A Healthier You with Diabetes Participant Workbook

Napa-Solano Health Education

Napa-Solano Health Education Workbook A Healthier You with Diabetes

PowerPoint Handout Pages: Your instructor will use these to help guide the discussion each week

Resource Handouts (not pictured): Detailed handouts to support each section will also be provided

Notes Pages: Please use these pages to take down any notes that may come up during or after the class. We’ve also included a checklist section as a space to write down any to-do’s or even use as a healthy grocery list

Meal and Blood Glucose Daily Logs: We encourage you to log the following details each day and we will review your data each week as a group:

Why Do I Need Insulin?

What Affects Your Blood Sugar Levels?

. Physical activity . What and how much you eat . Stress . Sickness or infection . Your diabetes medication

Diagnosis of Diabetes & Prediabetes

Range Hemoglobin A1C Fasting Blood Sugar (HgbA1C) (FBS) Glucose

Normal 4.4%-5.6% 70-99 mg/dl

Prediabetes 5.7%-6.4% 100-125 mg/dl

Diabetes 6.5% and above 126 mg/dl and above

Or one random blood sugar over 200 mg/dl with symptoms

Specific Goals for A1C Goal for A1C A1C < 7 A1C < 8*

Goal for pre-meal 80–130 mg/dL 100–160 mg/dL blood sugars

Goal for 2 hours Less than 180 mg/dL Less than 200 mg/dL after a meal

Goal for bedtime 100–160 mg/dL 100–200 mg/dL blood sugars

*People older than 65 or with additional health conditions.

Taking care of your diabetes means taking care of what's important, such as your family.

How to Test Your Blood Sugar

healthy living Testing Your Blood Sugar

Talk with your doctor or other Testing tells you how health care professional to learn different things affect how to make adjustments to your blood sugar level, such as: your insulin dose. How do I check my blood sugar? what, how much, physical activity 1. Review the booklet that came & when you eat with your meter. 2. Gather together all the supplies you need before you test: meter, test strips, logbook, etc. your medications stress or illness 3. Wash your hands with warm water and soap before testing. 4. Prick the side (not the pad) of Checking your blood sugar gives your fingertip with a lancing you more flexibility in making device or “penlet.” decisions about what to eat and 5. Apply blood to the test strip how much exercise you need. If according to your meter Keeping your blood sugar you have made changes to your directions. at or near normal levels habits, it also tells you what worked 6. Write down the blood sugar or didn’t work and lets you know helps to prevent diabetes numbers in your logbook. when it’s time to call your doctor. complications, such as Your blood sugar goals may be Your doctor or other health care problems with your eyes, different from the ideal A1c goals professional can use this important kidneys, or feet. shown in the table at left. Ask your information to make needed hecking your blood sugar doctor or other health care changes in your treatment. puts you in charge of your professional what blood sugar goals If you use insulin, testing can help diabetes by giving you are best for you. It is very important C you learn when to adjust the important information that you to know what actions to take when amount of insulin you need for can track over time. your blood sugar number is either optimal control of your diabetes. higher or lower than the numbers in the table. You may want to take a diabetes class to learn more. Goal for A1C A1C < 7 A1C < 8 Not everyone needs to test his or Goal for pre-meal 80–130 mg/dL 100–160 mg/dL her blood sugar the same number of blood sugars times each day. Ask your doctor or other health care professional Goal for 2 hours Less than 180 mg/dL Less than 200 mg/dL what amount of testing is best for after a meal you and at what times of the day you will need to test. Here are Goal for bedtime 100–160 mg/dL 100–200 mg/dL blood sugars

HEALTH EDUCATION healthy living Testing Your Blood Sugar

some general guidelines about • To get more blood flowing to how often to test. your fingertips, shake your hand Other resources up and down or run warm water The LifeScan meter booklet and You may be asked to test more over your hand before you prick blood sugar logbook are available often when you are: your finger. from your doctor, other health care • sick or have an infection • Ask your doctor or other professional, local Health Education • changing your diabetes health care professional about Center, or pharmacy. medications or increasing the other lancet options. • Visit dose of your medications with • kp.org/mydoctor/diabetes for your doctor or other health care Don’t share your lancing device with others. day-to-day tips and tricks on professional how to manage your diabetes. • Don’t reuse lancets. • considering becoming pregnant, or • Visit your doctor’s home page you are pregnant More tips for testing your at kp.org/mydoctor to find reliable • not in good control of your health information, view your diabetes own blood sugar medical record, check lab results, • If you have problems with your email your doctor, and much more. LifeScan meter, call the number Safety and comfort • Contact your Kaiser on the back. Some people feel pain or have a hard Permanente Health Education time getting enough blood when • For accurate results, keep test Center or Department for health pricking their fingers. Here are some strips in their airtight bottle information, programs, and other ideas to help make it easier: and do not use strips after the resources. expiration date shown on the • Prick a different spot or different • bottle. If you are hit, hurt, or finger each time to reduce redness threatened by a partner or spouse, and soreness in your fingertips. this can seriously affect your health, including your diabetes. There is help. Call the National Domestic Violence Hotline at 1- 800-799-7233 or connect to ndvh.org.

Name: Medical Record Number: ______

This chart can help you keep track of the results of your important medical tests. Record the date and result of each test and/or service on the chart below.

Sharing this chart with your health care team during each visit can be helpful. Use the information to talk about your results or ask questions about the tests.

Recommended care Date & Date & Date & My Goal and testing Result Result Result

A1C (%): 3-month average Below 7% blood sugar; does not require for most fasting. people*

Blood pressure check: High blood pressure increases your Below risk for heart attack, stroke, 140/90 kidney, and eye damage.

Statin medication: Taking the right dose of statin medication mg of , can help reduce your risk of taken ______times a day. heart attack and stroke.

* If you are older than 65, or have additional health conditions, your goal may be an A1C below 8 percent.

Record when your last procedure or test was done: Diabetes eye exam / retinal screening every 1 to 2 years: Date ______• Patients without retinopathy should get a retinal screening every 1 to 2 years. • Patients with retinopathy should get a retinal screening every year.

Urine microalbumin or kidney function test (every year): Date ______Thyroid function (every year): Date ______Foot exam (every year): Date ______Dental exam (every 6 to 12 months.): Date ______Date ______

My Diabetes Care Plan

Managing Your Diabetes There are many things you can do to feel well and stay healthy. Every once in a while, it may be helpful to take some time to think about what your diabetes management plans and goals are.

To start, you might ask yourself:

How am I doing managing my diabetes? Check the box that applies to you. Great! I’m totally on track. My diabetes is well controlled. Pretty good. Most days I do well managing my diabetes. Not so good. It’s a challenge to manage my diabetes every day. Other: ______Next, think about how you are doing with the following diabetes management skills. Check the boxes that apply to you. I am doing well with: I could improve on: Being physically active Being physically active Eating healthy Eating healthy Checking my blood sugar Checking my blood sugar Reducing my stress Reducing my stress Taking my medications as prescribed Taking my medications as prescribed

Having routine blood tests Having routine blood tests Other: ______Other: ______

Once you have an idea of the diabetes self-management skills you want to improve, it can help to create a personal goal or action steps to focus on that problem. Ask yourself: What is the one skill from the list above that I would like to work on to better manage my diabetes? ______

Finally, list the action steps you will take to reach your goal:

1. ______

2. ______

3. ______

This information is not intended to diagnose health problems or to take the place of medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult your doctor. Some conditions, including diabetes, can be seriously affected by violence or abuse. If you are hit, hurt, or threatened by a partner or spouse, this can seriously affect your health. There is help. Call the National Domestic Violence Hotline at 1-800- 7997233 or connect to ndvh.org. Some photos may include models and not actual patients. © 2007, The Permanente Medical Group, Inc. All rights reserved. Regional Health Education. 00679-004 (Revised 9/16) A small change I want to make this week: ______Goal achieved?

MEALS & BLOOD GLUCOSE COMMENTS DATE BREAKFAST LUNCH DINNER SNACKS BEDTIME Before After Before After Before After Before After Before After 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8

Name: MRN: Date: A small change I want to make this week: ______Goal achieved?

Name: MRN: Date: Date:

My Checklist

My Notes

Additional Notes

Eat Well with Diabetes

When? What? How Much?

Eat a meal or Choose a variety of Eat portions that are healthy snack at foods from all food right for your weight least every 4 to 5 groups. and activity level. hours.

Surprising Sources of Carbohydrates (Carbs)

• Grains like • Fruits • Milk • Sweets breads, rice, • Starchy • Cottage cheese • Desserts pasta, cereal and vegetables with fruit • Fried food tortillas • Yogurt • Soda

Healthy Carbs

• Whole-wheat • Brown rice • Beans bread or pasta • Grains: quinoa, • Lentils • Whole grain cereal couscous, barley, popcorn, & oatmeal • Whole-wheat tortillas

Let’s Practice the Plate Method!

Simple Sugars

. Turn quickly into sugar in the blood stream . Raise your blood sugar quickly . Examples of simple sugars: table sugar, honey, candy, soda, and sugary drinks.

How Many Carbs (Simple Sugars) are in a 20 oz. Soda?

20 ounces of soda = 15 teaspoons of sugar = 60 grams of sugar! 1 teaspoon of sugar = 4 grams of sugar

healthy living Eating Well with Diabetes and Carbohydrate Basics

2 blood sugars may get too high. But if you eat smaller amounts and spread WHAT to eat your meals throughout the day, you You do not need special foods because will better control your blood sugar you have diabetes. In fact, the foods and feel healthier. that are good for you are good for everyone in your family. It is a good What foods contain idea however, to try to choose more carbohydrates? whole grain foods full of fiber. Fiber • Starches (grains, beans, starchy helps to keep your blood sugars in vegetables) control. Each day try to eat a variety of • Fruit and fruit juice healthy foods like: • Milk and yogurt • Grains, whole grain breads and cereals, A single serving from any of these food pasta and rice, beans and peas, starchy groups equals 1 carb serving and contains vegetables (like corn, potatoes or yams) 15 grams of carbohydrates. • Fruit • Sweets, and desserts, chips, crackers, • Vegetables here are three things to keep in and fried foods usually contain a lot of • Low-fat, nonfat milk or soy milk, and mind to help control your blood carbs and fats and often do not T nonfat artificially sweetened yogurt sugars: provide much added nutrition. Plan to • 1. When you eat Fish, poultry (without skin), lean, eat small servings of these foods as a 2. What you eat trimmed meats, tofu, low-fat or special treat every once in a while. nonfat cheeses, peanut butter 3. How much you eat For more help with carbs, check the Choose heart healthy fats more often. Here are some tips to get you started. Diabetes Food Pyramid or the Diabetes These include olive or canola oils and Exchange Lists, or other diabetes nutri- 1 some kinds of nuts such as almonds or tion reference books you can find at our WHEN to eat walnuts. Limit sweets or baked goods Health Education Centers. Eating at regular times will help control and other foods with saturated and Why are carbohydrates your blood sugars. This also helps to pre- trans fats. vent low blood sugars (or hypoglycemia). important to my diabetes? 3 Your body turns most of the carbohy- • Eat at least 3 meals each day HOW MUCH to eat including breakfast. This helps you drates (carbs) you eat into sugar (glucose). Your body changes most of the food feel satisfied. It also reduces your As we said earlier, when you have dia- you eat into blood sugar (or glucose), to chances of overeating later. betes, the cells in your body have prob- supply your body with energy. When • Try to eat at the same times each day. lems storing this sugar to use for energy. you have diabetes, your body has a hard • So watching your carbs is important. Try to eat a meal or a snack every 4 time turning this sugar into energy. to 5 hours during your day. If you • If you eat too many carbs overall, or More of the sugar stays in your blood. If take insulin at dinner or bedtime, you too much at once, your blood sugars you eat too much food, especially too may need a small bedtime snack. can rise too high. many carbohydrates (or carbs), your • To prevent low blood sugars, don’t skip or delay your meals and snacks. healthy living Eating Well with Diabetes and Carbohydrate Basics

• If you eat too few carbs, your blood Where can I start? When you make your plate, aim for: sugar can go too low, and your A good place to start is to limit less body may not get the energy it healthy carbohydrates like candy, needs. You might feel dizzy or faint. sodas or desserts. It helps to: 1/4 grains How many carbohydrates • Choose diet sodas, calorie-free drinks, or water instead of sugar-sweetened should I eat? drinks. The amount of carbohydrates you • Consider using sugar substitutes or need depends on your diabetes goals, artificial sweeteners in place of regular calorie and nutrition needs and activity sugar. level. For most adults with diabetes, it • If you want a sweet, plan ahead to may help to eat between 3 to 4 carb 1 include it with your meal. At the /2 vegetables 1/4 protein servings (45 to 60 grams carbohydrate) same time, try to add a little extra at each meal and 1 carb serving (15 time for exercise to help keep those grams carbohydrate) for snacks. Some high sugars down. Aim for a small men and very active adults may require dessert (1 carb serving) such as 1/2 Additional resources more carbohydrates than this. Work cup of ice cream or 3 graham • To learn more about nutrition and with your dietitian or diabetes educator crackers or 2 small cookies. to find the right amount of carbs you’ll diabetes, visit: need at each meal or snack to feel your kp.org/healthyliving or call your Health Education Center for best. diabetes programs, classes and videos available at your local How do I read a food label? Kaiser Permanente facility. Reading food labels is important. It can • Visit your physician’s Home show you how different foods fit into Page at kp.org/mydoctor. your meal plan. The label tells you what • Visit kp.org/diabetes. the size of one serving is and the amount of grams of “Total Carbohydrate” that serving has. You do not need to look at the sugar grams, since these are already counted in the Total Carbohydrate grams. Carefully read the label on food packages with claims such as “No Sugar Added” or “Reduced Sugar,” even foods that claim to be “Sugar Free.” Many of these foods still contain carbohydrates. Remember: 1 carb serving = 15 grams of carbohydrates.

KAISER PERMANENTE Controlling your diabetes healthy with healthy eating living

Establish Consistent Eating Patterns • Watch the amount of fat you add to foods such • Eat three meals a day, add snacks if meals are as margarine, mayonnaise, salad dressing or more than 4 -5 hours apart gravy • • Eats meals and snacks at about the same time Use low fat cooking methods such as broiling, each day baking, steaming or grilling • Eat about the same amount of carbohydrate at each meal Eat More Fiber • Increase the intake of fiber – aim for 21 to 38 grams per day Eat a Variety of Foods • • Eat foods from each of the food groups to ensure Fiber is found in whole grain breads and cereals, you are getting all the nutrients you need fruits and vegetables, and dried beans and peas • • Eat the recommended number of servings for Increase fiber intake slowly and drink plenty of each of the food groups fluids

Control Your Carbohydrate Intake Be More Active • • Control total carbohydrate intake, not just sugar Increase lifestyle activity - use stairs, park further away • Carbohydrate includes starches and sugars and • both make your sugar go up – at about the same Aim for 30 – 60 minutes per day of some type of amount and at about the same speed regular activity e.g., walking, swimming, biking, dancing • 1 serving of starch, fruit or milk provides 15 • grams of carbohydrate and is referred to as 1 Use a step counter to measure your activity and aim carbohydrate choice for 10,000 – 12,000 steps/day • A general guide is women need 3-4 choices per meal and men need 4-5 choices per meal Maintain a Healthy Body Weight • • It’s OK to occasionally eat sweets, but they must If overweight, aim for a moderate weight loss of 5 – be substituted for other carbohydrates, rather than 10 % of current weight just added to the meal plan • Watch portion sizes, be active and keep a daily food/fluid/activity record Eat Less Fat • Choose foods that are low in saturated fat, trans fat, and cholesterol

Foods with carbohydrates

Starch Fruit Milk and yogurt Other carbohydrates 6 Servings per day 3-5 Servings per day 2-3 Servings per day

1 • /4 large bagel • 1 small apple • 1 cup fat-free or Combination Foods Sweets • 1 slice bread • 1 small banana 1% milk • 1 cup casserole • 1 tbsp table sugar, • 1 cup soy milk 1 pancake syrup or honey • /2 pita or English muffin • 1 cup berries • 1 cup chili with beans • 6-8 oz. plain nonfat • 1 • 1 1 tbsp jelly • /2 hamburger bun /2 cup grapes • 1 cup spaghetti & yogurt meat sauce • 3 graham cracker • 1 6-inch tortilla or chapati • 1 cup melon • 6-8 oz light yogurt squares 1 • 1 cup macaroni and • /2 cup sweetened cereal • 1 small orange cheese • 3 gingersnaps 3 1 • /4 cup unsweetened • /2 grapefruit • 1 slice thin-crust pizza • 5 vanilla wafers cereal • 2 tbsp. raisins 1 • 1 cup noodle soup • 1 granola or cereal bar • /3 cup cooked pasta, • 1 small pear rice or couscous • 1 cup bean soup • 2x2 square Rice Krispie • 1 1 /2 cup 100% fruit juice 1 bar • /2 cup cooked cereal • /3 cup hummus • 1 1 /2 cup canned fruit • 3 cups air popped • /2 cup beans (in juice or light syrup) or light microwave • 1 /2 cup peas or corn 1 popcorn • /2 mango • 1 small potato (3 oz.) • 1 frozen fruit juice bar

1 1 • /2 cup sweet potato • /2 cup frozen yogurt or

• 1 cup winter squash light ice cream 1 • 2 • 4 to 6 crackers / cup sugar-free pudding • 3 graham cracker squares • 3 cups light popcorn

Non carbohydrates and other food groups

Vegetable Protein Fat and oil Reduced calorie and low calorie 4-6 Servings per day 4-6 Servings per day 3-6 Servings per day sweetners Heart Healthy Choices Less Healthy Choices 1 cup raw • 1 oz fish Sugar alcohols (reduced calorie 1 • vegetables or /2 • 1 tsp. oil: olive, canola, 1 tsp. butter • 1 oz skinless chicken sweeteners) are often used in corn, soybean, sunflower, cup cooked • 1 slice bacon sugar-free foods, but they do not or turkey sesame, safflower vegetables. contain sugar or alcohol. They • 1 oz lean beef, pork, • 1 tsp. regular mayonnaise • broccoli • 1 tbsp. tub margarine or provide less carbohydrates and a lamb, or veal trans fat free margarine • 1 tbsp cream cheese or • cucumber smaller rise in blood glucose than • 1 regular salad dressing /2 cup tofu • 2 tbsp. fat free, light, other carbohydrates. Sugar alcohols • carrots • 1 egg or 2 egg reduced fat, or low-fat salad • 1 tbsp half & half are not “free foods” and may cause • cauliflower dressing diarrhea. whites • 3 tbsp. low fat sour 1 • • celery • /4 cup egg substitute 1 tbsp. fat free, low-fat, cream Low-calorie sweeteners are reduced-fat or light • • 1 “free foods.” They do not count as green beans /4 cup low fat cottage mayonnaise carbohydrates. • cheese peppers • 6 almonds • Examples include: • lettuce 1 oz low fat cheese • 1/8 avocado • • Acesulfame K • 1 tbsp. peanut spinach • (Sunett® or Sweet One®) butter 10 peanuts in shell • 1 /2 cup V-8 or • Aspartame (Equal®) tomato juice • Saccharin • greens (Sweet N Low®) (kale, collard, mustard) • Stevia (TruviaTM or PureViaTM) • zucchini • Sucralose (Splenda®) • mushrooms

Free foods “Free foods” are any food or beverage with less than 20 calories and 5 grams or less carbohydrate per serving. Some can be eaten in unlimited amounts, others should be limited to 3 servings per day, spread throughout the day. Kaiser Permanente does not endorse any brand names; any similar products may be used. The food plate

Protein 1 Vegetables Fill /4 of your plate with 1 Fill /2 of your plate with lean meat or protein. non-starchy vegetables.

Carbohydrate 1 Fill /4 of your plate with grains or starchy foods.

Carbohydrate choices per meal: Women: 3- 4 (45- 60 grams) Men: 4- 5 (60- 75 grams)

1 2 3 4 5 6 7 8 9

Select a 9 inch plate and use this guide to help keep your portions in control.

1 1 1 cup /2 cup /3 cup 2 Tbs 1 Tbs 1 tsp 3 oz. 1 oz.

Baseball Light bulb Egg Golf ball Walnut Penny Deck of cards Four dice

REGIONAL HEALTH EDUCATION, HEALTH PROMOTION AND WOMEN’S HEALTH 0036-0048 Revised/reprinted 7/10 Kaiser Foundation Health Plan of the Mid-Atantic States, Inc. 2101 East Jefferson Street, Rockville, MD 20852

healthy living How to Read the Food Label

ou can make healthier food Check the serving size to find out choices by reading the how much you are actually eating. If you Y eat 2 servings, this doubles the calories “Nutrition Facts” label on the and nutrients, including the Percent Daily foods you buy. Values (DV). Serving size: Make your calories count. Look at the Look here first! calories on the label and compare them with Is your serving the same as the the nutrients it contains. Then decide one on the label? whether the food is a good choice for you. • If you eat double the serving size listed, you need to double Know your fats. Look for foods low in saturated fats, trans fats, and cholesterol to the calories and other nutrient help reduce the risk of heart disease (5% DV values. or less). There is no DV for trans fat because • If you have diabetes or are it is best to limit or avoid it entirely. following a specific meal plan, the serving size on the label Keep sodium in check. Processed foods may not match the serving are often high in sodium. Look for low- sodium foods with less than 140 mg per sizes in your meal plan. serving. Track the total amount you eat. Always double check the serving size. See sample label at right. Fiber. Aim for 25 to 38 grams of fiber per day. Calories This is the number of calories you Some vitamins and minerals may be will consume in one serving of this listed with DV in one serving. food. Knowing how many calories your food contains helps you Percent Daily Values (DV) tell you how much you should be eating based on a monitor calorie intake over the 2,000 or 2,500 calorie diet. This section is the same on every food label. It is a refer- course of the day. Calories per gram Fat 9 • Carbohydrates 4 • Protien 4 ence to remind you how much of these The number of calories needed nutrients you should aim for each day. each day depends on your age, sex, height, weight, and level of Sample label Number of calories in a gram of physical activity. Estimates range fat, carbohydrate, and protein. from 1,600 to 2,400 calories for Total fat women and 2,000 to 3,000 This tells you how much fat is Saturated fat and trans fat: calories for men. If you are trying in one serving. A low-fat food Saturated fat and trans fat are to lose weight, you should avoid has 3 grams (g) or less of total included in the amount of total or limit high-calorie foods. fat per serving. fat. They are also listed separately because they are the 2 types of fat we should try to limit or avoid in our diets. healthy living How to Read the Food Label

Sodium Protein We know this as “salt.” Too much Protein is found in both plant sodium may raise your blood and animal foods, including pressure. Less than 2,300 mg of beans, nuts, fish, poultry, meat, sodium each day is recommended. eggs, and dairy products. A low-sodium food has 140 mg or less in one serving. Percent Daily Value This is the percentage of the Total carbohydrate recommended daily amount of A quick check of the Carbohydrates are found in this nutrient in one serving of “Nutrition Facts” label can bread, pasta, rice, cereal, fruit, the food. The Percent Daily help you spot foods that are potatoes, starchy vegetables, and Values (DV) are what would be good for your health. sweets. If you have diabetes, pay recommended in a 2,000 calorie attention to total carbohydrate per day diet. Diets high in these fats may grams per serving, not just the increase the risk of heart disease. The important part of these sugar grams. Trans fats increase your risk more percentages is that they help you than saturated fat. Dietary fiber: It is important to find foods that are high in good eat plenty of fiber, and most nutrients and low in nutrients you A food is low in saturated fat if it Americans don’t get enough. want to avoid. If the value is 20% has less than 1 gram per serving. Fiber helps reduce the risk of or more, it’s considered high. If Aim for fewer than 20 grams of diabetes and heart disease and it’s 5% or less, it’s low. saturated fat per day, and as little can help with weight control. trans fat as possible. Aim for 25 to 38 grams of fiber Other resources Visit Cholesterol per day. It is found in whole Cholesterol is found only in grains, vegetables, and fruits. kp.org/mydoctor to: foods from animal sources, such Sugars: Sugar is listed separately, • View most lab results and as meats, poultry, fish, eggs, and and is also included in the total check your preventive health dairy products. Try to keep your grams of carbohydrate. It includes reminders. cholesterol intake to less than both naturally occurring and • Email your doctor 300 milligrams (mg) per day. A added sugar. It’s best to avoid • low-cholesterol food has less added sugar when possible. Use online tools to help keep than 20 mg per serving. you and your family healthy.

You may want to add snacks to your Snack ideas  1 cup soup. meal plan. Healthy snacks may:  1 granola bar (check the  Add nutritional value. 0 carbohydrate choice label). (less than 5 grams of carbohydrate)  Prevent hunger and overeating.  1/2 cup sugar-free pudding.  Sugar-free gelatin.  Help prevent low blood sugars.  1 Dixie cup ice cream.  Celery and cucumber sticks. Healthy snacks still need to be limited to prevent weight gain.  Broccoli and cauliflower florets 1 carbohydrate choice Keep in mind that hidden fats in with light ranch dip. and protein* snacks will increase your calorie  Green salad with light ranch (15 grams of carbohydrate) intake. When you want to limit dressing.  1/2 meat sandwich. calories, choose a low-calorie, low-carbohydrate snack.  1 large carrot or 8 baby carrots.  1 oz. cheese or meat with 4–  6 cherry tomatoes. 6 Triscuits or whole-grain When you want to prevent low crackers. blood sugar, adding a carbohydrate  Salsa. choice and sometimes a protein  1/2 cup refried beans with food is helpful.  Nuts (these add protein and fat): salsa. When possible, choose a fresh fruit • 1/4 cup peanuts or  1 Tbl. peanut butter on 3 or vegetable, whole-grain starches, sunflower seeds. graham-cracker squares. and lean or low-fat protein foods. • 20 almonds.  1/4 cup cottage cheese • 10 walnut halves. with 1/2 cup cut-up fruit.  1 oz. string cheese with 3 1 carbohydrate choice cups popcorn. (15 grams of carbohydrate)  1 cup chili.  Fruit:  1 hard-cooked egg with • 1 small orange, apple, or pear. 1 slice of toast. • 1/2 banana.  1 cup milk. • 15 grapes.  6–8 oz. light yogurt. • 2 Tbl. raisins or cran-raisins. * These snacks provide the correct balance of protein and carbohydrate • 1 frozen juice bar (check for a snack after treating low blood the label). sugar.  Starch/bread: • 1 slice whole-wheat bread. • 5 Triscuit crackers, reduced fat. • 15 multigrain Wheat Thins. • 3 Rye Krisp. • 3 graham cracker squares. • 1 package plain instant hot cereal.

from Cultiating Health(R) Managing Diabetes Kit (c)Kaiser Foundation Health Plan of the Northwest healthy living How Fats Compare

for heart disease. Trans fats also • Plant sterols and stanols (phytosterols) increase your risk for heart disease help lower LDL cholesterol. Tub, because they lower HDL, or good liquid, or squeeze margarine products, cholesterol. A high level of HDL some cheese, and fruit juices are cholesterol in your blood helps to available with these beneficial protect your heart. compounds. • Omega-3 supplements and other Which fats help to protect products may not be appropriate my heart? or necessary for you depending upon your current health and • Monounsaturated and polyun- risk for heart disease. saturated fats help to raise your HDL level. Some people may be at high risk for at is a necessary part of a healthy bleeding with large doses of fish oil • Omega-3s, an important eating plan. It supplies your body polyunsaturated fat, are found in supplements. Discuss whether or not Fwith energy and essential fatty acids fish oils and some plant sources they are recommended for you with (EFA). Fat from your diet also helps and protect your heart in several your health care team before you start you to absorb vitamins such as A, D, ways. Omega-3 fatty acids help to use them. E and K. Unfortunately, not all fats to reduce inflammation inside are created equal. The key to healthier your blood vessels, which slows How do I find foods that eating? Choose foods with fats that plaque build-up in the arteries, a will help protect my heart? help protect your heart and reduce process also called your heart disease risk. Read food labels carefully. Compare atherosclerosis. Selecting up to the nutrition information of similar Research shows that a very low-fat 12 ounces of fish a week helps food products when you shop. Foods diet is not necessary to protect the your heart while limiting your with less than 3 grams of fat in a heart. Instead, the goal is to eat a exposure to toxins like mercury serving are low-fat. They may be heart moderate amount of healthy fat found in some types of fish. healthy options. To avoid foods that combined with more fiber-rich whole • For pregnant and nursing contain trans fats, choose foods grains each day. A moderate amount women or women who plan to without any ‘partially hydrogenated’ of fat means no more than 25-35 get pregnant, we recommend oils or shortening listed on the label. percent of your total daily calories that they eat no more than 6 For example, many types of tub or come from fat. ounces of fish a week. squeeze margarine are better choices Eating foods with lots of saturated • Alpha-linolenic acid (ALA) than stick margarines, which have fats, trans fats and cholesterol can comes mainly from plant trans fat. Review the chart on the next raise the LDL (or bad cholesterol) sources and turns into omega-3 page to see lists of foods with fats that and triglyceride levels in your blood. fatty acids in the body. ALA can protect your heart and those foods Having high levels of LDL and may also help to lower the risk with fats to avoid. triglycerides puts you at greater risk of heart disease.

HEALTH EDUCATION healthy living How Fats Compare

Healthy Fats Harmful Fats Choose in moderation Avoid High in High in polysaturated High in High in High in saturated fats monounsaturated fats fats omega-3 fat* trans fats

• olive oil • safflower oil • salmon • pastries, pies, Processed foods • canola oil • corn oil • sardines and bakery items including: • • • peanut oil and • walnuts mackerel (pacific palm oil, palm • chips or jack) kernel oil, and peanut butter • • cookies, pastries soybeans • herring coconut oil • olives • • • fried foods sunflower oil and tuna (canned light) • heavily marbled • avocados seeds • tuna (albacore) • fast food meats • almonds • sesame oil and • pollack • crackers • trout • meats high in • pecans seeds • stick margarine • soybean oil fat, such as • oils made from seeds • • macadamia nuts • walnuts sausage, cold cuts, regular shortening • cashews • brazil nuts (about • walnut oil hot dogs, bacon • chicken fat and • hazelnuts equal amounts of • ground flaxseeds skin • pistachio nuts mono- and polyun- • flaxseed oil • canola oil • Butter and • peanuts saturated fats) dairy products with *The fish listed tend to have lower amounts of mercury.

Are you ready to make some changes? Indicate on the scale below how ready you are to make a change. 10 means that you are very ready, and 0 means that you are not ready at all. Here are some ideas to help you get started:  Check the food label when I buy products to find those with little or no trans fat.  Add more fish to my diet.  Add more fiber to my diet by eating more fruits/vegetables and whole grain foods each day.  Consult my provider about which fish oil, ALA supplements, or other products could help me lower my risk for heart disease. 0 1 2 3 4 5 6 7 8 9 10 not ready very ready If you circled Consider these questions 3 or less What would need to happen for me to become more ready to make changes? 4 to 6 What are some of the advantages of keeping things the same and not making any changes? What are some of the advantages of eating a healthier diet? 7 to 10 What is the next step to create a realistic plan to eat healthier? Who can support me as I make changes?

Other resources • Ask your doctor for a referral to a registered dietitian.

• Visit kp.org/mercuryinfish • Check FDA’s Seafood Information and Resources website: cfsan.fda.gov/seafood1.html • Call 1-888-SAFEFOOD, CFSAN’s toll-free information line. • For other health education resources please visit kp.org/healthyliving This information is not intended to diagnose health problems or to take the place of medical advice or care you receive from your physician or other medical professional. If you have persistent health problems, or if you have further questions, please consult your doctor. © 2004, The Permanente Medical Group, Inc. All rights reserved. Regional Health Education. 915800069 (Revised 9-08) RL 7.5 healthy living Alcohol and Diabetes

If you have diabetes Table Wine and want to have an Malt Liquor 80-Proof Beer or occasional drink, it’s Spirits Cooler (gin, vodka, important to learn about whiskey, etc.) alcohol and diabetes. Before you decide to drink alcohol, there are some questions and issues to discuss with your doctor when you have diabetes or other health problems. 5% alcohol 7% alcohol 12% alcohol 40% alcohol Why might it be a good 12 oz. 8.5 oz. 5 oz. 1.5 oz. idea for me to limit or to stop drinking alcohol? about how to stay safe and avoid problems. Drinking alcohol may change One Alcoholic Drink. . . • Your diabetes is not well controlled the way these medications work. = One 12-ounce bottle of and your blood sugars are either too beer or wine cooler; or high or too low. If you decide to drink = One 5-ounce glass of wine; • You have high blood triglycerides alcohol: or (a type of fat in the blood). = 1.5 ounces of liquor (like • Limit how much you drink. Keep • vodka, scotch, or gin) in a You have other health problems, it to 1 drink a day for women; shot or a mixed drink (with such as nerve damage, eye disease, 2 drinks or fewer a day for men. or problems with your stomach or tonic or juice). • pancreas. Always eat a meal or a snack when you plan to drink alcohol. • You are pregnant or breastfeeding. If you take insulin or diabetes pills,  To prevent low blood sugar (hyp- • You have had problems with drinking or if you drink on an empty glycemia), don’t drink if you just alcohol in the past. stomach, alcohol can make your exercised or plan to exercise. blood sugar drop. This is called • Choose your drinks wisely. Will alcohol interfere hypoglycemia (blood sugar less than What you drink makes a difference. with any of my 70mg/dL). Eating a meal or a small Sweet wines or mixed drinks made medications? snack when you drink alcohol can with regular soda or juices not only When you have diabetes, your health reduce your chances of having a low have extra calories, they also have care team will probably prescribe several blood sugar reaction. carbohydrates that can raise your blood sugars. types of medications to help control  Check your blood sugar often your blood pressure, cholesterol, and to learn your body’s response to  Use calorie-free and sugar- blood sugars. You may also take several alcohol. free-beverages like club soda, over-the-counter medications or • Be careful with exercise. Alcohol tonic, or water as mixers supplements. Be sure to talk with your and exercise both lower blood sugars. doctor, pharmacist, or diabetes educator

HEALTH EDUCATION healthy living Alcohol and Diabetes

• Be safe. Alcohol can affect your Carbohydrate judgment and behavior. It can also Drink Amount Calories cause blood sugars to get dangerously grams low. Friends and family members could easily mistake symptoms of regularregular beerbeer 12 oz. 150 13 severe low blood sugar for indications llightight beerbeer 12 o 100 5 that you have had too much to drink. regular beer

 To prevent this problem—or nonalcoholic beer nonalcoholic beer 12 oz. 60 12 any embarrassment—make dry wine sure your family and friends dry wine 4 oz. 80–90 0–5 recognize your low blood sugar nonalcoholicnonalcoholic wine 4 oz. 25–35 6–7 symptoms, how to treat it, and

how to help you in case you champagnechampagne or or 4 oz. 100 4 can’t help yourself. If you take sparsparklingkling wine wine

insulin or diabetes medications, always wear medical identi- sweet dessert wine 2 oz. 100 7 fication. Never drink and drive. wine cooler 12 oz. 215 30

Calorie and Carbohydrate gin, rum, vodka, 1.5 oz. 100–115 0 brandy, Values in Alcoholic scotch whiskey Beverages Alcoholic beverages often have liqueurs, cordials 1.5 oz. 160 17 different amounts of carbohydrates and can contain a lot of calories. Drinking martini 2.5 oz. 156 0 too much can make you gain weight margarita 8 oz. 420 80 an d make your blood sugars harder to control. A registered dietitian or piña colada 5 oz. 290 44 diabetes educator can show you how to use the chart on this page if you want bloody mary 5 oz. 115 5

Other resources • Connect to our website at kp.org/mydoctor/diabetes to learn more. • Contact your Kaiser Permanente Health Education Center or Department for health information, programs, and other resources. • If you are hit, hurt, or threatened by a partner or spouse, this can seriously affect your health. There is help. Call the National Domestic Violence Hotline at 1-800-799-7233 or connect to ndvh.org.

‘

Name: MRN: Date: A small change I want to make this week: ______Goal achieved?

Name: MRN: Date: Date:

My Checklist

My Notes

Additional Notes

Being Active with Diabetes: How to Get Started

s you may already know, being Depending upon your health and adjust the amount of insulin you use Aactive improves your health in fitness level, other aerobic and/or discuss how you might want many ways. options include: to change your meal plan to account • for the amount and type of activity Physical activity can help: jogging • biking you plan to do. This is especially • control your blood sugar • swimming important to help you prevent low • lower your blood pressure • low-impact or chair aerobics blood sugars during long periods • help you feel better and reduce stress (over 3 hours) of exercise. • dancing • lower your risk of heart disease • You may need to eat an extra snack • using an elliptical or step machine when your insulin or diabetes pills It helps to start with an activity Physical activity and diabetes are working the strongest or you are that you find to be: doing moderate to high levels of • simple Remember that some people living exercise for over 30 minutes. with diabetes need to be more cautious • something you want to do • Be aware that moderate to high before starting a new physical activity • easy to start slowly—and easy activity levels can lower your blood program. to increase a little each week sugar right away or up to 24 hours For most people with diabetes, Here are some important things after you have stopped being active. walking is an ideal activity. Using a to keep in mind: • If you do not take insulin, plan to step counter or a pedometer can • Always carry fast-acting sugar be active within an hour after eating help you keep track of your progress sources such as a tube of glucose gel your meals or snacks to prevent over time. It’s also important to try or 3-4 glucose tablets, identification, low blood sugars. If you have type to be more active throughout your and your Medic-Alert bracelet, if 1 diabetes and your blood sugar is day. For example, you may want to you have one. less than 120 before exercising, eat try taking stairs instead of an elevator • Stop exercising right away if you are 15-30 grams of carbohydrate before as part of your daily routine—or try dizzy, have shortness of breath, feel you start exercising. parking a little further away from sick to your stomach, or are in pain. • If you have type 1 diabetes and your where you usually park. • Drink extra fluids before, during, blood sugar is over 250, use a urine and after exercise. test strip to check your urine for Be sure to check with your doctor or • Wear shoes and socks that fit well. ketones before you start exercising. diabetes care team to see if the Do not exercise if ketones are activity you choose is right for you. Low blood sugar precautions moderate or high. Ketones are a When you begin any new physical If you have type 1 diabetes or if you certain type of chemical that forms activity program, try to check your have type 2 diabetes and take insulin in your blood when your body starts blood sugars more often so that you and/or diabetes pills, be sure to: to break down fat to use for energy know your body’s response to the • Check your blood sugar before and instead of glucose. This happens new activity. after physical activity. If you use when you have high blood sugar insulin to manage your diabetes, levels and not enough insulin in your work with your diabetes care team body. When the level of ketones in to learn how you might need to your blood gets

Being Active with Diabetes: How to Get Started

too high, your kidneys help to Other resources remove it from your blood so it • Connect with someone else to keep appears in your urine. you motivated and to make it more • Visit kp.org/mydoctor to try an Online Health Coach video coaching enjoyable. Invite a friend to be your program. Start today to improve your What can help you stick exercise partner. eating habits and get more active. • with your activity plan? When you reach your goal, give • Visit our Web site at kp.org/diabetes. It may be hard to add activity into yourself a reward. Treat yourself to Here you’ll find more information your life, especially if you haven’t movie tickets, a book, a magazine, about diabetes and other topics. been active lately. Once you have a song or album. • Try our personalized online programs chosen a simple, easy activity which • If you get bored doing one activity at kp.org/healthyliving to get appeals to you and which can be over and over, try a different activity. support for your weight loss and increased gradually, try to: Or do different types of activities on activity goals. • Contact your facility’s Health • Make your activity as regular as different days of the week. or sleeping and eating. Mark it on your • When it is raining or too cold out- Education Center Department for side, try doing aerobics or stretching books, videos, classes, and additional calendar like any other appointment. resources. You may also want to write it down exercises inside where it’s warm on an activity goal sheet. (See the instead of not doing any activity. You “Weekly Plan” below.) can try walking in an indoor mall, using an exercise video or fitness

To help you get started—and keep you going—you may want to use the “Weekly Plan” to set activity goals that you can easily reach.

Weekly Plan

This week, I will ______(what?)

______(how much?)

______(when?)

______(how many?)

How confident am I that I can follow my plan? 1 2 3 5 6 7 8 9 10

Not at all confident ______Very confident

How I plan to reward myself:

Name: MRN: Date: A small change I want to make this week: ______Goal achieved?

Name: MRN: Date: Date:

My Checklist

My Notes

Additional Notes

Diabetes Medications How They Help You

Diabetes medications help keep you well There are many types of diabetes medications that work in different ways to help control blood sugars. It is important to learn about these medications and how they work so you are prepared to discuss your options with your diabetes care team. Blood sugar goals To lower the risk of complications, the goal for most people with diabetes is to get to an A1C test result of less than 7 percent or an estimated average glucose (eAG) result of below 150 mg/dL. If you are over age 65, or have certain conditions such as heart disease, your doctor or health care professional may recommend an A1C goal of less than 8 percent. Both the A1C and eAG measure your average blood sugar over the past 2 to 3 months.

Common medications explained

Medication type: biguanides Main site of action: liver Medication type: sulfonylureas and glinides How it controls blood sugar: Keeps the liver from releasing Main site of action: pancreas too much glucose. How it controls blood sugar: Helps pancreas to make more Names: metformin (Glucophage) insulin. metformin ER (extended release) Names: sulfonylureas: Medication type: insulin glipizide (Glucotrol) How it controls blood sugar: Helps get blood sugar out of the glyburide (Micronase, DiaBeta) bloodstream and into cells for glinide glimepiride (Amaryl) energy. Most patients will choose to add insulin to achieve or maintain their blood sugar goals. Medication type: thiazolidinediones Names: Main site of action: muscle cells • Long-acting: NPH insulin How it controls blood sugar: • Rapid-acting: regular insulin, Makes muscle cells more insulin lispro (Humalog) sensitive to insulin. Names: pioglitazone (Actos) Information to remember about diabetes medicines • Take diabetes medicines to help lower high blood sugar levels. They do not take the place of healthy eating and exercise. • Know when and how to take the medicines. Do not skip a dose. • Wear a medical alert bracelet for emergencies. • Bring an updated list of your medications to visits with your doctor or other health care professional. To learn more about your diabetes medications, find information at our website at kp.org/medications or consult with a pharmacist.

Questions to ask your diabetes Tips to help you remember to take care team about your medications your medications • When do I need to take the medicine— Everyone struggles with remembering to do things before a meal, with a meal, or after a meal? regularly. There are a number of ways that can help • How often should I take the medicine? you remember. Check off things you might try: • Should I take the medicine at the same Make a simple chart and post it in an obvious time every day? place where you will see it every day, like on the mirror in the bathroom. • What should I do if I forget to take Set an alarm clock or watch as a reminder. my medicine? Establish a daily routine for taking your • What kind of side effects could I have medications, such as at bedtime, and what symptoms should I look for? mealtime, or the beginning of a daily TV • How should I manage my medications show, such as the evening news. when I’m sick and can’t keep my food or Use a pillbox that has sections drinks down as usual? representing the days of the week. Record taking your medications on a wallet card or calendar. Can you think of others?

It’s easy to get prescription refills at Kaiser Permanente pharmacies. • Reorder your medications at least 1 to 2 weeks before you run out. • Use EasyFill, our automated phone prescription refill system. Find the number to call in the upper right- hand corner of your prescription label, or call the pharmacy near you. • Refill prescriptions at our website at kp.org/mydoctor/diabetes. You can also arrange to have many medications sent to you by mail.

Some conditions, including diabetes, can be seriously affected by violence or abuse. If you are hit, hurt, or threatened by a partner or spouse, there is help. Call the National Domestic Violence Hotline at 1-800-799-7233 or connect to ndvh.org.

This information is not intended to diagnose health problems or to take the place of medical advice or care you receive from your physician or other medical professional. If you have persistent health problems, or if you have further questions, please consult your doctor. If you have questions or need additional information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.

MEALS & BLOOD GLUCOSE COMMENTS DATE BREAKFAST LUNCH DINNER SNACKS BEDTIME Before After Before After Before After Before After Before After

1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8 1 2 3 BREAKFAST LUNCH DINNER SNACKS BEDTIME 4 5 6 7 Before After Before After Before After Before After Before After 8

Name: MRN: Date: A small change I want to make this week: ______Goal achieved?

MEALS & BLOOD GLUCOSE COMMENTS DATE BREAKFAST LUNCH DINNER SNACKS BEDTIME Before After Before After Before After Before After Before After

Name: MRN: Date: Date:

My Checklist

My Notes

Additional Notes

Better Blood Sugar Control

. Pattern management is making changes in your diabetes self- care plan based on your blood sugar readings over time.

Finding Patterns

. Keeping a log or record for several days can help identify patterns to your lifestyle. . What are some things we can write down to help us find patterns? – Doses and times of your medication – Times and results of blood sugar tests – Foods you ate and when you ate them – When you exercise – Stressful events – Missing a meal

Let’s Review Ed’s Numbers

Date Before Breakfast Before Dinner Before Bed Oct 14 143 130 No test Oct 15 118 No test ( ate pizza) No test Oct 16 253 No Test 161 Oct 17 137 102 No test Oct 18 151 No test (ate dessert: 263 pie, ice cream)

Oct 19 251 No test 160 Oct 20 153 141 No test

Ed aims for a blood sugar target between 80 and 140 before meals.

Pattern Management Helps You Make Decisions

. The times you should eat your meals and snacks . The amount of daily exercise . Portion sizes for each meal or dessert . The types of food you eat . When to call your doctor

A small change I want to make this week: ______Goal achieved?

Name: MRN: Date: A small change I want to make this week: ______Goal achieved?

Name: MRN: Date: Date:

My Checklist

My Notes

Additional Notes

Take Advantage of Your Medical Appointments

. Before Appointment – Come prepared with specific questions – Bring a family member for additional support . During Appointment – Repeat your doctor’s key points – Make notes and ask for clarification . After Appointment – Stop by the health education center for helpful resources and/or activate your kp.org account – Send non-urgent emails to health care team with other questions that you might have

How to Stay Healthy with Diabetes

Find tips and tricks on how to eat well, exercise, and take your diabetes medications to keep you feeling healthy and well:

 Day to Day  3 to 6 Months  Every 12 Months

Text DIABETES to 45356 or visit kp.org/mydoctor/diabetes

Taking Care of Your Diabetes: Managing Sick Days and Infections

olds, flu, and infections can Write down the following information Self-care tips to manage Chappen at any time. If you have and have it ready when you call the your diabetes on sick days diabetes, being sick can cause your Appointment and Advice line, your When you are not feeling well, it is blood sugar to get too high. When doctor, or your health care professional: easy to forget your daily self-care you are not feeling well, you may not 1. How long you have been sick. tasks. However, monitoring your be able to eat or exercise as usual. blood sugar and other symptoms is These changes in your usual routine 2. Your temperature. very important on sick days. Here can affect your blood sugar control. 3. Your blood sugar levels and urine are some simple guidelines: ketone test results. • Infections in any part of your body, Test your blood sugar 2 to 4 times including teeth or gums, can cause 4. Whether you are throwing up or a day. If your blood sugar is over have diarrhea. 300 mg/dL, test every 3 to 4 high blood sugar. Good dental hygie- hours. ne and regular checkups with your 5. The last time you urinated. • dentist are important ways to prevent Track how much fluid you drink. this type of infection from starting. 6. How much food and liquids you To prevent dehydration, try to have had. sip at least 8 ounces (1 cup) of fluids every hour while awake. How much medication 7. How much and what type of • Check your temperature twice a day should I take? diabetes medicine you have taken and the time you took it; other and record it. Keep taking your usual dose of medications you have taken. • If you take insulin, and if your diabetes medications or insulin, unless blood sugar is above 300 mg/dL, your doctor or health care professional 8. Any other symptoms, including test your urine for ketones.* advises you to make changes while you your mood. Record whether you have small, are sick. If you are on insulin, your moderate, or large amounts. Your doctor or health care professional may What foods and drinks can blood glucose meter will remind suggest you use extra insulin. I have when I am sick? you to test for ketones when a blood sugar level is over 240 There is an exception to this recom- When you aren’t feeling good, you mg/dL. Get emergency care mendation if you take metformin may not want to eat three meals a day. right away if your blood sugar (Glucophage). Stop taking this If you are unable to keep any food in is 500 mg/dL or above.* your stomach (due to throwing up) medicine temporarily when you have *Ketones are a type of chemical that nausea, vomiting, or diarrhea. Call the and your blood sugar is under 240 forms in your blood when your body starts Appointment and Advice line for the mg/dL, it is OK to have foods that to break down fat to use for energy facility near you to get instructions on are not “diet,” such as regular gelatin instead of glucose. This happens when you have high blood sugar levels and not when to begin taking metformin again or a sports drink (such as Gatorade). enough insulin in your body. When the when you are feeling better. The chart on the back of this page lists level of ketones in your blood gets too easy-to-tolerate foods. All of these high, your kidneys help to remove it from If you choose to use over-the-counter your blood so it appears in your urine. medications, look for sugar-free items have about 15 grams of products and others that do not affect carbohydrate. Try to eat or drink one of these foods or beverages every If you feel symptoms of low blood your blood sugars. If you have sugar, check your blood sugar. If it is questions about which products to hour when your blood sugar is below 240 mg/dL. If your blood sugar is 50 to 70 mg/dL, eat a fast-acting use, contact a pharmacist at your local source of sugar with about 15 grams of Kaiser Permanente pharmacy, or over 240 mg/dL, try to eat or drink them every 2 hours. carbohydrate, like 3 or 4 glucose tabs or through the Pharmacy Center at a glucose gel tube. If your blood kp.org.

What to eat What to drink

1/2 cup gelatin (such as Jell-O)* 6 saltines 1/2 cup juice 1 1 /2 cup applesauce 1/2 cup cooked cereal /2 cup regular* or caffeine-free soda 6 oz. yogurt, plain or 6 vanilla wafers 1 cup sports drink (such as Gatorade)* artificially sweetened 1/2 cup custard water 1/2 banana 1 popsicle herbal tea 1 slice toast or bread 1/4 cup sherbet broth 3 graham crackers 1/2 cup ice cream clear soups 1 /2 cup pudding* 1/2 cup mashed potato

*Be sure to use calorie-free and/or sugar-free products if blood sugars are over 240 mg/dL. sugar is less than 50, eat or drink 2 Be sure to talk to your family, friends, subsalicylate (such as Kaopectate) carbohydrate sources (30 grams total). or caregivers about what to do when for children Re-check your blood sugar to make you have a diabetes emergency. Teach • Nasal decongestants: sure it is rising closer to normal. Then them: phenylephrine (such as Neo- eat something more to keep your • How to recognize and help you synephrine) or oxy-metazoline blood sugar level in the normal range. manage your low blood sugar. Your solution (such as Afrin) doctor or health care professional • Rectal suppositories for Call the advice nurse or may prescribe a glucagon kit for you severe nausea (available by your doctor or health care if you use insulin and are at high risk prescription) professional when: for extremely low blood sugar. • Ketone testing sticks (such as • Your blood sugar is less than • The appropriate steps to take if Ketostix, unopened, foil-wrapped) 70 mg/dL 2 times in 1 day. you lose consciousness or remain • An extra bottle of quick-acting • Your blood sugar is over 300 mg/dL unconscious. insulin as prescribed by your doctor for 2 days or your blood sugars are or health care professional much higher than they usually are. Prepare a Sick Day Kit • Phone number for the • Your temperature is over 100°F You may need certain medications to Appointment and Advice line for 2 days. help manage sick days. Talk with your (advice nurse) or health care team at diabetes care team or pharmacist • You have diarrhea for more the facility nearest to you beforehand to make sure you have the than 6 hours. • Phone numbers of friends medications that are appropriate for • You have thrown up more than once. or relatives who are able to help you. Routinely check the expiration you • You have small to moderate ketones date of products and replace them if in your urine. they have expired. • You experience deep or troubled Here are some suggested items to Other resources breathing; dry, cracked lips, mouth, have on hand before you get sick: • Visit kp.org/mydoctor. or tongue; or have a fruity odor to • List of sick day foods and • Try our personalized online pro- your breath. beverages (in case someone should grams at kp.org/healthyliving • You have been sick for 2 days, and shop for you) to get support for your weight loss and activity goals. you are not getting better. • Sugar-free cough medicine and throat • • You are not sure what you need lozenges and any other over-the-coun- Contact your facility’s Health to do to take care of yourself. ter medications Education Center or Department for books, videos, classes, and Get emergency care right away if • Thermometer additional resources. you have either of the following: • Aspirin or acetaminophen (such as • If you are hit, hurt, or • Blood sugar over 500 mg/dL Tylenol) threatened by a partner or • Moderate to large amounts • For diarrhea: loperamide (such as spouse, this can seriously affect of ketones in your urine. Imodium, for adults) or bismuth your health. There is help. Call the National Domestic Violence Hotline at 1-800-799-7233 or connect to ndvh.org.

This information is not intended to diagnose health problems or to take the place of medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only. Some photos may healthy living Relaxation Skills

or 20 minutes once or twice a day. • If you feel lightheaded, dizzy, or It may take two to three weeks to anxious, you may be breathing too fully develop these skills, but once deeply or too quickly. If this you have trained your mind and happens, stop practicing for a body to relax, you’ll be able to get moment and breathe normally the same relaxed feelings quickly. until the symptoms pass. Try inhaling and exhaling through your Deep breathing nose to prevent hyperventilation. When it is done with purpose, deep • As you progress, practice deep breathing can help calm you down. breathing in a variety of settings It can help you let go of stress and (e.g., sitting at your desk, waiting worries and focus quietly on the in line, or watching television). present moment. • Be patient and gentle with yourself. How to do deep breathing Progressive muscle relaxation Place both hands on the lower part The body responds to tense of your stomach and inhale so that thoughts or situations with muscle your belly pushes gently against tension, which can cause pain or your hands. Your stomach muscles discomfort. Progressive muscle should be relaxed. Then, gently relaxation will help you reduce There are many ways you can relax. push with your hands as you exhale stress and become more relaxed. It Deep breathing, muscle relaxation, slowly. If it helps, imagine a balloon involves tensing and releasing each and the relaxation response are in your stomach that inflates when muscle group to create a deeper simple and good for your health. you inhale and deflates when you sense of relaxation. It can also exhale. Practice this several times. reduce feelings of anxiety. You can When you breathe out, try to imag- use a recording to help you go elaxation has many benefits. ine tension and stress leaving your through all the muscle groups, or It can help you feel calmer, body; say to yourself, “I am feeling R you can follow the instructions think more clearly, and relieve relaxed and calm.” stress, headaches, and tight below. Progressive muscle relax- muscles. Whether you want to Here are some important tips for ation often helps with stress-related take a break from a stressful practicing this skill: health problems and can help you day or manage your stress for • Wear loose, comfortable clothing fall asleep. the long-term, a regular and find a quiet, relaxing place to relaxation practice can really practice. Note: If you have fibromyalgia help you get back to a calmer • Start practicing for just one to or myofascial pain syndrome, state. two minutes. Slowly increase your check with your health care practice time up to five minutes. professional before practicing There are many ways to relax. Practice several times a day. progressive muscle relaxation. Three common methods are: deep • In the beginning, it may help to breathing, progressive muscle practice deep breathing while relaxation, and the relaxation lying down on your bed or on response. When learning these the floor. Lie on your back, bend skills, it is important to find a quiet your knees, and place your feet place where you won’t be comfortably apart. disturbed. Try to practice for 10

HEALTH EDUCATION healthy living Relaxation Skills

How to do progressive muscle relaxation • Stomach: Suck your • Sit quietly for several minutes until stomach into a tight knot. you are ready to open your eyes. Pick a place where you can stretch out comfortably, such as on a pad • Hips and buttocks: Press • Notice the difference in your or carpeted floor. Tense each mus- your buttock cheeks together breathing and your pulse rate. cle group for 4 to10 seconds (hard, tightly. Don’t worry about becoming deep- but not to the point of cramping). • Thighs: Clench hard. ly relaxed. The key to this exercise Then release the muscle and give • Lower legs: Point your toes is to be passive, to let yourself 10 to 20 seconds to relax. toward your face, as if trying to distracting thoughts slip away like Try to relax each muscle group a bring them up to touch your head. waves on the beach. Practice for 10 little more deeply each time you do • to 20 minutes once or twice a day, this exercise. Lower legs: Point your toes away and curl them downward at but wait for at least two hours after How to tense muscle groups the same time. a meal. When you have set up a routine, the relaxation response • Hands: Make a fist. should come with little effort. • Wrists and forearms: Extend Relaxation response your arms and bend hands back at The relaxation response slows the the wrist. heart rate and breathing, lowers Additional resources • Biceps and upper arms: Make a blood pressure, and helps relieve fist, bend arms at elbows, and flex muscle tension. It can help you • Connect to our Web site at kp.org. biceps. slow down, reduce stressful • Visit your facility’s Health feelings, and refocus your thoughts. Education Department for books, • Shoulders: Shrug them. videos, classes, and additional • Forehead: Wrinkle it into a deep Technique (adapted from Herbert resources. frown. Benson, MD): • Want a customized online stress • • Around the eyes and bridge of Sit quietly in a comfortable management plan? Check out with your eyes closed. our HealthMedia® RelaxTM the nose: Close eyes as tightly as position • Become aware of your Healthy Lifestyles program at possible. (Remove contact lenses kp.org/healthylifestyles. before beginning this exercise.) breath-ing. Breathe slowly and • Try out our Health Coach Stress • Cheeks and jaws: Grin from steadily; breathing from your belly and not from your chest. Less Program at kp.org/mindbody. ear to ear. • If you are hit, hurt or threatened • • Around the mouth: Press lips Each time you exhale, say by a partner or spouse, this can together tightly. the word “one” (or any other seriously affect your health, word or phrase) silently or aloud. including your ability to manage • Back of the neck: Press head back Or, you may choose to fix your stress. There is help. Call the against the pad or supporting surface. gaze on a stationary object. Any National Domestic Violence • Front of the neck: Touch mental stimulus will help shift Hotline at 1-800-799-7233 or your chin to your chest. your mind away from distracting connect to ndvh.org. • Chest: Take a deep breath, thoughts. hold it, then exhale. • Continue this for 10 to 20 • Back: Arch your back up and minutes. As distracting thoughts away from support surface. enter your mind, don’t dwell on them. Just allow them to drift away.

This information is not intended to diagnose or to take the place of medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products A small change I want to make this week: ______Goal achieved?

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A Healthier You with Diabetes: Class Evaluation Form

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