44 – Hemoglobin A1C (HbA1C) explanation: http://guidelines.diabetes.ca/bloodglucoselowering/a1cvideo
5 – CANRISK: http://www.diabetestest.ca
August 16, 2017 Version 1October 2017 Service Delivery - Step-by-Step
Station A
“Welcome to our Diabetes Awareness event. You will be receiving information about diabetes and your health. This information will be recorded in a passport for you to take with you. To start, we will record your name, year of birth, your gender and today’s date. Please proceed to the next station.” To start, we will record your name and today’s date. Please proceed to the next station.”
August 16, 2017 Version 1October 2017 August 16, 2017 Version 1October 2017 Station B: “At this station, we will start by explaining the role of blood sugar and what diabetes is. We will then take your body measurements and talk about your general lifestyle. Do you have any questions before we start?”
1. Screening questionBASIC DEMOGRAPHIC INFORMATIONBasic demographic information Age and gender Ask if they have known diabetes or pre-diabetes
2. PATIENT EDUCATIONPatient education SUPPLIES: We recommend the usinge of visuals loaded onto an iPad/laptop or /illustrative ddiagrams: o Blood sugar regulation o Type 1 vs. Type 2 diabetes o Diabetes complications
CONTENT:Content: a. Glucose role/regulation/measurement – Key messages Discuss Kkey messages: o -Glucose is a sugar that travels through your blood to fuel your cells o -The brain is completely dependent on glucose for energy, it cannot use any other fuel o -Glucose comes from 2 places: . -The gut: Carbohydrates in our diet are broken down into glucose . -The liver: Made within the body, self-regulated based on blood glucose and insulin levels o -Insulin in is a hormone made by the pancreas that tells your cells either to take glucose from the blood for immediate energy or to store it the glucose for later use o -When blood sugar is low, a hormone called glucagon is released that tells your liver and muscles to release stored glucose into the blood o -Insulin and glucagon work together to help closely regulate blood sugars o The lock and key analogy can be helpful-May find helpful to use lock and key analogy: https://public.health.oregon.gov/DiseasesConditions/ChronicDisease/Diabet es/resourcebank/Documents/Type_2.pdf
August 16, 2017 Version 1October 2017 Result of
b. Result of unregulated blood sugars/Type 1 vs. Type 2 diabetes – Key messages Discuss Kkey messages: o -Diabetes occurs when your body’s use or production of insulin and glucagon are off balance o -Type 1 Diabetes is thought to be due to an autoimmune p rocess where your body attacks and destroys cells in the pancreas that make insulin o . People with Type 1 diabetes are dependent on insulin to survive. o -Type 2 Diabetes results when your pancreas still produces insulin, but your cells have difficulty or “resistance” to using insulin. This makes it more difficult for glucose to enter cells leading to elevated blood sugar levels. o -Pre-diabetes – This is a condition when your body begins to use insulin less efficiently and is a known risk factor for developing Type 2 Diabetes Canadian Diabetes statistics – Key messages c. Canadian diabetes stats Discuss https://www.diabetes.ca/getmedia/513a0f6c-b1c9-4e56-a77c- 6a492bf7350f/diabetes-charter-backgrounder-national-english.pdf.aspx
Kkey messages: o -10% of all people with diabetes have Type 1 diabetes o -2016 data indicates approximately 11 million Canadians have diabetes or pre- diabetes (29% of the population) with a cost of $3.4 billion to the health care system o -Over the past 10 years there has been a 72% increase in Canadians living with diabetes o -Diabetes complications are associated with premature death and lifespan is reduced on average 5-15 years o -Diabetes is responsible for 30% of strokes, 40% of heart attacks, 50% of kidney failure requiring dialysis and 70% of non-traumatic lower limb amputations o -Diabetes is the leading cause of vision loss
Measurements/Lifestyle 4. Measurements/lifestyle assessmentMEASUREMENTS/LIFESTYLE ASSESSMENT
August 16, 2017 Version 1October 2017 Measure height (in cm) and weight (in kg) o Introduction to the stadiometer o Obtaining accurate measurements with the stadiometer o Measure waist circumference. Recommended technique – start at the bellybutton and wrap around the patient’s waist to complete full circle. Try to ensure patient is not sucking in their stomach.
Calculate BMI o Introducetion to the BMI calculation tool - simple formula BMI = kg/m 2 , thus, any calculator used to enter in values can be used o Calculateing and recording BMI – any online calculator can be used – can use Diabetes Canada version: o Canada version: https://www.diabetes.ca/diabetes-and-you/healthy-living- resources/weight-management/body-mass-index-bmi-calculator https://www.diabetes.ca/diabetes-and-you/healthy-living- resources/weight-management/body-mass-index
Lifestyle questions (tobacco use, exercise and diet) o SUPPLIES: Digital Scale/stadiometer, BMI calculator (any app), measuring tape
CONTENT -Take the following measurements and record in passport Weight, height, calculate BMI Waist circumference Lifestyle questions (tobacco use, exercise and diet)
“You are now ready to move on to Station C3 where we will be taking your blood pressure, ask you some additional questions and calculate your overall risk for diabetes.”
August 16, 2017 Version 1October 2017 Station C “At this station, we are going to measure your blood pressure, I will ask you questions related to risk for diabetes and we will calculate your overall risk of developing diabetes. Do you have any questions before we start?”
BLOOD PRESSURE MEASUREMENTBlood pressure assessment Measure with automated BP machine. One measurement in one single arm is sufficient unless reading is different from usual for the patient abnormally high and patient does nno t have a hypertension history of hypertension SUPPLIES: Automated BP Cuff 1 measurement in single arm is sufficient unless reading is abnormally high and patient does not have a history of hypertension
SYMPTOM ASSESSMENTSymptom assessment “I am going to review a list of symptoms that can sometimes be caused by high blood sugars. Many people who have type 2 diabetes may display no symptoms at all.”
-Review following list verbally and note any reported by participant in passport: o Unusual/intense thirst o Frequent urination o Feeling very hungry even though you are eating o Extreme fatigue o Blurry vision o Cuts/bruises slow to heal o Weight change (gain or loss) o Tingling or numbness in the hands or feet
Risk factor checklist/CANRISK scoreRISK FACTOR CHECKLIST/CANRISK score (simultaneously) “I am now going to ask you some additional questions to help us assess your overall diabetes rrisk of developing diabetes.”
SUPPLIES: Canrisk calculator on iPad: http://www.diabetestest.ca/
Checklist in passport:Review checklist in passport: o ≥ 40 years o History of elevated blood sugar test and/or pre-diabetes
August 16, 2017 Version 1October 2017 o History of gestational diabetes and/or gavegave birth to baby ≥ 9lbs/4.1kg o Family history of diabetes (mother, father, siblings, children) o Aboriginal, Hispanic, South Asian, Asian, African descent o Heart disease (History of heart attack, stroke, mini-stroke) o Overweight (BMI >24.9 kg/m2) o Elevated waist circumference o BHigh blood pressure above target o Low HDL and/or high triglycerides (if known) o Hemoglobin A1C >6.0% (if known) o o Diagnosed with: Sleep apnea, depression, bipolar disorder, schizophrenia, HIV infection, polycystic ovary syndrome, acanthosis nigricans o o Medications which may impact blood sugar (e.g. steroids, antipsychotics)
Calculate CANRISK score On-line tool: http://www.healthycanadians.gc.ca/en/canrisk Paper form: http://health.canada.ca/apps/canrisk-standalone/pdf/canrisk- en.pdf Enter results in the passport
“You are ready to move on to Station D where a pharmacist will review the information we’ve gathered, discuss your results and answer your questions.”
August 16, 2017 Version 1October 2017 Station D (Consult) “AtIn this station we will review any medications you’re taking, the results of your blood sugar test (if you have HbA1C data available) and risk for diabetes as well as answer any questions you may have.”
Medication list You may choose to have a pre-printed copy of your patient’s medications at this stage, so , such that you can verify the list, and use it in your consultationas part of your comprehensive consult. Medication list You may choose to have a pre-printed copy of your patient’s medications at this stage, such that you can verify the list, and use it as part of your comprehensive consult.
Interpretation of results: Tailor discussion based on participant “type” (see below): For all participants: CANRISK score, ask for A1C, review screening frequency http://guidelines.diabetes.ca/screeninganddiagnosis/refguide
Supplemental Information for Patients or if you have A1C data available: Hemoglobin A1C (A1C) explanation: http://guidelines.diabetes.ca/bloodglucoselowering/a1cvideo
-A1C is a blood test that checks the amount of sugar (glucose) found on hemoglobin in red blood cells; it does not require fasting -When hemoglobin and glucose bond, a coat of sugar forms on hemoglobin and this coat gets thicker when there’s more sugar in the blood -A1C measures how thick that coat has been over the past 4 months, which is how long a red blood cell lives -Your actual A1C result can be up to 0.5% higher or lower than what test shows -If the test you have here today indicates pre-diabetes/diabetes you need to follow up with your doctor for repeat bloodwork at a lab for diagnosis -(If applicable): A1C may be less accurate in: people of African, Mediterranean or Southeast Asian descent; sickle cell anemia or thalassemia, severe anemia, liver or kidney failure
CANRISK score explanation: -The Canadian Diabetes Risk Questionnaire is a validated tool to assess risk of developing diabetes -Knowing your risk can help you make healthy choices now that will reduce your risk or prevent you from developing diabetes
August 16, 2017 Version 1October 2017 -While you can't change some factors such as age, gender, family history, and ethno-cultural background, other risk factors for diabetes may respond to lifestyle changes. These include weight, physical activity, diet, and smoking.
a. Low risk for diabetes, all measurements normal, no risk factors Positive reinforcement of lifestyle measures and review screening frequency
b. Moderate risk for diabetes or low risk with modifiable risk factors Review risk factor modification and review screening frequency
c. High risk for diabetes/pre-diabetes Review risk factor modification and review screening frequency
d. Known diabetes Review blood sugar control/targets and medications, assess frequency of self- monitoring of blood glucose, assess for complications/hypoglycemia, uncontrolled CV risk factors, lifestyle modifications, refer as required
You may choose to provide patients with any applicable handouts (optional): -CDA fact sheets: prediabetes, T1DM, T2DM -HealthLink BC fact sheets: HbA1C, heart healthy eating, artificial sweeteners
Final steps Document the plan in the passport under “My Plan” If the participant has more questions, wants more information on supplements or has issues for the pharmacist, suggest they follow up at another time If the participant has risk or issues that warrant a medical visit, ask them to follow up with their family doctor or GP o Moderate to high risk for diabetes with medication modifiable risk factors o Documented diabetes that is not optimally controlled “Thank you for participating in this event. We hope you found it useful. Do you have any feedback that we can use to make this event better in the future?” o Document feedback
August 16, 2017 Version 1October 2017 o Flag patients for referral to GP: Types of patients appropriate for referral: -Moderate to high risk for diabetes with medication modifiable risk factors -Known diabetes that is not optimally controlled
Flag patients for referral to PC -Any participant with unanswered questions/medication related concerns -Mod-high risk cardiovascular disease (Sunlife Heart Health Program)
August 16, 2017 Version 1October 2017