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Diabetes: Self-Management

Table of Contents Diabetes and You: Protecting Your Health...................................................................................................1 Blood Glucose: Home Testing......................................................................................................................5 Hyperglycemia: Controlling High Blood Sugar...........................................................................................7 Hypoglycemia: Controlling Low Blood Sugar...........................................................................................11 Diabetes: Long-term Complications...........................................................................................................13 Physical Activity for the Person With Cancer and Diabetes......................................................................16 Body Mass Index (BMI) and Waist Circumference...................................................................................19 Sick-day Rules for Persons With Diabetes.................................................................................................21 Foot Care for Persons With Diabetes.........................................................................................................22 Steroid-induced Diabetes...........................................................................................................................24 Insulin: Injecting from One Vial................................................................................................................26 Insulin: Injecting from Two Vials...............................................................................................................30 Diabetes Education Resources: Video List................................................................................................34 Additional Resources.................................................................................................................................36 Notes..........................................................................................................................................................37

Diabetes and You Protecting Your Health

Glucose is the body’s major source of energy. It comes from the foods we eat. Glucose is found in the blood. When it cannot be absorbed from the blood into the cells, the condition is called diabetes. Diabetes causes two problems: cells starve for sugar (energy), and the blood level of sugar in the blood goes too high.

Blood Glucose Levels A normal fasting blood sugar level is 70-99 mg/dL. Two hours after eating, blood sugar should be less than 140 mg/dL. Diabetes is diagnosed when:  the fasting blood glucose level is 126 mg/dL or higher,  blood glucose is 200 mg/dL or higher at any time of the day with symptoms of diabetes or  blood glucose is 200 mg/dL or higher two hours after eating. (Example: Lunch started at 12:30 p.m., and a test is at 2:30 p.m.) You may have pre-diabetes if your fasting glucose is 100-125 mg/dL, or if blood sugar is 140199 mg/dL two hours after eating. The body makes a hormone called insulin, which helps cells absorb glucose. Persons with diabetes have a problem with insulin working effectively or not making enough of it in the pancreas. Some people do not make any insulin. Some people require 2 to 3 times more insulin to get the job done. Other times, the body doesn’t use insulin properly when it is available.

Type 1 Diabetes Type 1 diabetes is when the body cannot produce insulin. Previously called juvenile diabetes, this condition usually appears in children or young adults. However, people of all ages can be diagnosed with Type 1 diabetes. Without insulin, a person’s blood sugar gets too high. As a result, the body tries to flush sugar out by frequent urination. This leads to thirst and may result in drinking lots of water. Also, because the body’s cells cannot absorb sugar, they begin to starve. This makes a person feel hungry.

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In summary, the three main signs of diabetes are:   

increased urination increased thirst and increased hunger.

Because persons with Type 1 diabetes cannot make insulin, they must take insulin for life, usually by injections. They need insulin for the rest of their lives to prevent sudden illness, known as ketoacidosis or burning of their fat for energy.

Type 2 Diabetes With type 2 diabetes, the body still produces some insulin. It may not be enough, or the body may be resistant to it. Therefore, symptoms of Type 2 diabetes are often less severe. Although a person may have some increased thirst, urination and hunger, Type 2 diabetes may go undetected. This can delay diagnosis. Some people do not have any symptoms even with very high sugar levels. Type 2 diabetes is much more common than Type 1. About 90 percent of patients with diabetes are Type 2. It usually occurs in people over the age of 30. However, it is becoming more common in children and adolescents who are overweight. Diet and medicines usually can control Type 2 diabetes. Patients may or may not need insulin therapy. Risk Factors for Type 2 Diabetes  Family history – Children of parents with Type 2 diabetes have an increased risk of developing the disease.  Race – Hispanics, African-Americans, Pacific Islanders, American Indians and Asians have an increased risk.  Being overweight – Increased body weight increases risk.  Body fat distribution – Abdominal fat increases your risk.  Sedentary lifestyle – Many people who develop Type 2 diabetes do not exercise regularly. Note that 45 minutes to one hour per day of physical activity decreases risk.

Other Types of Diabetes Secondary Diabetes Secondary diabetes occurs because of other diseases or treatments. It may or may not resolve. Patients have symptoms similar to Type 1 and Type 2 diabetes. Some causes include:  Disorders of the pancreas: such as pancreatic cancer or pancreatitis  Cancer treatments: such as steroids and some chemotherapy medicines  Cushing’s syndrome and others

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Diabetes Management Diabetes can be managed through the following steps:  Take medication.  For Type 1, receive insulin either by injection, pump or inhalation.  For Type 2, take oral medications, or for some, take insulin.  Check glucose levels.  Test blood glucose at home at least every day, usually before meals and bedtime.  Get regular lab work.  Have regular labs for Hemoglobin A1c (HbA1c), usually every three months until stable.  Eat healthy.  Follow a meal plan recommended by your dietitian.  Exercise.  Physical activity helps your body absorb glucose.  Manage weight.  Maintain a healthy weight and work to lose weight if overweight or obese. Learn about Body Mass Index (BMI). Ask your nurse for other patient education handouts:  Hyperglycemia: Controlling High Blood Sugar  Hypoglycemia: Controlling Low Blood Sugar  Self-Monitoring of Blood Glucose  Diabetes Education Resource: Video List  Waist Circumference and Body Mass Index (BMI)  Physical Activity for the Person With Cancer and Diabetes

Routine Health Maintenance When diabetes is not managed, blood sugar levels become too high. High blood sugar damages small blood vessels called capillaries. Good capillaries are critical for healthy eyes, kidneys, nerves, skin and feet. Taking your medicine, following your meal plan, regular exercise and keeping a good weight will protect your health. You can also maintain your health by doing the following:  Eye Care  Get an eye exam every year. Tell your eye doctor that you are diabetic. Diabetic retinopathy, or damaged blood vessels in the eye, is the leading cause of blindness in the U.S.  Immunizations  Yearly flu vaccine  Pneumococcal vaccine (one-time dose and then revaccinate once older than 65 years, after five years have passed since the first vaccine). There are now two types of pneumococcal vaccines, and it’s recommended that you have both. Talk with your doctor.  Tetanus vaccine booster every 10 years Diabetes and You: Protecting Your Health © 2010, 2014 The University of Texas MD Anderson Cancer Center, Revised 02/20/15 Patient Education Office

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 Varicella vaccination. It is recommended even if you have had chicken pox in childhood. Talk with your doctor. Testing  Get a yearly test for microalbunuria, serum creatinine and glomerular filtration rate (GFR). Diabetes is the leading cause of end-stage renal disease Foot Care  Have your feet examined at least once a year.  Look at all areas of your feet every day. Use a mirror, or have someone help you if necessary.  Wash feet daily with mild soap. Dry thoroughly, especially between the toes.  Moisturize feet daily with an alcohol-free lotion. Do not apply between the toes.  Inspect your shoes daily. Feeling the inside for cracks or irregularities that may irritate.  Wear well-fitting shoes. Wear soft cotton or wool socks.  Do not go barefoot, even when indoors.  See a podiatrist regularly for foot care. This includes nail cutting, blisters, calluses, wounds or ingrown toenails. Take care of your teeth and gums:  Brush teeth twice daily with a soft toothbrush and Fluoride toothpaste  Floss teeth every daily  Visit the dentist regularly for teeth cleaning and full exam

Resources For more information on diabetes, please contact Diabetes Education. Monday-Friday, 8 a.m.-5 p.m., 713-792-8042 Diabetes Self-Care Class - This class is available for patients and/or caregivers. Learn how to control your blood sugar. Get information about insulin, carb counting and nutrition, exercise and how to manage your medicines. Walk-ins are welcome. Main Building Classroom Floor 4, near Elevator A, through The Learning Center, Room R4.1121 Thursdays, 10-11 a.m. The American Diabetes Association http://www.diabetes.org Centers for Disease Control and Prevention http://www.cdc.gov/diabetes/consumer/index.htm National Diabetes Information Clearinghouse http://diabetes.niddk.nih.gov/ Academy of Nutrition and Dietetics http://www.eatright.org/

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Blood Glucose: Home Testing Checking your blood glucose level daily is critical to managing your diabetes. Blood sugar that is too low or too high can harm the body. Testing and recording allows you to see the relation between your medicines, foods and activity to the blood sugar levels. This allows good control of your blood sugar. Good control of blood sugar reduces complications. Poor blood control of blood sugar can lead to blindness and kidney failure among other things.

Goals for Blood Glucose Control Talk with your doctor to set desired blood glucose goals. Time Before breakfast (fasting) Before lunch, supper or snack Two hours after meals Bedtime Hemoglobin A1c level (measures average glucose level for past three months)

Acceptable Level

Testing Your Blood Sugar Here are the supplies you need:  Finger stick device  Pricks the finger to get a drop of blood  Uses lancets  Test strips  Flat strips with a reagent on the end  Place test strip in glucometer first  Place a drop of your blood on the end  Blood glucose meter  A hand-held unit  Purchased at a pharmacy (often provided for free)

Image from the Centers for Disease Control

You will be shown how to use the equipment. Glucometers from different companies are each handled a bit differently. Always wash hands before testing. Warm water helps bring up a drop of blood. Pricking the side Blood Glucose: Home Testing © 2008, 2015 The University of Texas MD Anderson Cancer Center, Revised 02/20/15 Patient Education Office

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of the finger instead of the finger pad is more comfortable. Use different sites so one finger does not get too sore.

When to Check Your Blood Glucose Follow your doctor’s instructions on when to check your blood sugar. The usual times to check are before breakfast, before lunch, before dinner and at bedtime. People taking insulin injections or using an insulin pump will test several times a day. Those taking pills usually check less often.

Extra Blood Sugar Checks The following instances may be times when you need to conduct extra blood sugar tests in addition to the regular checks:  If you feel bad. Your sugar may be too high or low. The only way to tell is to measure it.  Change in dosage or types of diabetes medications  At times of increased stress, illness or surgery  If you begin new medications, such as steroids

Record Keeping Keeping an accurate record helps you and your doctor manage your diabetes. Most glucometers record and store blood sugar results. Take your meter with you to your doctor’s visit. Some doctors may ask you to write down your results. Discuss this with your doctor. Ask your doctor what levels require immediate action or reporting. For very low levels, (less than 70), doctors often want you to eat something. Ask your nurse for the handout “Hypoglycemia.” For very high levels (over 250), see your doctors. Ask for the handout “Hyperglycemia.”

Storage and Disposal of Supplies Be sure to store your testing supplies in a cool, dry place. Keep the test strip container cap on tightly. Check the expiration date on your test strips. Throw away any outdated test strips. Lancets are for single use only. Discard used lancets in a safety container. A thick plastic container with a screw top works well. A used laundry detergent bottle is an example. When the container is nearly full, seal it with tape and place it in the trash.

Resources

The American Diabetes Association http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucosecontrol/?loc=hottopics

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Hyperglycemia

Controlling High Blood Sugar Hyperglycemia is a condition in which the amount of sugar in the blood is too high. The body needs some sugar in the bloodstream. It feeds the cells and supports brain activity. However, if sugar amounts are either too high or too low, there can be problems.

Causes There are many reasons blood sugar levels may elevate:  Medications such as steroids (prednisone, dexamethasone, cortisol)  Medical conditions such as diabetes, surgery or infection  Enteral and parenteral nutrition treatments (tube feedings and IV nutrition)  Foods, especially those high in carbohydrates (fried foods, sugar-sweetened beverages, desserts, etc.).

Non-medication Control Take these actions to help keep your blood sugar within your goal for control.  Make healthy choices.  Include non-starchy fruits, vegetables, whole grains and other minimally processed foods in your diet.  Choose foods that are low in sugar, sodium and saturated fat.  Read the nutrition label on all packaged foods to check grams of carbohydrates.  Eat healthy carbohydrates.  Choose complex instead of simple carbohydrates.  Complex carbohydrates are foods such as beans, whole grains, vegetables. Their sugars are strung together in longer chains. Because these chains must be broken, blood sugar rises slower.  Limit simple carbohydrates (sugar-containing foods) such as desserts, candy, cookies and sodas. These foods have fewer chains and break down quickly. Therefore, blood sugar rises rapidly and can be more difficult to control.  Control serving sizes.  Keep a journal of the foods you eat with portion sizes (½ cup, 1 cup or ounces). Share the journal with the dietitian or nurse.  Weigh or measure foods to become familiar with serving sizes, or estimate ½ cup portions for most foods. Hyperglycemia Controlling High Blood Sugar © 2006, 2014 The University of Texas MD Anderson Cancer Center, Revised 09/23/14 Patient Education Office

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 Visually estimate the portion sizes of foods, 1 cup is approximately the size of 1tennis ball, and 3 ounces is the size of a standard deck of playing cards. Eat less fat for health and lower calories. It may not directly lower blood sugar, but it is important for staying healthy.  Choose lean meats and protein.  Eat protein alternative such as beans, tofu and eggs. Egg yolks are rich in fat, so don’t use them too often. Egg substitutes such as Egg Beaters are without fat and usually consist of only egg whites. Less fat equal fewer calories.  Bake, broil, roast, grill or boil meats instead of frying them.  Be aware that meats dipped in batter or breading will cause a rise blood sugar as well as those cooked in a sweet sauce or marinade (BBQ, honey, molasses, fruit juice, etc.)  Choose non-fat or reduced-fat dairy products.  Eat a meatless meal once or twice a week. Avoid skipping meals.  Long periods between meals can lead to an unsafe drop in blood sugar.  Eat meals and snacks often to avoid large fluctuations in blood sugar.  Low blood sugar can cause some people to consume unhealthy, sugary food that can lead to more instances of hyperglycemia.  Skipping meals can also lead to overeating.  Follow a meal plan or pattern that works for you. Maintain a healthy weight.  Talk to your dietitian or doctor to determine a healthy weight for you.  Discuss weight management with your dietitian and doctor.  Avoid excess calories. Ask for assistance to learn about your calorie needs.  Participate in daily physical activities.  Consult with your doctor before you begin an exercise program  Find activities that you enjoy and do them regularly.  Activities such as walking and gardening are simple ways to burn calories.  Exercise for 30 to 60 minutes five or more days per week.

Medication Control Your doctor may give you a pill or injection to keep the blood sugar under control. You may need this only for a short time. For instance, after the treatment causing hyperglycemia is complete, your blood sugar may return to normal. Or you may have a medical condition like diabetes that requires continued medical evaluation. Talk to your doctor. If you have diabetes or pre-diabetes, learn to check blood sugar levels at home. This will help you understand your symptoms and levels. Treatment depends on the amount of sugar in the blood.

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Basic Diet for Elevated Blood Sugars This diet eliminates foods that contain high amounts of simple carbohydrates. Simple carbohydrates are sugars found in desserts, beverages, candy, sweets and syrups. These foods typically have low nutritional value and can cause elevated blood sugars. Choose foods with little or no added sugar. Be aware that other names for sugar include corn syrup, and words that end in “ose” such as dextrose, fructose, sucrose, and maltose. This diet is appropriate for people who have elevated blood sugar levels and/or need a basic introduction to diabetes management. Food Group Beverages

Breads and Cereals Fruits

Vegetables Meat and Meat Substitutes Milk Desserts and Snacks

Choose

Limit or Avoid

Sugar-free drinks, sugar-free carbonated beverages, sugar-free instant breakfast, plain tea, plain coffee or seltzer. These beverages may be sweetened with sugar substitutes. Whole grain breads and cereals.

Avoid more than ½ cup of fruit juice daily; sugar-sweetened carbonated beverages including “all natural” flavored drinks; drinks sweetened with sugar; milkshakes and sports drinks.

Fruits canned in water or their own juice; fruits sweetened with sugar substitute, fresh or frozen fruits without added sugar. Fresh or frozen non-starchy vegetables. Beef, pork, chicken, fish, eggs, beans, shellfish, cheese, tofu. Low fat milk or buttermilk, plain or light yogurts, soymilk. Sugar-free syrup, jelly, jam, gelatins, puddings, ice cream and angel food cake, plain graham crackers and vanilla wafers; sugar substitutes such as NutraSweet®, Splenda®, Sugar Twin®, Equal®, Aspartame, Acesulfame-K.

Avoid sweetened cereals, granola and granola-type bars, breakfast bars, pastries and donuts. Limit portions of rice and pasta. Avoid fruits canned in syrup or sweetened with sugar. Limit 100% fruit juice to ½ cup daily. Limit portions of starchy vegetables such as potatoes, corn, beans and peas. Avoid meats that are high in sodium or fat such as cold cuts, hot dogs, bacon, sausage and any meat that has been fried. Avoid flavored or sweetened milk and yogurt. Avoid sugar (brown, white, powdered, natural, raw), honey, syrup, candies, molasses, frosting, marmalade, jam, jelly, cookies, marshmallows, ice cream, cakes, pies, gelatin, pudding, custard, condensed milk, sherbet, sorbet, fruit bars.

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Resources American Diabetes Association 800-342-2383 www.diabetes.org American Dietetic Association – Consumer Nutrition Information and Referrals 800-366-1655 www.eatright.org Current Oncology http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3851349/ National Institutes of Health http://www.nlm.nih.gov/medlineplus/ency/imagepages/19529.htm

Cookbooks American Diabetes Association http://www.diabetes.org/mfa-recipes/recipes/

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Hypoglycemia

Controlling Low Blood Sugar Hypoglycemia is a condition in which the amount of sugar in the blood is too low. The body needs some sugar in the bloodstream. It feeds the cells and supports brain activity. However, if sugar amounts are either too high or too low, there are problems. Normal blood glucose level is between 70-95 mg/dL.

Causes There are many reasons blood sugar may fall:     

Medications, such as too much insulin Skipping or delaying meals Drinking alcohol Interactions with other medicines Vigorous or prolonged exercise

Hypoglycemia is a serious condition. It can cause you to pass out because the brain is not getting enough sugar. Symptoms usually go away with immediate treatment. Call your doctor if your symptoms do not go away after you’ve eaten food.

Signs of Hypoglycemia It is important for you and anyone close to you to recognize the warning signs of hypoglycemia. You can then act quickly.      

Shaking Blurred vision Fast heartbeat Tingling around the mouth or lips Cold, pale, moist skin Being unresponsive

     

Irritability, or sudden changes in personality Drowsiness Fatigue Confusion Hunger Sweating

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Actions to Treat Low Blood Sugar 1. Test your blood sugar as soon as possible. Always carry your meter with you when you go out. Also bring glucose tablets or a quick sugar source when you leave your house. 2. For blood sugar less than 70mg/dL: Drink 4 ounces of juice or take 3 to 4 glucose tablets or equal sources of 15-20 grams of simple carbohydrates (fast absorbing sugar). See list below. 3. Wait 15 minutes and test blood sugar again. 4. If your blood sugar is still less than 70mg/dL: repeat step 2. Call your doctor or clinic to report problem. 5. Wait 15 minutes, then test blood sugar again. If it is still less than 70mg/dL, continue repeating until glucose is above 70. Then call your doctor. 6. Glucose tablets can be purchased at most pharmacies without a prescription. Each tablet contains 4-5 grams of carbohydrate.

Foods Containing 15 Grams of Carbohydrates      

½ cup regular carbonated soda ½ cup fruit juice (orange or apple juice) 4 teaspoons sugar 1 tablespoon honey 2 tablespoons raisins ® 8 Lifesavers candies or 10 jelly beans

These are general guidelines. Ask your doctor or nurse if they apply to you.

Preventing Low Blood Sugar     

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Eat meals and snacks as instructed. Do not skip or delay meals. Check blood glucose as instructed. Take insulin as directed. Always carry some form of concentrated carbohydrate. Monitor blood sugar during and after exercise, particularly activities that are more vigorous and more prolonged than usual for you.

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Diabetes: Long-term Complications Diabetes can affect many parts of the body. The areas especially at risk include eyes, kidneys, nerves and blood vessels. Keeping your diabetes under control (HgA1C of less than 7) reduces the chance of damage. Controlling blood sugar may reduce long-term problems. Making healthy choices in all areas (diet, exercise, blood pressure control, etc.) also helps manage long-term problems.

Eye Problems You may not immediately notice changes in your vision. People with diabetes should have an annual eye exam by an ophthalmologist. Treating early changes may prevent vision loss or slow existing problems. 

Diabetic Retinopathy  Damage to the blood vessels of the retina (back of the eye) is called diabetic retinopathy. The retina is responsible for vision. Retina damage can lead to blindness. Cataracts  A cataract is a clouding of the lens in the eye. A healthy lens is clear and allows light to pass through to the retina. A cloudy lens interferes with clear vision. Any person can get glaucoma. People with diabetes are more at risk. They may get cataracts earlier than others. Glaucoma  Glaucoma is an increase in the fluid pressure within the eye. People with diabetes are twice as likely to develop a type of glaucoma. Most people have no symptoms and no early warning signs. If glaucoma is not diagnosed and treated it can cause loss of vision. It usually responds well to medication, especially if caught early.

Controlling your diabetes helps prevent eye problems. Achieve and maintain acceptable HgA1C levels.

Kidney Disease The kidneys filter and remove waste and excess fluid from the body. They help regulate blood pressure. The kidneys can be damaged by large sugar molecules. Long term kidney damage leads to kidney failure. People with diabetes should get urine tests and blood tests annually to check kidney function. Identifying problems early and getting treatment minimizes damage.

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Signs of kidney problems may include:  Increased blood pressure  Swelling  Protein in the urine  High levels of waste products in the blood Controlling your diabetes helps prevent kidney damage. Achieve and maintain acceptable HgA1C levels.

Nerve Disease Diabetes can cause neuropathy, which is damage to nerves. Peripheral Neuropathy The nerves that are responsible for feeling temperature, pressure, pain, etc. are called peripheral nerves. Peripheral neuropathy in the feet can cause numbness, burning pain, shooting pain and tingling. Autonomic Neuropathy The nerves that control automatic functions of the body (such as blood pressure regulation, bladder emptying, digestion, etc.) are called autonomic nerves. This table shows the common body systems affected by autonomic neuropathy. Heart

Affected Area

  

Problems / Causes

No pain with heart attack No increase in heart rate with activity Resting tachycardia (heart rate over 100) Blood pressure falls when going from a lying to a standing position

Blood pressure

Bladder

 Unable to empty bladder completely  Unable to feel urge to urinate Slow digestion

Stomach / Intestines

Sexual functioning Unaware of low blood sugar Skin

Men: impotence Women: vaginal dryness No early warning signs of low blood sugar   

May not feel an injury Slow wound healing Increased dryness

Symptoms / Effects

“Silent heart attack”

- Dizzy - Feeling faint - Passing out - Bladder infections - Kidney infections - Nausea and/or vomiting - Diarrhea - Constipation - Sexual problems - Impotence Passing out Infections

Controlling your diabetes helps prevent nerve damage. Achieve and maintain acceptable HgA1C

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levels.

Blood Vessel Problems Diabetes can damage blood vessels. Since blood vessels feed the body, damage to them can starve body cells. If the damaged vessel does not allow any blood flow, the body cells die. Other risk factors include high blood pressure and high cholesterol. Talk to your doctor about ways to manage these problems. 

Reduced blood flow to the heart leads to angina (heart pain). Total loss of blood flow to a section of the heart muscle, causes that part to die (heart attack). Signs of a heart attack include: - Chest pain or feeling of tightness - Pain or discomfort in the arms, jaw, neck or stomach - Shortness of breath

-

Clammy skin Sweating Nausea Light-headedness

Some people with diabetes may have a heart attack without feeling chest pain. They may not know they are having a heart attack. The lack of pain may be caused by nerve damage. 

Reduced blood flow to the brain leads to transient ischemic attack (TIA). Total loss of blood flow to a section of the brain, causes that part to die (stroke). Symptoms of a stroke include: - Sudden weakness or numbness of the face, arm or leg on one side of your body - Sudden confusion, trouble talking or trouble understanding - Sudden dizziness, loss of balance or trouble walking - Sudden trouble seeing out of one or both eyes or sudden double vision - Sudden severe headache

Peripheral vascular disease is a group of diseases affecting blood vessels outside the heart and brain. Lifestyle changes to lower your risk include the following:  Keep your blood sugar under control.  Follow your meal plans as directed.  Take medicine as directed.  Quit smoking.  Control your blood pressure.  Keep physically active.

Images courtesy of the Centers for Disease Control

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Physical Activity for the Person With Cancer and Diabetes Regular exercise is important for good health. When you have cancer and diabetes, daily exercise has added benefits. Exercise helps to increase flexibility, strength and endurance. It helps control weight and manages blood sugar level. People with cancer who keep active have less fatigue.

Before You Start Talk to your doctor before starting an exercise program. You may need a full medical evaluation. If you have taken steroids, you may be at risk of muscle strains, ligament tears and bone fractures. Ask for a referral to physical therapy for proper and safe home exercises. Ask your health care team about activities that are right for you. This is especially true for those over 35 or those with complications from diabetes.

Types of Physical Activity Aerobic exercise is best. It works your heart and lungs plus your muscles. Choose activities that you enjoy. If you have leg and foot problems, try activities that are less stressful on joints, such as water aerobics. In addition to exercise, try these tips to increase your activity level:  Skip the elevator and take the stairs.  Park your car further away.  Walk whenever you can.  Walk a few blocks before getting on the bus, and get off a few blocks before your stop.  Take a break from your desk to stretch and move around.  Do household chores such as raking leaves, washing the car or mowing the lawn.

Physical Activity and Low Blood Sugar Physical activity helps move sugar out of the blood and into the cells. This lowers your blood sugar. This is one of the benefits of exercising, and helps to control diabetes. However, be aware

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of symptoms of low blood sugar while you exercise:  Blurred vision  Rapid heart rate  Hunger  Headache  Dizziness  Trembling  Irritability  Sleepiness  Excessive sweating  Difficulty concentrating If you experience these symptoms, eat at least 15 grams of carbohydrates. Have simple carbohydrates (fast absorbing sugars) available. These include:  ½ cup regular carbonated soda  3 to 4 glucose tablets  ½ cup juice  2 tablespoons raisins  8 Lifesavers candies or 10 jelly beans Test Before and After When you begin an exercise program, test your blood sugar before and after the activity. Keep a log of your activities and blood glucose results. Your doctor will review them with you. Timing Your Physical Activity People who control diabetes with insulin must carefully plan when they exercise. Know the time your type of insulin is at its peak effect. This is the time you are most likely to have low blood sugar. Do not exercise at your insulin peak time. It may cause even more of a drop in blood sugar. Some insulin continues to work through the night. If you exercise before bed while on this longlasting insulin, you may have very low sugar levels while you sleep. This may be dangerous. Talk to your health care team about the timing of your exercise program. Once you develop a schedule, keep it consistent.

Tips for Success       

Schedule time to exercise 3-5 times a week for 30 minutes a day. Find an exercise partner to help you stay motivated. Warm up for five minutes before starting your workout. Cool down at a low intensity for five minutes. Remember to stretch after you’ve cooled down. If you have not been exercising, start with five to 10 minutes of activity. Slowly add more time as you progress. Avoid immediately exercising the part of your body where you have recently injected insulin. For example, do not inject insulin into your leg before bicycling or into your arm before playing tennis or into your abdomen before doing sit-ups. Always carry ID or wear a bracelet or necklace (such as MedicAlert®). It should include your

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diagnosis, doctor’s phone number and an emergency contact name and number. Check your feet. Inspect your feet for sores or blisters, and wear comfortable, properly fitting shoes. Choose thick, cotton-blend exercise socks to prevent blisters. Keep your feet dry. Consider using an insert for extra foot support. See Diabetes Skin and Foot Care video for more information. Drink enough water that your urine is light colored. During exercise drink even if you are not thirsty. Avoid outside physical activity in hot, humid weather. Do not exercise if you are sick. Avoid alcohol before or immediately after exercise. Drinking alcohol without eating may increase risk of low blood sugar.

Resources Ask your nurse for the handout “Benefits of Reducing Your Cancer Risk with Physical Activity.” For additional information visit the following websites: American Cancer Society http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/dealingwithsy mptomsathome/caring-for-the-patient-with-cancer-at-home-exercise American Diabetes Association http://www.diabetes.org/food-and-fitness/fitness/ National Diabetes Information Clearinghouse http://diabetes.niddk.nih.gov/dm/pubs/physical_ez/

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Physical Activity for the Person with Cancer and Diabetes. © 2008, 2015 The University of Texas MD Anderson Cancer Center, Revised 02/20/15 Patient Education Office

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Body Mass Index (BMI) and Waist Circumference BMI and waist circumference are tools your health care team may use to judge your health risks. Having a high waist circumference and BMI may increase your risk for several cancers. BMI can be a helpful tool for most people but has limitations. Your health care team can help you decide if this is the right tool for you.

Body Mass Index (BMI) How to Calculate Your BMI  Enter your height and weight in an online calculator, such as www.cdc.gov/healthyweight/assessing/bmi. Then, use the table below to check your status: BMI* Below 18.5 18.5 – 24.9 25 – 29.9 30 and above

Weight Status Underweight Normal Overweight Obese

*Based on population data for 20 years of age or older

OR Use the chart. Find your height. Move your finger across until you find your weight. For example, if you’re 5 feet 6 inches and 140 pounds, you’re in the “normal weight” range.

Waist Circumference and Body Mass Index © 2011, 2014 The University of Texas MD Anderson Cancer Center, Revised 12/19/14 Patient Education Office

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Waist Circumference How to Measure Your Waist Circumference 1. Find the top of your hip bone and the bottom of your ribs. 2. Place a tape measure half way between these two points. Wrap the tape measure around this part of your waist. The tape should be snug, but not pressing into the skin. 3. Exhale, and record your measurement in inches. Waist circumference = ________ inches To reduce your health risks, aim to maintain the following waist measurements: Men: 40 inches or less Women: 35 inches or less

Image used by Permission, American College of Gastroenterology ©2008

Additional Resources For more information, ask your health care team about the following patient education materials:  “Reducing Your Cancer Risk Through Nutrition”  “Reducing Your Cancer Risk Through Physical Activity”  “Weight and Your Health”

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Waist Circumference and Body Mass Index © 2011, 2014 The University of Texas MD Anderson Cancer Center, Revised 12/19/14

Sick-day Rules for Persons With Diabetes Illness or infection may affect your diabetes management. Sick day rules can prevent a minor problem from becoming a serious problem when you are ill. 

Ask your doctor if you should take your diabetes medicine if you are unable to eat. Medicine Name

    

Sick-day Instructions

Check your blood sugar regularly. Follow your meal plan as best as you can. If you can’t eat normally, drink 4 ounces of beverages containing sugar every hour to keep your blood sugar from falling too low. Call your doctor if you begin to vomit and you are unable to keep down liquids or take your medicines. Notify your doctor if you are ill for longer than 24 hours. Call your doctor if your blood sugar remains above 240 mg/dL for more than 24 hours.

Diabetic ketoacidosis (DKA) can occur within hours. This happens when you do not have enough insulin. Symptoms of DKA include:  Fruity, acetone smelling breath  Flu-like symptoms  Muscle aches  Nausea

  

Vomiting Dizziness Confusion

If you experience the above symptoms, call your doctor or go to the nearest emergency center. This can quickly become serious.

Reference

The Art and Science of Diabetes Self-Management Education Desk Reference, Second Edition, Editor in Chief Carole Mensing, RN, MA, CDE, FAADE, 20ll American Association of Diabetes Educators, Chicago, Illinois. Sick Day Rules for Persons with Diabetes © 2002, 2015 The University of Texas MD Anderson Cancer Center, Revised 02/20/15 Patient Education Office

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Foot Care for Persons With Diabetes People with diabetes have to take special care of their feet. People with diabetes can develop damage to the nerves and blood vessels in their feet. Nerve damage leads to numbness, burning pain, shooting pain, and tingling in the feet. Blood vessel damage results in poor blood flow to the feet. With diabetes, you may develop a sore on your feet and not feel it. Sores take a longer time to heal for people with diabetes. If left untreated, the sore can become infected. You will need to check your feet and treat sores as soon as they appear. Follow these instructions for healthy feet: 

Wash your feet daily with lukewarm soap and water.

Dry your feet well, especially between the toes.

Keep the skin supple with a moisturizing lotion, but do not apply it between the toes.

Encourage good blood flow.

When seated, put your feet up.

Wiggle your toes for 5 minutes, 2 or 3 times a day. Move your ankles up and down and in and out to help blood flow in your feet and legs.

Do not cross your legs for long periods of time.

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Do not wear tight socks, elastic or rubber bands around your legs.

Do not smoke. Smoking can lower the amount of blood flow to your feet. Ask for help to stop smoking. Call 713-792-QUIT for additional information.

Keep your feet warm and dry. Preferably wear padded socks and always wear shoes that fit well.

Additional Tips       

Ask your doctor about custom-made shoes for people with diabetes. Never walk barefoot, indoors or outdoors. Do not wear open toe shoes. Check your feet daily for blisters, cuts or sores, redness or swelling. If you can’t see the bottoms of your feet, use a mirror. Tell your doctor right away if you find something wrong. Use an emery board gently to shape toenails so they are even with the ends of your toes. Do not use a sharp nail file, pocketknife or razor blades. Visit a podiatrist if you need help with nail care. Change daily into clean, soft socks or stockings, not too big or too small. Examine your shoes every day for cracks, pebbles, nails or anything that could hurt your feet.

Resources National Diabetes Education Program: http://ndep.nih.gov/publications/publicationdetail.aspx?pubid=67 MD Anderson Tobacco Treatment Program: http://www.mdanderson.org/patient-and-cancer-information/care-centers-and-clinics/specialty-andtreatment-centers/cancer-prevention/tobacco-treatment-program/index.html

Foot Care for Persons with Diabetes Patient Education Office© 2015 The University of Texas MD Cancer Center, 02/20/15

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Steroid-induced Diabetes Steroids medicines may be used for treatment of cancer or to enhance radiation or chemotherapy treatments. Common steroids are dexamethasone, prednisone, hydrocortisone, prednisolone and methylprednisolone.

Steroids Affect Blood Sugar Steroids block insulin. Insulin’s action is to help sugar move from the blood into the cells. So when insulin is blocked, sugar builds up in the bloodstream. This is called steroid induced diabetes. High levels of sugar in the blood harm the brain and small blood vessels. Steroid-induced diabetes can occur at any time, even after months of treatment. You can develop diabetes even when you did not have problems with your previous treatments. When high blood glucose is properly controlled between 80-180 mg/dL, there is little chance of long-term damage. Short periods of higher glucose do not have long lasting effects.

Symptoms of High Blood Sugar (Hyperglycemia) Symptoms of high blood sugar (glucose) are the same as someone with diabetes. They include but are not limited to: • • • • •

Feeling hot Dry mouth Extreme thirst Frequent urination Blurred vision

• • • • •

Headache Muscle aches Hunger Loss of appetite Feeling flushed

Testing Your Blood Sugar During steroid treatment, your blood sugar needs to be tested regularly. You will be taught how to use the glucose monitor. Glucose levels should be between 80-150 mg/dL before meals and at bedtime. Discuss your blood glucose with your doctor at each clinic visit and bring in your blood glucose log for review. Your doctor will recommend the best times to check your blood sugar.

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Steroid Induced Diabetes. © 2011, 2015 The University of Texas MD Anderson Cancer Center, Revised Patient Education Office

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Controlling Blood Sugar You may be prescribed medicine to control your blood sugar levels. It may be pills or injections. Follow instructions about medicine. Also you may be given a special diet to help control blood sugar. Ask to speak with a dietitian if you have questions. If your steroid dose changes, notify your doctor. Your treatment may need to change.

Ending Steroid Treatment When steroid treatment is done, blood sugar usually returns to normal. However, some people develop permanent diabetes. Special tests may be ordered to determine if you have diabetes.

Resources National Institutes of Health http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3851349/

Steroid Induced Diabetes. Š 2011, 2015 The University of Texas MD Anderson Cancer Center, Revised Patient Education Office

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Insulin: Injecting from One Vial Insulin helps to regulate blood sugar by lowering the amount of sugar in the blood. People with diabetes may need insulin when they do not make enough of it. Insulin will be ordered by your doctor by what type, how to give it and when to give it. Insulin is injected into the subcutaneous (fat) in the abdomen, arms or legs. Follow these steps if your insulin comes in one vial. Never re-use needles. Never share needles. Always discard after one use.

Gather Supplies • •

Vial of insulin Alcohol prep pad or bottle of alcohol and cotton balls

• • •

Insulin syringe Band-Aid (optional) Container to throw away needles

Fill the Syringe 1. Wash your hands with soap and water.

1

2. If you are taking a cloudy insulin, roll the vial of insulin between your hands. NEVER shake a vial of cloudy insulin. You do not need to roll the clear type of insulin.

2

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3. Wipe the top of the insulin vial vigorously with alcohol. 3

4. Pull the plunger down to draw air into the syringe equal to the amount of insulin you need. 4

5. Push the needle through the top of the rubber stopper straight into the vial.

5

6. Push air into the insulin vial. Leave the needle in the insulin vial. This makes it easier for you to draw the insulin out of the vial.

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7. Turn the insulin vial and syringe upside down. 7

8. Pull the plunger down slowly to get insulin into the syringe. Be sure to get the right number of units. 8

9. Look for air bubbles in your syringe. Air bubbles in the syringe means that you will get less insulin. If you have air bubbles, push the insulin back into the vial and start from step 8. Check your syringe to make sure you have the correct units of insulin (no air). Pull the syringe and needle out of the vial.

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Choose the Injection Site • • • •

This picture shows where you may safely inject. Rotate sites every day. Using different sites prevents scar tissue. Allow 3 to 4 weeks before returning to the same spot.

Clean the skin with an alcohol swab. Let the alcohol dry completely.

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Inject the Insulin 1. Pick up the syringe and hold it like a pencil. Do not let the needle touch anything. 2. Pinch up your skin. 3. Quickly push the needle into your skin. Go straight in unless you were told to angle the needle. 4. Push the plunger to inject the insulin. 5. Pull the needle out. 6. Press an alcohol swab over the spot where you gave your injection. Do not rub this spot. You may use a Band-Aid if you wish. 7. Throw the needle away in a sharps container. A thick plastic bottle works well. Sharps containers are available for purchase at most pharmacies.

Discard the Used Needle and Syringe Once your container is full, seal the cap with tape. Throw away the container in the trash or take it to a local pharmacy for disposal.

Resources Diabetes and You: How to Use Your Insulin Manage diabetes with better skills. To schedule a personal appointment, call the Internal Medicine Center at 713-792-2340. Main Building Internal Medicine Classroom Floor 4, near Elevator A, through The Learning Center, Room R4.1121 Diabetes Self-Care Class This class is available for patients and/or caregivers. Learn how to control your blood sugar. Get information about insulin, carb counting and nutrition, exercise and how to manage your medicines. Walk-ins are welcome. Thursdays, 10-11 a.m. Main Building Classroom Floor 4, near Elevator A, through The Learning Center, Room R4.1121

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Insulin: Injecting from Two Vials Insulin helps to regulate blood sugar by lowering the amount in the blood. People with diabetes may need insulin when they do not make enough of it. There are two kinds of insulin. The shortacting type of insulin (clear) comes in one vial. The longer-acting insulin (cloudy) comes in another vial. Mixing both types in one syringe keeps you from having to give two separate shots. Your doctor will tell you how many units of each kind you need. ___ units of cloudy insulin + ___ units of clear insulin = ___ total units of insulin in one syringe This handout shows you how to mix them in one syringe. Never re-use needles. Never share needles. Always discard after one use.

Gather Supplies  

Both vials of insulin Alcohol prep pad or bottle of alcohol and cotton balls

  

Insulin syringe Band-Aid (optional) Container to throw away needles

Fill the Syringe 1. Wash your hands with soap and water.

1

Then prepare the vials. 2. Roll the vial between your hands. NEVER shake a vial of insulin. 3. Wipe the top of both vials vigorously with alcohol.

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Insulin: Injecting from Two Vials © 2015 The University of Texas MD Anderson Cancer Center, Revised 03/04/15 Patient Education Office

2

3

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Now you are ready to measure air and inject into the cloudy vial. Injecting air assures you do not create a vacuum.

6

5

4

4. Pull the plunger down to draw air into the syringe equal to the units of cloudy insulin. 5. Push the needle through the rubber top of the cloudy insulin vial. 6. Push air into the cloudy insulin vial. Pull the needle out of the cloudy insulin vial. You are not going to draw out any of the cloudy insulin yet. Now you are ready to measure air and inject into the clear vial.

7

8

9

7. Pull the plunger down to draw air into the syringe equal to the units of clear insulin. 8. Push the needle through the rubber top of the clear insulin vial. 9. Push air into the clear insulin vial. Leave the needle in the insulin vial.

10

11

12

10. Turn the clear insulin vial and syringe upside down. 11. Pull the plunger down slowly to get clear insulin into the syringe. Stop when you have the correct number of units. 12. Look for air bubbles in the syringe. Air bubbles in the syringe mean that you will get less insulin. If you have air bubbles, push the insulin back into the bottle and start from Step 11.

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Check the syringe for the correct number of units of clear insulin with no air bubbles. Pull the needle out of the clear insulin bottle. The syringe now has the units of clear insulin you need. You are ready to add the cloudy.

13

15

14

13. Push the needle through the rubber top of the cloudy insulin vial. 14. Turn the vial upside down. Do not push the plunger! You do not want any clear insulin injected into the cloudy vial. 15. Slowly pull down the plunger to get the total number of insulin units you need. Be sure you have the right number of units because you must not push any of the insulin back into the vial. The syringe should have all your ordered units: ___ units of cloudy insulin + ___ units of clear insulin = ___ total units of insulin in one syringe 16. Pull the syringe out of the bottle. You are now ready to inject your insulin.

Choose the Injection Site    

This picture shows where you may safely inject. Avoid scars, visible blood vessels, other injected sites and bruised areas. Rotate to different sites, but stay within the same region with each injection. Stay within the same region for the entire week. Stay at least 1 inch away from previously injected site for at least 4 weeks. This will prevent scar tissue.

Clean the skin with an alcohol swab. Let the alcohol dry completely.

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Insulin: Injecting from Two Vials © 2015 The University of Texas MD Anderson Cancer Center, Revised 03/04/15 Patient Education Office

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Inject the Insulin 1. Pick up the syringe and hold it like a pencil. Do not let the needle touch anything. 2. Pinch up your skin. 3. Quickly push the needle into your skin. Go straight in unless you were told to angle the needle. 4. Push the plunger to inject the insulin. 5. Pull the needle out. 6. Press an alcohol swab over the spot where you gave your injection. Do not rub this spot. You may use a Band-Aid if you wish. 7. Throw the needle away in a sharps container. A thick plastic bottle works well. Sharps containers are available for purchase at most pharmacies.

Discard the Used Needle and Syringe Once your container is full, seal the cap with tape. Throw away the container in the trash or take it to a local pharmacy for disposal.

Resources Diabetes and You: How to Use Your Insulin Manage diabetes with better skills. To schedule a personal appointment, call the Internal Medicine Center at 713-792-2340. Main Building Internal Medicine Classroom Floor 4, near Elevator A, through The Learning Center, Room R4.1121 Diabetes Self-Care Class This class is available for patients and/or caregivers. Learn how to control your blood sugar. Get information about insulin, carb counting and nutrition, exercise and how to manage your medicines. Walk-ins are welcome. Thursdays, 10-11 a.m. Main Building Classroom Floor 4, near Elevator A, through The Learning Center, Room R4.1121

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Diabetes Education Resources Video List

The following videos are available on the TVs in the inpatient hospital rooms and at The Learning Center. For more information, please ask for a copy of the “Patient Education Guide MDA-TV.”                      

Diabetes: Being Prepared for Sick Days and Emergencies Diabetes Skin and Foot Care Diabetes Skin and Foot Care (Spanish) Everyone Can Carbohydrate Count Everyone Can Carbohydrate Count (Spanish) Freestyle® Freedom Lite Blood Glucose Monitoring System Glucagon Training: Be Prepared A Guide to Lantus®: Lantus SoloStar® A Guide to Lantus®: Lantus Vial and Syringe How to Use KwikPen™ Prefilled With the Humalog® Brand of Insulins Humalog®: Small Steps to Help You Manage Your Diabetes Non-Insulin Medications (pills) for Diabetes Non-Insulin Medications (pills) for Diabetes (Spanish) Nutrition and Cancer One Touch® Ultra Blood Glucose Monitoring System: An Ultra New Day Simple Start: Diabetes and Food Taking Insulin Taking Insulin (Spanish) Understanding Insulin Understanding Insulin (Spanish) What is Diabetes? (Type 2) What is Diabetes? (Type 2) (Spanish)

404 449 450 288 289 403 326 309 310 417 327 156 187 256 271 320 158 188 157 188 155 186

How to Watch a Video 1. In your hospital room: Simply use the bedside remote to access MDA-TV. Enter the video number, or use the Arrow Keys to highlight the title, and then press Select.

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Diabetes Education Resources: Video List © 2010 The University of Texas MD Anderson Cancer Center, 12/11/14 Patient Education Office

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2. You can also access patient education videos at The Learning Center: Theodore N. Law Learning Center Main Building Floor 4, near Elevator A Monday-Friday, 9 a.m.-4 p.m. 713-745-8063

Levit Family Learning Center Mays Clinic Floor 2, near The Tree Sculpture Monday-Friday, 9 a.m.-4 p.m. 713-563-8010

Additional Resources Diabetes Self-Care Class - This class is available for patients and/or caregivers. Learn how to control your blood sugar. Get information about insulin, carb counting and nutrition, exercise and how to manage your medicines. Walk-ins are welcome. Main Building Classroom Floor 4, near Elevator A, through The Learning Center, Room R4.1121 Thursdays, 10-11 a.m. 713-792-2340

Diabetes Education Resources: Video List Š 2010 The University of Texas MD Anderson Cancer Center, 12/11/14 Patient Education Office

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Additional Resources For further information on managing diabetes, see the following resources: MD Anderson Diabetes Management http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancertopics/dealing-with-cancer-treatment/diabetes/index.html MedlinePlus - Videos on Diet http://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query meta?&v:project=medlineplus&query=diabetic%20diet&binningstate=group%3d%3dVideos%20and%20Tutorials& Centers for Disease Control and Prevention - Resources for Hispanics http://www.cdc.gov/features/Fotonovela/index.html Centers for Disease Control and Prevention - Resources for African-Americans http://www.cdc.gov/diabetes/ndep/new-beginnings.htm

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Notes _____________________________________________________________________________

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Notes Š 2008, 2014 The University of Texas MD Anderson Cancer Center, Reviewed 09/19/14 Patient Education Office

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Š 2010, 2015 The University of Texas MD Anderson Cancer Center, Revised 03/30/15 Patient Education


Diabetes: Self-Management