This animation focuses on how the body normally breaks down and uses food, and explores how the body maintains a healthy level of glucose, the simple sugar used for energy.

There are several types of nutrients, we will focus on how the body digests one type, called carbohydrates, as this most directly affects glucose levels.  Carbohydrates are made up of long chains of sugars.

After you swallow food, it travels into the throat and down the esophagus and into the stomach.

Carbohydrates in the food are broken down into smaller chains of sugars and eventually into glucose, the main energy source used by the body.  Enzymes are biological molecules, or proteins, that help complex reactions occur everywhere in life.  Enzymes like alpha glucosidase are responsible for the breakdown of carbohydrates into smaller chains of sugars.  These sugars travel to the intestines where they are absorbed into the blood.  Hormones, such as GLP-1 and amylin, are released by the intestines and help to slow food leaving the stomach.  These hormones also act on the brain, causing it to slow food leaving the stomach and all-around creating a feeling of fullness.

In the pancreas, there are groups of cells called islets. Beta cells, which produce insulin, are a type of cell within the islets. Glucose from digested food and the gut hormone GLP-1 both stimulate beta cells to release more insulin into the blood stream when food is eaten.

Most cells in the body, including muscle and fat cells, need insulin to bind to cells before glucose can enter the cell and be used for energy.

Glucose entry allows these cells to function and also lowers glucose levels in the blood stream.

Since most cells in the body need glucose for energy, it’s important for the body to maintain steady glucose levels in the blood.  The liver helps maintain blood glucose levels by storing glucose when insulin is present.  When you are fasting (or not eating food for long periods of time), less insulin is present and the liver releases stored glucose into the blood.

The kidneys help filter toxins from the blood and excrete them into the urine.

The kidneys also filter out some glucose, but the body is able to re-absorb that glucose through protein transport channels on the surface lining of the kidney so that glucose is not lost in the urine.

Type 2 diabetes is the more common form of diabetes

In type 2 diabetes, cells in the body become more resistant to the effects of insulin, so less glucose is taken up by the cells.  This raises blood glucose.

Beta cells in the pancreas try to produce and release more insulin to overcome this resistance.  However, over time the pancreas cannot produce enough insulin and blood glucose levels remain high, resulting in diabetes.

The liver also becomes more resistant to insulin, which normally stops it from releasing stored glucose.  As a result, the liver releases too much glucose into the blood.

The higher levels of glucose in the blood causes damage to the blood vessels in organs throughout the body in both these forms of diabetes.

Hello.  Thank you for listening to my presentation “Nutrition for People with Diabetes.”  I’m Christine McKinney, a Registered Dietitian Nutritionist and Certified Diabetes Educator with Johns Hopkins Medicine.

My talk is divided into four parts so you can listen to the entire talk or just the parts you choose.  This is Part 1:  An Overview of Nutrition

To start, I want to talk about the general relationship between food and blood glucose.  It’s important to eat at the right time to keep blood glucose steady and to prevent glucose from dropping too low.  Eating the right amount is also important.  Eating too much food can raise blood glucose and too little food can lower blood glucose.  Eat healthy foods from all the food groups and eat Whole Foods.  Whole Foods are as close to their natural form as possible.  For example, a baked potato is considered a whole food, but french fries are not.

A good starting place for when to eat is to think about consistent timing with meals and snacks.  When possible, eat about the same time each day.  Eat at least three times during the day.  Plan meals no more than 4 to 5 hours apart.  Avoid skipping meals, which can cause you to become more hungry and overeat at the next meal or cause a low blood glucose if you take certain diabetes medications.  Some diabetes medications are recommended to be taken with food so consider balancing the time you take your medication with the times you eat.

To help control glucose, try eating about the same amount at each meal.  Snacking between meals should depend on your personal preferences, individual eating plan, meal timing, and hunger.  Think about the timing of your meals.  If lunch is at 12 noon and dinner is at 7 pm, that’s 7 hours and you need to plan a snack between those meals.  In general, if your meal timing is more than 4 hours apart you may need a snack.  When it comes to snacking, avoid snacking out of boredom, or habit, especially nighttime snacking.

An important part of eating the right amount of food is learning to listen to our body’s signs of satisfaction and fullness.  Satisfaction means I’m no longer hungry.  Think about asking yourself before, during, and after you eat if you are satisfied and that will help you to eat the right amount of food.

This concludes Part 1 of the Presentation.

In Summary: Eat three meals each day and snack if you are hungry or if there was a long time between meals.  Eat about the same amount at each meal to help control glucose.  Listen to your body and stop eating when you are satisfied.

Welcome to Nutrition for People with Diabetes – Part 3: Nutrition Labels.  I’m Christine McKinney, a Registered Dietitian Nutritionist and Certified Diabetes Educator with Johns Hopkins Medicine.

The Nutrition Facts label gives us helpful information about the food we eat.  At this time we have two food labels.  Larger companies are required to update the labels by January 2020, and smaller companies by January 2021.  There were several changes, including:

• Removing calories from fat, because research shows that the type of fat is more important than the amount.
• Enlarging the type size for “servings per container”, “servings size”, and “calories” to focus on serving size and calories.
• Including added sugars under total sugars. On the old label, sugars included natural sugar from milk and/or fruit and added sugars.  On the new food label, added sugar is listed under total sugars.  With the new label, it’s easy to tell how many carbohydrates come from added sugar.  As a reference four grams of sugar is equal to one teaspoon.

When reading a food label, start at the top with a serving size.  The nutrient information on the label is for one serving of the size listed.  The percent daily values (%DV) are a guide based on a 2,000 calorie diet for adults.  So, if the label says 10% DV total fat, that means it’s providing 10% of fat for your day.  You can use the percent daily value as a quick reference for nutrients.  5% or less is low for a nutrient and 20% or more is high for a nutrient.  6 to 19% is in the middle range.  Total carbohydrates include starches, natural and added sugars, sugar alcohols, and fiber.  If you are counting carbs look for total carbohydrates in grams.  If you are using carb choices divide the total carbohydrates by 15 because one carb choice has 15 grams of carb.

Let’s practice label reading.  How many grams of carbs are in two tablespoons of this peanut butter?  If you answered eight grams, that’s correct.

Which nutrients are high in this product?  The answer is total fat and niacin, because those contain more than 20% of the daily value.

Which nutrients are low in this product?  If you answered cholesterol, sodium, calcium, iron, and potassium, that’s correct, because the percent daily value is 5% or less

Let’s read another food label.  How many grams of carbs are there in three cups of riced cauliflower?  Remember to check the serving size first.  If you answered 12 grams of carbs that’s correct because one cup equals 4 grams of carb.

How many calories are in the entire package?  There were 4 servings in the container so the entire package is equal to 80 calories.

How much fiber is in 2 cups?  If you answered 4 grams of fiber, that’s correct, because each cup contains 2 grams of fiber.

This concludes Part 3 of the presentation.

In Summary: Read the Nutrition Facts label to compare products and make healthy choices.  Use the percent daily value as a guide for nutrients.  Remember 5% is low and 20% is high for any nutrients on the label.  If counting carbohydrates, count total carbohydrates on the label.

When we as dieticians talk about nutrition, you’ll hear us talk about three main kinds of nutrients:

• Protein
• Fat
• and Carbohydrate

We’ll be talking about carbohydrate more in a later video.

 Protein comes from many different foods.  It helps us build and rebuild tissue, and it functions as part of our immune system that helps us fight disease.

 Protein comes from animal sources such as meat, eggs, cheese, and other dairy, like milk.  It also comes from vegetable sources such as soy products like tofu, beans, lentils and other legumes, nuts, and seeds.

 When eaten by itself, protein doesn’t have much of an effect on your blood sugar.  But when you combine it with foods that contain carbohydrate, it can improve your blood sugars response to the carbohydrate.

 Fat, though many think it’s not very good for you, is a very important part of our diets.  It helps insulate us from the cold, and it cushions your organs from injury.

 It can be found in healthy sources such as mono and polyunsaturated fats.  Most of these types of fats are either found in fatty fish like salmon, or in vegetable sources such as olives and olive oil, and nuts, seeds, and avocados.

 Unhealthy fats – trans – which are man-made fats, and saturated fats, which come from animal products, are found in things like full-fat dairy, butter, cheese, and the white fat that you might see on meat, which is called marbling, and also from things like full-fat dairy.

The word carbohydrate has been used several times in the previous videos. 

You might be wondering what exactly is carbohydrate.  Carbohydrate is really just a word for different kinds of food that, when you eat them, most of what is in that food will turn into sugar.  That being said, there’s nothing wrong with carbohydrate foods.  Our bodies use sugar the same way that a car uses gasoline.  The problem is diabetes is not a problem with the food, but our body’s ability to handle the food.  When there’s an imbalance of the hormone insulin and sugar from these carbohydrate foods, that’s when your blood sugar start to get out of control.

Carbohydrates come from many different foods, and they fall into one of two categories:

• Complex carbohydrates or starch; and
• Simple carbohydrates or sugar

Both sugar and starch are carbohydrate, just like a Dachshund and a Dalmatian are both dogs.  Both will wind up as sugar, or glucose, which is a simple sugar, eventually.  But some may raise your blood sugar faster than others. 

Two main sources of starch in our diet are grains, such as oats, rice, and bread products such as of course bread, pasta, and crackers, as well starchy vegetables such as potatoes, sweet potatoes, peas corns, beans, and legumes.

Sugar comes from added sources such as sweets like cake, candy, and cookies, as well as natural sources such as fruit, fruit juice, milk, and yogurt.

All of the foods pictured here, including the sweets, can fit into a healthy diet.  Moderation is the key.

You might be wondering how many carbohydrates do I need.  For more specific information to yourself, you may want to see a dietitian for specific advice.

A general rule of thumb is for men, if your blood sugars are not in good control or if your doctor has told you to lose weight, you should aim for 45 to 60 grams of carbohydrate for each meal.  If you’re looking to maintain your weight and your blood sugars are well-controlled, you may have more than 60 grams or up to 75 grams per meal.

For women, same thing.  If you are looking to lose weight or if your blood sugars are not in good control, you would shoot for 30 to 45 grams of carbohydrate for each meal, or if you’re in good control and your weight is at a healthy level, you may have 60 grams of carbohydrate for each meal.

Muy buenos días mi nombre es el Dr.Stanley Chen Cárdenas del departamento de endocrinología de la Universidad de Johns Hopkins y en el día de hoy queremos hacer un video para nuestros pacientes, ayudarlos un poco con la educación en diabetes. Esta charla la hemos dividido en dos partes: una que es la parte básica sobre qué es la diabetes y cuáles son sus complicaciones y la segunda parte habla un poco de manejo en general.

Entonces en la primera parte es transmitirle por qué es importante conocer sobre diabetes? Según los datos de la Asociación Americana de Diabetes en el 2018 alrededor de 34 millones de personas tenían diabetes o 10.5% de la población en los Estados Unidos y dentro de ese grupo 12.5% o aproximadamente uno de cada 10 hispanos tenía diabetes. Es también la séptima a causa de mortalidad los Estados Unidos y esta enfermedad tiene complicaciones como enfermedades del corazón, enfermedades de los riñones, enfermedades de la circulación, además de ceguera amputaciones de miembros inferiores que desde luego impactan la calidad de vida de los pacientes.

Cómo prevenimos estas complicaciones? con mucha educación. Es importante que el paciente con diabetes se eduque y continuar aprendiendo a lo largo de la enfermedad.  El que se diagnostique a un paciente con diabetes no significa necesariamente que va a desarrollar estas complicaciones. Si se controla la diabetes pueden prevenirse (o retrasarse) entonces para iniciar quisiera darles un breve una breve introducción que es la insulina y cómo es su funcionamiento normal en el cuerpo. La insulina es una hormona que muchos de ustedes quizás han escuchado y es producida en un órgano que se llama el páncreas y usted lo aprecia en la diapositiva de color amarillo o dorado y dentro de ese órgano existe un grupo de células que se llaman las células Beta, está células Beta producen la hormona que se llama insulina y su papel principal entre muchos que tiene en el metabolismo es regular o disminuir los niveles de azúcar en la sangre.

Cómo actúa la insulina? como dijimos en la diapositiva anterior esta es producida en esa célula que se encuentran en el abdomen y una vez es liberada en la sangre ella va a unirse a un receptor en el tejido blando blanco como el tejido muscular, el tejido adiposo o grasa y como ven en la diapositiva a la insulina, se representa por unos triángulos morados (circulo verde). Cuando esta hormona se une a su célula que está representada por los círculos amarillos (chocolate-higado-liver), abre unas compuertas donde permite el paso de la glucosa o azúcar que son las esferas rojas y permiten que pase de la sangre hacia dentro de la célula y de esa forma la insulina disminuye los niveles del azúcar o la glucosa en sangre. Ustedes se podrán imaginar que si alguien tiene alguna condición que se llama resistencia a la insulina, la hormona está presente, pero no puede actuar y no puede retirar la glucosa de la sangre para que entre al tejido y esto mantiene el nivel de azúcar elevado. Esto es como para darle una introducción de como es el funcionamiento normal. Si tienen una pregunta sobre esto no duden en pregúntale a su medico.

La insulina normalmente es producida de dos maneras una producción continua que es a lo largo de todo el día aunque uno no coma y hay otra producción qué es en respuesta los alimentos o los nutrientes principalmente la glucosa y que ustedes ven en esta gráfica representada por ese incremento en el área en naranja en el desayuno y el almuerzo y la cena. Por eso es que ustedes van a ver que muchos pacientes con diabetes utilizan dos tipos de insulina que le llaman lenta, que es la parte basal y la insulina de las comidas que la parte que representa los los picos de elevación en esta gráfica.

Pasando del funcionamiento básico a qué es la diabetes mellitus? la diabetes mellitus en general se define como una condición caracterizada por el aumento de la glucosa en la sangre, existen dos tipos principales: la tipo 1 que se da cuando el cuerpo no produce insulina y esto en la gran mayoría de los casos es por una respuesta inmune anormal donde el propio cuerpo destruye estas células Beta que mencioné previamente y finalmente no se produce la insulina. La tipo 2 es la más común y es donde el cuerpo es resistente a la acción de la insulina y fue la que les trataba de explicar en la diapositiva previa que a pesar de que haya insulina inicialmente el cuerpo no responde a la hormona y luego lo que pasa es que el cuerpo trata de producir más insulina para compensarla, pero llega un punto donde ya no hay suficiente hormona para compensar la resistencia a la insulina y se desarrolla entonces finalmente la diabetes.

Que causa la diabetes tipo 2? existen múltiples factores, genéticos y factores que son modificables en el estilo de vida, como la obesidad o el sobrepeso, la dieta alta en azúcares o en grasas y más adelante les hablaré un poquito más de estos que son factores importantes en la predisposición a desarrollar diabetes tipo 2 .

Cómo se dan cuenta que ustedes pueden tener la azúcar elevado o cuáles son esos síntomas? Muchos pacientes experimentan cuando su azúcar está alta excesiva orina o va mucho al baño, excesiva sed, exceso de apetito y a pesar de eso hay pérdida de peso principalmente por cierto grado de deshidratación, fatiga o cansancio.  De la glicemia elevada o el azúcar elevado sostenido pueden surgir lo que le llamamos complicaciones de la diabetes mellitus y se han clasificado de dos tipos dependiendo del tamaño de los vasos sanguíneos que afecten y pueden afectar órganos como los ojos y una de las complicaciones de la pérdida de la vision, los nervios donde se manifiesta con dolor en las extremidades, con pérdida de la sensibilidad que predispone a úlceras o heridas, afectación en los riñones predisponiendo enfermedad renal y muchos pacientes lamentablemente llegar a necesitar diálisis o trasplante renal para aliviar su su función de los riñones. Dentro del grupo de las enfermedades macrovasculares (vasos sanguineos grandes) están los infartos al corazón, enfermedad cerebrovascular o derrame también conocido (stroke) otro que está también es la insuficiencia o la falta de circulación en las piernas que también predispone a infección y amputaciones.

Pero todas estas complicaciones son potencialmente prevenibles, como les decía al principio de la charla, con educación y control de la diabetes apropiado no necesariamente estas complicaciones van a ocurrir.

Si por ejemplo está experimentando síntomas, cómo se diagnostica la diabetes? Hay múltiples formas de diagnosticarla. Una de ellas es medir la glucosa en ayuno, si su glucosa en ayuno luego de 8 horas de ayuno en más o igual a 126 mg/dl es diagnóstico de diabetes,  si tiene una hemoglobina glicosilada mayor de 6.5% también es criterio de diagnóstico de diabetes o luego de una prueba de tolerancia, que es donde se le da una cantidad medida de glucosa al paciente, si la glucosa es más 200 mg (luego de 2 horas) es considerado diagnóstico de diabetes y si la glucosa es más de 200 a cualquier momento del día al azar y tiene síntomas que mencionamos previamente también se considera que tiene el diagnóstico de diabetes.

Muchos de ustedes ya han escuchado el nombre de hemoglobina glicosilada y saben que su médico le mide esto y que su meta está cerca de 7, que quiere decir esta hemoglobina glicosilada?  nos da un estimado un promedio de cómo fueron los valores de glucosa a lo largo de los últimos tres meses aproximadamente y por ejemplo si su hemoglobina glicosilada está en 8%, su glucosa ha estado a lo largo de los meses como un promedio de 183 mg/dl y ahí existe una tabla donde entre más alta como ustedes ven correlaciona con el nivel de glucosa. La hemoglobina glicosilada es importante porque los estudios han asociado a su valor con el riesgo de complicaciones, entre más alta la hemoglobina glicosilada mayor es el riesgo y este riesgo aumenta por encima de la hemoglobina glicosilada mayor de 7  tanto de microvasculares (pequenos vasos sanguineos) como retinopatía, nefropatía y neuropatía diabética se asocian a esto, o sea que si su hemoglobina glicosilada está muy alta, está en alto riesgo de presenter estas complicaciones, por eso es importante monitorear su hemoglobina glicosilada cada tres meses, si su diabetes está bien controlada se pueden espaciar un poco los controles pero tres meses en la recomendación general.

La meta en la mayoría de los adultos y mujeres no embarazadas es menos de 7%, pero en aquellos pacientes que tienen alto riesgo de hipoglicemia o azúcar baja se puede ser más flexible y menos de 8% es adecuado.  

De esta presentación cuales son los puntos importantes que me gustaría que ustedes recordaran y es uno que la diabetes es una enfermedad muy común y que se caracteriza por el azúcar elevado en la sangre, este azúcar elevado puede tener complicaciones si no se controla, el segundo punto que me gustaría que recuerden es que la obesidad, el sedentarismo y la alimentación inapropiadas son los factores de riesgo modificables más importantes para la diabetes tipo 2 y de esto es lo que me voy a concentrar en la siguiente de parte de esta presentación gracias 

Good morning, my name is Dr. Stanley Chen Cárdenas, from the Department of Endocrinology at Johns Hopkins University and today we wanted to make a video for our patients to help them with diabetes education and we have divided this talk into two parts, one that is the basic part explaining what diabetes is and what its complications are and the second part talks about management of diabetes in general.

The goal of the first part is to convey to you why it is important to know about diabetes. According to the data of the American association of diabetes in 2018 around 34,000,000 people had diabetes or 10.5% of the population in the United States and within that group 12.5%, ​​approximately one in 10 Hispanics had diabetes. It is also the seventh cause of mortality in the United States and this disease has complications such as heart disease, kidney disease, circulation diseases as well as blindness, limb amputations, and of course they impact the quality of life of patients.

How we prevent these complications? with a lot of education. It is important that the patient with diabetes educate himself and continue learning throughout the disease. The fact that a patient is diagnosed with diabetes does not necessarily mean that will develop these complications. If diabetes is controlled they (the complications) can be delayed or prevented. To start, I would like to give you a brief introduction about what is insulin and how it normally functioning in the body.  Insulin is a hormone that many of you may have heard and it is produced in an organ called the pancreas and you can see it on the slide it is golden/yellow and inside that organ there is a group of cells called Beta cells. These Beta cells produce a hormone called insulin and its main role among many it has in metabolism is to regulate or lower blood sugar levels.

How insulin works? as we said in the previous slide, it is produced in that cell found in the abdomen (pancreas) and once it is released into the bloodstream, it will bind a target tissue such as muscle or adipose tissue also known as fat. As you can see, insulin in the slide is represented by purple triangles (green circles).  When that hormone binds to its cell which is represented by the yellow circles (brown) it opens some gates where it allows the passage of glucose or sugar, which are the red spheres, and allow the transport from the blood into the cell, in this way insulin lowers blood sugar or glucose levels. You can imagine that if someone has a condition called insulin resistance, meaning that the hormone is present, but it can’t act and it cannot remove the glucose from the blood so that it enters the tissue that will result in high blood sugar levels, this is to give you an introduction of how it works, do not hesitate to ask your doctor if you have further questions.

Insulin is normally produced in two ways: a continuous production throughout the day even though one does not eat and there is another way of production in response to food or nutrients, mainly glucose that you see in this graph represented by an increase in the area in orange at breakfast, lunch and dinner. That is the reason why you are going to see that many patients with diabetes use two types of insulin that are called the basal insulin, and the meal time or short acting insulin the latter represents the elevation peaks in this graph.

Moving to discuss what is diabetes mellitus? It is in general defined as a condition characterized by increased glucose in the blood. There are two main types, type 1 that occurs when the body does not produce insulin, in the vast majority of cases due to an abnormal immune response where the body itself destroys the beta cells that I mentioned previously and finally insulin is not produced.  type 2 is the most common and occurs when the body is resistant to the action of insulin and was the one that I was trying to explain in the previous slide where insulin is present initially, but the body does not respond to the hormone and then what happens is that the pancreas tries to produce more insulin to compensate it, but there comes a point where there is no longer enough hormone to compensate for insulin resistance and finally type 2 diabetes appear.  

What causes diabetes? There are multiple factors including genetic factors, modifiable factors in lifestyle such as weight, diet high in sugar or fat that later I will discuss in more detail. These factirs are important as they predispose to the development of type 2 diabetes. 

When you should suspect that you may have high blood sugar? What are those symptoms? when their blood sugar is high many patients experience excessive urination, excessive thirst, excessive appetite, and despite that there is weight loss, mainly due to a certain degree of dehydration. There is fatigue or tiredness, and from sustained high blood sugar complications of diabetes mellitus may arise. These have been classified into two types depending on the size of the blood vessels that affect and can affect organs. Small vessels (microvascular) such as the eyes resulting in vision loss, in the nerves where it manifests with pain in the extremities, with loss of sensation that predisposes to ulcers or wounds affectation, the kidneys can be affected predisposing to kidney disease and many patients unfortunately end up needing dialysis or a kidney transplantation to alleviate their kidney function.  Within the group of macrovascular diseases are heart attacks, cerebrovascular disease or stroke, insufficiency or lack of proper circulation in the legs that also predisposes to infection and amputations. 

All these complications are potentially preventable as I said at the beginning of the talk, with education and appropriate diabetes control these complications may be prevented or delayed. 

If for example you are experiencing symptoms, How diabetes is diagnosed? there are multiple ways to diagnose it, one of them is to measure your fasting glucose, if your fasting glucose after 8 hours of fasting is more than equal to 126 mg/dl means you have diabetes. If you have a glycosylated hemoglobin (HbA1c) greater than 6.5% is also a diagnostic criteria for diabetes or after a glucose tolerance test. Which is a test where a measured amount of glucose is given. If the glucose is higher than 200 mg/dl is considered diagnosis of diabetes, and if glucose levels are over 200mg/dl at any random time of day and you have symptoms of high blood sugar as mentioned previously it is also considered that you have the diagnosis of diabetes.

Many of you have already heard the name of glycosylated hemoglobin (HbA1c), you know that your doctor will look at this test to evaluate your control and that your goal is usually close to 7%, and what does it means? Glycosylated hemoglobin (HbA1c) gives us an average estimate of how the glucose values ​​were throughout the last three months approximately and for example if your glycosylated hemoglobin is 8% your glucose has been throughout the months as an average of 183 mg/dl. There is a table where you can appreciate that the higher the HbA1c represents a higher level of glucose for that period. It is important because studies have associated its value with the risk of complications, the higher the glycosylated hemoglobin, the greater the risk and this risk increases above the glycosylated hemoglobin > 7%. Microvascular (small blood vessels) diseases such as nephropathy, retinopathy, and diabetic neuropathy are associated with higher HbA1c, therefore if your glycosylated hemoglobin is very high, you are at high risk to develop of all these complications, this is why it is important to monitor your glycosylated hemoglobin every three months, if your diabetes is well controlled, the checks can be spaced a little, but three months in the general recommendation. The goal in most adults and non-pregnant women <7% is appropriate, but in those patients who are at high risk of complication, frequent hypoglycemia or low blood sugar can be more flexible and < 8% is adequate.

From this presentation, which are the important points that I would like you to remember? First, that diabetes is a very common disease and is characterized by high blood sugar this high sugar which can have complications.  the second point I would like you to remember is that obesity, a sedentary lifestyle, are the most important modifiable risk factors for type 2 diabetes and these what I am going to focus on in the next part of this presentation thanks

Muy buenos días mi nombre es Sananda Moctezuma Vega del departamento de endocrinología de la Universidad de Johns Hopkins y en el día de hoy queremos hacer un video para nuestros pacientes, ayudarlos un poco con la educación en diabetes.

Tal vez haya escuchado el término MCG, pero no está seguro de qué se trata. Analicemos lo que debe saber. Un sistema de monitoreo continuo de glucosa (MCG) es un dispositivo que le permite monitorear de manera continua los niveles de glucosa en la sangre. El MCG le ofrece a una persona con diabetes (o a una persona que cuida a alguien con diabetes) un modo fácil y rápido de acceder a los niveles de glucosa en la sangre las 24 horas del día. Como la mayoría de las personas con diabetes sabe, controlar la glucosa en la sangre es fundamental para el control de la diabetes. Se ha demostrado que con los sistemas de MCG se ayuda a las personas a mantener los niveles de glucosa estables, a reducir los episodios tanto de glucosa baja en la sangre (hipoglucemia) como de glucosa alta en la sangre (hiperglucemia) y a disminuir los riesgos de complicaciones por la diabetes. A diferencia de los medidores de glucosa tradicionales que dan información de la glucosa en la sangre en tiempo real, con el MCG usted puede saber dónde están sus niveles de glucosa actuales, dónde estaban y hacia qué dirección están yendo.

Las mediciones del CGM pueden ayudarle a decidir qué comer y cómo ejercitarse. Y también pueden ayudarle a saber cuánto medicamento tomar. Puede observar en el receptor cuando hace estas cosas. De esa manera, usted puede ver cómo afectan estas actividades su nivel de azúcar en la sangre durante el día y la noche. Toda esta información detallada les da a usted y a su médico una mejor idea de cuáles son sus necesidades de tratamiento. 

Un medidor continuo de glucosa (CGM, por sus siglas en inglés) tiene varias partes.

Usted usa una parte, el sensor, contra la piel. Tiene una aguja diminuta que permanece debajo de la piel y mide el nivel de azúcar en la sangre de manera constante. Envía esta información a un receptor inalámbrico. El receptor puede indicarle si su nivel de azúcar en la sangre sube o baja y con qué rapidez cambia el nivel de azúcar en la sangre. Y puede visualizar los datos almacenados para ayudarle a identificar tendencias en sus niveles de azúcar en la sangre.

Algunas bombas de insulina incluyen un CGM. En este caso, la bomba de insulina también es el receptor.

La tecnología de los medidores continuos de glucosa cambia y mejora constantemente. Estas son algunas cosas que debe saber sobre la mayoría de los CGM. Es posible que no se apliquen a todos los sistemas.

Es necesario cambiar los sensores. Según el sistema, es posible que tenga que cambiar el sensor cada pocos días. Algunos sistemas tienen sensores que duran 10 días.

Algunos CGM requieren que se pinche el dedo para confirmar la precisión del CGM.

Los elementos del sistema de MCG trabajan a la perfección para brindarle la información que necesita. Los sistemas de MCG incluyen un sensor, un transmisor y un receptor que trabajan en conjunto para registrar la información sobre la glucosa. Otros sistemas de MCG requieren un lector que usted utiliza para escanear el sensor al menos cada ocho horas para que no se pierda la información. También, se puede utilizar una aplicación móvil para escanear el sensor y evitar tener que llevar un dispositivo adicional.

EL SENSOR: Es un dispositivo pequeño resistente al agua que mide los niveles de glucosa en el fluido intersticial de manera casi continua y se aloja de forma parcial debajo de la piel. Algunos sensores tienen el tamaño de una pestaña y se implantan por completo debajo de la piel bajo la supervisión de un médico. El sensor dura un tiempo (esto varía según el sistema) antes de que sea necesario reemplazarlo. EL TRANSMISOR: Este es un transmisor resistente al agua recargable o recambiable que envía información de manera inalámbrica desde el sensor hacia el receptor o hacia un dispositivo inteligente compatible. El dispositivo transmite de manera automática o solo cuando se escanea el sensor. La información sobre la glucosa se transmite sin dolor y puede enviarse a través de la ropa. El transmisor puede ir por separado o estar incorporado al sensor. EL ESCÁNER O

LECTOR: Es un dispositivo independiente recargable del tamaño de un teléfono celular o más chico, o se puede utilizar una aplicación en su teléfono inteligente. La información se muestra en forma de gráfico y se actualiza de manera constante con datos nuevos sobre la glucosa. La información en la pantalla también incluye las flechas de tendencia con las que se muestra en qué dirección se mueven los niveles de glucosa y se proporcionan datos previos y actuales. Toda esta información puede ayudarlo a usted y a su proveedor de atención médica a tomar decisiones sobre el tratamiento

Sistema de monitorización flash. La principal característica de este sistema es que no tiene transmisor. El sensor, que realiza una monitorización continua, almacena los datos hasta 8 horas y es necesario “escanear” el sensor con el lector para que éste le transfiera la información. Es el sistema FreeStyle Libre®.   

El  FreeStyle Libre utiliza este tipo de sistema, y en sus primeras generaciones carecia de avisos en tiempo real para hipo e hiperglucemias, esto cambio con las mas recientes versiones que incluyen alarmas para estas situaciones.

Sistemas de monitorización continua. Estos incorporan el transmisor, por lo que los datos son enviados al receptor de manera constante. La principal ventaja de estos sistemas es que se pueden programar alarmas y cuando los niveles de glucosa se desvían de un valor preestablecido, el receptor avisa para la toma de medidas oportunas. Actualmente, hay dos sistemas; Guardian y Dexcom.

Medir el éxito: A1c y el tiempo en rango Conocer los datos sobre su glucosa es una de las claves para mejorar el control de la diabetes. La mayoría de las personas con diabetes se realiza una prueba de sangre llamada hemoglobina A1c (o simplemente A1c) una vez cada tres a seis meses. Los resultados muestran el promedio de glucosa en la sangre durante los últimos dos a tres meses y ofrecen un panorama general sobre qué tan bien se está controlando la glucosa en la sangre. Sin embargo, la prueba de A1c no registra el tiempo en que la glucosa en la sangre se encuentra por debajo o por encima del rango objetivo. El MCG ofrece una nueva manera de medir qué tan bien está alcanzado sus objetivos. Su tiempo en rango (TIR, por su sigla en inglés) hace referencia al porcentaje de tiempo que la glucosa en la sangre está dentro de un rango objetivo específico. Este rango objetivo puede variar, pero en la mayoría de las personas se encuentra dentro de los 70 y los 180 mg/dL. Tener información sobre qué porcentaje de sus lecturas están por debajo, dentro y por encima del rango objetivo permite que su proveedor lo ayude a decidir cualquier cambio en los medicamentos o en el estilo de vida necesario para poder alcanzar sus objetivos. Por lo general, un TIR ideal es >70 %. Estos detalles pueden ser útiles para establecer o modificar su plan de tratamiento.

El MCG brinda más información. El medidor de glucosa en sangre le ofrece un panorama en tiempo real, informándole con exactitud cuál es el nivel de glucosa en la sangre en ese momento. No establece relaciones entre los niveles de glucosa pasados y futuros. El MCG puede darle más información sobre la historia, mostrando las tendencias actuales, las tendencias predictivas y las tendencias a lo largo del tiempo. 

Así como el furgón de cola se arrastra detrás de la locomotora, las lecturas del MCG van apenas más atrás de las mediciones de la glucosa en la sangre. Los resultados de los sensores de glucosa pueden ir un poco más atrás que las mediciones de la glucosa en la sangre, es decir, con las lecturas del sensor de glucosa se le informa cómo estaba su glucosa unos minutos antes.

Cuando el nivel de glucosa en sangre se encuentra estable durante un tiempo, los niveles de la glucosa en ambos líquidos se equilibran y coinciden. Pero como la composición del líquido intersticial depende de los intercambios entre las células en el tejido y la sangre, cuando hay fluctuaciones de glucosa en sangre, existe un retardo de la intersticial respecto a la capilar de unos 5-10 minutos.

Normalmente, esto no debería afectar la capacidad de usar el sensor de glucosa para tomar decisiones sobre el tratamiento. Sin embargo, es bueno saberlo en situaciones donde la glucosa puede alterarse con rapidez, como, por ejemplo, durante el ejercicio físico o luego de haber tomado una dosis de insulina para corregir una lectura alta de glucosa.

Es posible que aún necesite punciones digitales. Algunos sistemas de MCG deben calibrarse para mostrar resultados correctos. Para esto, se necesitan lecturas de punción digital. Tal vez le aconsejen que se haga punciones digitales en determinadas ocasiones, como, por ejemplo, cuando su sensor se está iniciando (a menudo durante las dos horas posteriores a la inserción), cuando las lecturas del sensor son bajas o altas, si tiene síntomas de glucosa baja o alta en la sangre o si sospecha que las lecturas son incorrectas por alguna razón. Puede haber diferencias y no necesariamente tiene el mismo valor.

¡Muchas Gracias!

Injecting Insulin Using a Pen

If you have diabetes and have been prescribed insulin to take via an insulin pen, there are a few things that you should know.  There are many kinds of insulin, and your doctor will decide what insulin type, amount, and injection times are best for you.  It’s understandable if you’re feeling a little nervous or anxious about taking insulin injections.  But with a little practice you will see that it takes only a few seconds to do, and can be rather easy.

To ease any anxiety you might have about taking insulin injections, we will demonstrate how to take an insulin injection using an insulin pen.  Now let’s begin.

First, start by washing your hands with some soap and water

Preparing the Insulin Supplies

Prepare the insulin supplies, and make sure you have the following items:

• The insulin pen
• Alcohol swab, or cotton ball moistened with alcohol
• And a new insulin pen needle

Preparing the Insulin Pen

Prepare the Insulin Pen.

• Always remember to check the label and the color of the insulin pen.
• Remove the cover of the pen
• Take your alcohol swab and wipe the tip of the pen where the needle will attach.
• Some insulin pens like NPH or mixed 70/30, or 50/50 insulin, will need to be gently mixed before use. These types of insulin look cloudy or milky white and need to be gently mixed by rolling the pen between your palms. If you are using a different type of insulin that looks clear like this one, you do not need to mix it. Only the cloudy insulin needs to be rolled.
• Take a new pen needle and remove the protective tab.
• Insert the needle into your pen and screw it on until it is secured.
• Now you want to prime the pen which means removing air from any of the needles. We do that by dialing the pen 2 units. Then, remove the needle cover.
• Point the needle up into the air. Tap on the side of the pen and then press down on the knob. By doing this you have primed the pen and made sure insulin is going through the needle.

Set the pen to your dose. Turn the knob until you see the correct dosage.

Choosing an Injection Site

Now it’s time to choose an injection site.  Insulin can be injected into any of the following sites:

• The stomach. This is the preferred injection site.  Stay at least two inches away from the bellybutton or any scars that you might have.
• You can inject insulin into the fatty tissue at the back of the arm or the top and outer area of the thigh or the upper and outer part of the buttocks. Remember, the insulin needle goes under the skin only, not into the muscle like the flu shot, for example.  Insulin injections in general are easier then intramuscular injections.
• Avoid injecting cold insulin, since this can cause discomfort. When using the insulin pen or vial for the first time, take it out of the fridge at least 30 minutes before injecting so it has time to warm up.
• Rotate the injection sites to use a slightly different spot with each injection and avoid injecting insulin into scar tissues or hard lumps that you may have. Insulin might not be absorbed as well if injected into these areas.  Injecting into the same spot too often can cause hard lumps under the skin and can impair insulin absorption.
• You can rotate the injection sites in a pattern that works for you. Examples of rotation patterns are shown here.

Once you’ve chosen your injection site, wipe it down with alcohol to make sure that it’s clean.

Injecting the Insulin

Now you are ready to inject the insulin.

• Gently pinch the skin with your free hand and quickly insert the needle at a 90 degree angle.
• Release the pinch, push down on the plunger at a steady motion for about 10 seconds until the pen goes back to zero.
• Pull the needle straight out of the skin.

Now that you have taken your injection you need to safely dispose of the pen needle or syringe.  FDA-cleared sharps disposal containers are generally available through pharmacies, medical supply companies, health care providers, and on-line.

If an FDA-cleared container is not available, some organizations and community guidelines recommend using a heavy-duty plastic household container as an alternative.  The container should be leak-resistant, remain upright during use, and have a tight-fitting, puncture-resistant lid, such as a plastic laundry detergent container.

All sharps disposal containers should be labelled to warn of any hazardous waste inside of them.  Follow your community guidelines for proper disposal methods.

• You should always store unused insulin pens in the refrigerator at a temperature of about 40°F or 4.4°C.
• Insulin pens can be used (if refrigerated) until the expiration date that’s listed on them.
• It’s likely that you bought more than one insulin pen at a time. You should store all extra insulin pens in the refrigerator except for the one that you are currently using.
• Remember, do NOT freeze insulin or keep the insulin near ice.
• Do NOT keep insulin in a hot place (warmer than 86°F or 30°C) or in direct sunlight.
• Do NOT use the insulin after the expiration date printed on the pen.
• You can keep the insulin pen that you’re currently using at room temperature (below 86°F or 30°C) for up to eight (8) weeks. The number of days or weeks depends on which pen that you use.

Congratulations!  You’ve just learned how to inject and store insulin.  Taking insulin injections can be a very simple process, and the more you do it, the easier it becomes.  If you would like to learn how to take an injection using a syringe and vial, please watch the next video.

Blood Glucose Monitoring

One of the most important parts of diabetes management is home blood sugar monitoring. Most people with diabetes have a home blood sugar meter that they use to read the level of glucose (or sugar) in their blood. This information is very important to help you and your health care provider make decisions about your treatment including medications, diet, exercise. In this video you will learn what a blood sugar meter or glucometer is, how it works, the best way to get a blood sugar reading at home, safe storage and disposal of the lancet needles and used test strips. Now let us begin. 

Setting up your blood sugar meter:

There are several parts and steps involved in checking your blood sugar. To check your blood sugar, you will need the following:

• The blood sugar meter
• Your lancing device and needles
• Your test strips
• A cotton or tissue
• A log book or another way to track blood sugar information
• A sharps container
• Optional: alcohol swab

How to check your blood sugar level:

First, start by washing your hands with some soap and water. If you are not in a place where this is possible or convenient, you can use an alcohol swab to clean your finger.

Next, insert a lancet or needle into the lancing device. First remove the cap from the lancing device. Then take a new needle and insert it. Then twist the protective cap covering the needle until it comes loose-remember, don’t pull on it until it is loose. Then replace the cap on the lancing device. On most lancet devices, you can decide how deep the needle will poke the finger by adjusting the number on the dial. Higher numbers are deeper, lower numbers are shallower. Take into account your skin thickness. A level 1 may not work on most adults. If you have very tough skin or any calluses, you will likely need a deeper setting. To start, most patients use a level 2.5 or 3.

Next, insert the test strip into the glucose meter. Remember that each meter has its own test strips that must be used. When the strip is inserted correctly the meter will turn on.

Now we need to get a drop of blood. To make this easier and more comfortable, there are a few tips to live by: Only use the sides of the fingers-avoid the tip of the finger and the pad of the finger. Rotate where you poke your finger-don’t always use the same finger twice or you can develop scar tissue. Use different fingers and different sides of the fingers.

Next we need to prepare the lancet to poke the finger. Slide back on the lever if you have one. Then put the end of the lancet to your finger. To make sure you don’t pull your hand away it might help to have your hand flat on a sturdy surface like a table. Now go ahead and poke the finger. Once you have a drop of blood, wipe it away with the Kleenex or the cotton swab. Then, use the second drop to check your blood sugar. Apply it to the strip-there will be a small line on the end of the strip where you will place the blood. When you touch it to the drop of blood, the test strip will “suck” the blood into the strip.

Dispose of the used lancet into a sharps container. Many needles  come with a cap that you can apply to the end that you had removed earlier. This will keep anyone from poking their finger accidentally.

As you can see the blood sugar meter (or glucometer) displays your blood sugar numbers. Most meters automatically store glucose readings as well, sometimes for up to three months. Ot you can record your blood sugar level in a log book or an app if you use one on your phone. 

Store test strips in a cool dry place. They do not need to be stored in the refrigerator and you should avoid storing them in a moist or very hot place. Make sure to check the expiration date on your strips before using them.

When to check your blood sugar:

There are several times during the day that you can check your blood sugar and different times may give you different information. Your healthcare provider will discuss with you the appropriate times and frequency to check your readings based on your treatment regimen. Most people using insulin will need to check about 3-4 times per day, often before meals and at bedtime. People with diabetes who are on oral medications alone may only need to check once per day.

However, it is important to check your blood sugar before you drive, and sometimes before bed especially if you are more prone to having hypoglycemic episodes or low blood sugar levels.

Most people that check only one time per day will check their blood sugar first thing in the morning before they eat or take medications (also called your fasting number).

Here are some points to remember:

1. There are many different types of glucose meters with different features and sizes. Check with your health care provider to find out which meter is best for you.
2. You cannot reuse test strips or the needle in your lancet. Please dispose after each use.
3. Do not use expired test strips-they may not give you accurate readings.
4. Do not throw lancets in the trash-use a sharps container.
5. Make sure the time and date in your meter are correct-don’t forget to change at daylight saving’s time.
6. Bring your meter with you to each visit with your doctor, nurse or dietitian.

Conclusion:

You have now learned how to use a blood glucose meter to monitor your blood glucose at home. When used routinely and properly, it can be a vital tool for you and your provider to manage your blood sugars. Talk to your provider about what your blood sugar targets are, how frequently you should check your blood sugar and what times you should check during the day. Bring your blood glucose meter to every visit, as your providers can learn more about how your diabetes is being managed and make recommendations to improve your control. Remember, the numbers are knowledge and knowledge is power to managing diabetes.

Glucagon

If you or someone you know has diabetes and is on either insulin or other medications that can cause severe low blood sugar, your doctor may have prescribed a medication called glucagon.  Glucagon is an injection that is given to a person who has severe low blood sugar.  If the person is unconscious and unable to take either food or beverage by mouth, you may have to administer this injection.

Remember:  Glucagon is for emergencies only, so it can be helpful to be familiar with the process before the emergency happens.  To help you become more familiar and comfortable with the process, follow along and I will demonstrate how to administer glucagon.

• Open up the glucagon kit.
• There are instructions inside of the kit if you need them later.
• Inside the kit is also syringe full of liquid and a vial full of powder.
• You will need to inject the fluid into the vial to mix up the medication.
• To do this, set the vial on a hard surface and inject the fluid into the vial.
• Remove the syringe and gently mix the powder into the liquid.

Once it’s thoroughly mixed together like this, insert the syringe again and turn both the syringe and vial upside down so that the vial is on top, like this.  Draw up the mixture into the syringe.  Once the syringe is full, remove the vial and make sure you remove any bubbles from the syringe.  Now the injection is ready.

Unlike an insulin injection, the glucagon injection is an intramuscular injection, much like epinephrine.  This means that you have to use some force when giving the injection.  The person receiving this shot will most likely be unaware or unconscious when this shot is given, so don’t be afraid to use more force.  This shot can be given through the clothes and anywhere in the body that there’s muscle but most people give it to the person in the arm or leg or buttocks.

Giving glucagon can be a scary process and is usually an emergency situation.  But now that you’ve seen this video you can refer back to it as needed or look at the instructions in the glucagon kit.