OF DIABETES MANAGEMENT

OF DIABETES MANAGEMENT

DISCLOSURES No financial support or benefit. I am a family physician who believes that the family physician is the best person to treat patients with diabetes. Diabetes is not just about high blood sugar, but it affects every aspect of a patient s being. Every diabetic has the right to information and proper treatment. Diabetes affects both the quality and quantity of a patient s life. It is our duty to treat every diabetic to the best of our ability and to make sure that our ability is based on current knowledge.

OUTLINE 1. The ELEPHANT diet 2. The BUFFALO exercise 3. The RHINO diabetic management 4. The LION medical treatment 5. The LEOPARD diabetic complications

DIET THE ELEPHANT Eats about 300 400 lb of food per day Eats a large variety of leaves, grasses, fruits and seeds Has no body fat

DIET IS THE CORNERSTONE OF THE MANAGEMENT OF TYPE 2 DIABETES (AND TYPE 1) There is no such thing as a diabetic diet, only a healthy diet Children do not just inherit the diabetic genes from their parents, but also learn their eating habits Important to change the family diet rather than punishing the diabetic patient (no time to prepare two different meals)

MAIN DIET TYPES RECOMMENDED FOR DIABETICS 1. Low GI (Limitation GI only refer to carbohydrates) 2. Mediterranean diet (What is it?) 3. Carb counting (We are all different needs to be adjusted for each patient and meal. It is influenced by the fat and acid content and complexity of the meal) 4. High protein/low carb diet (Can cause tiredness, hyperlipidemia, gout. Expensive. Effective to move a lot of weight quickly, but not sustainable) 5. The simple diet more vegetables and less of the rest

MEDITERANEAN VARIATIONS 10-fold reduction in risk of CVD VARIATION BREAD PASTA CEREALS FRUIT VEGETABLES FISH LEGUMES CHEESE WINE OLIVE OIL Italy +++ +++ + ++ ++ ++ + + ++ +++ Greece +++ - + ++ +++ ++ + +++ + +++ France +++ - + + ++ + + +++ +++ ++ Spain + + + ++ ++ ++ + + + +++ North Africa + - +++ + ++ + ++ + - ++ East Basin + - ++ + ++ + + + - ++

Patients need to understand that calorie intake also plays a role Credit card shopping Budget overspending causes trouble Fuel for your car Gas vs diesel

EXERCISE THE BUFFALO Home range of over 10 000sqkm Moves 18 hours per day

EXERCISE SECOND MOST IMPORTANT TREATMENT FOR DIABETES The Big 1 5 0 (150 minutes per week) Moderate Frequent (no more two consecutive off days) Simple changes in daily life (stand and work, stairs, walk wherever possible) Muscles can burn glucose without insulin during exercise Combine resistance and cardio training Some patients will have a tendency to high blood glucose after exercise (due to adrenalin and cortisol production unpredictable) Most patients blood sugar will drop after exercise (medication, snack)

DIABETES MANAGEMENT THE RHINO Large animal with virtually no sight but excellent smell and hearing Sadly hunted to near extinction due to misinformation regarding the magical properties of their horns

RULES OF DIABETES MANAGEMENT 1. DIAGNOSIS Clinical high index of suspicion FBG > 7.1mmol/l Random BG > 11.1 HBA1c > 6.5% 1 H GTT 2. START EARLY AND AGGRESSIVELY De-escalate rather than escalate Success vs failure

3. TESTS AND MONITORING Labs - HBA1c - Lipids - Creatinine/eGFR - Microalbumin/Albumin-creatinine ratio - LFT s (Fatty liver disease) Eyes - Retinal photos - Optometrist - At diagnosis and annually Feet - Shoes off - Monofilament, tuning fork - Podiatrist

Injection sites - Always check - Re-educate - Patients forget - Don t feel? Don t inject - Needles correct length, change frequently Cancer screening - Colon - Breast - Uterus Motivate - Set goals, revisit previous goals eg. Diet, exercise, smoking - Find positives to praise - Information repeat, don t assume that the patient knows - Don t use complications to threaten patients

Make testing worthwhile - Educate patients about goals eg. FBG <7 (8?), PPG <9 - Explain HBA1c what it is, values and realistic targets - Appropriate testing Metformin vs Insulin

HbA1c LIMITATIONS AND USES 1. Diagnosis of T2DM > 6.5% (ADA) 2. Fluctutations = complications 3. Fasting Blood Glucose 4. Post-prandial Glucose (1hr 1hr30min) 5. Questionable use in: Thalassaemia Anaemia Patients on EPO

MEDICAL TREATMENT THE LION The king of the savanna A lion is not a house cat, but a ferocious hunter that needs to be treated with respect

TYPES OF ORAL TREATMENT 1. REDUCE ABSORPTION OF GLUCOSE - Acarbose 2. IMPROVE INSULIN RESISTANCE - Metformin - Pioglitazone 3. STIMULATE INSULIN SECRETION FROM BETA CELLS - Sulfonylureas Gliclazide, Gliburide and Glimepramide 4. MODULATE SATEITY AND GLUCAGON SECRETION - GLP1 - DPP4 Inhibitors 5. INCREASE EXCRETION OF GLUCOSE - SGLT2 Inhibitors

TYPES OF INSULIN 1. LONG ACTING Glargine (Lantus) 2. INTERMEDIATE ACTING NPH (Humulin N, Novolin N) Detemir (Levemir) 3. SHORT ACTING Insulin regular (Humulin R, Novolin R) 4. ANALOGUES Glulisine (Apidra) Lispro (Humalog) Aspart (NovoLog) 5. MIXED INSULIN NPH/Regular (Humulin 30/70, Novolin 30/70) Insulin lispro protamine/insulin lispro (Humalog mix 75/25, 50/50) Insulin aspart protamine/insulin aspart (NovoLog mix 30/70)

RULES OF INSULIN TREATMENT 1. Start early - HBA1c > 8.5% - Rising HBA1c - Weight loss - High FBG, PP readings despite treatment 2. Start low - 10u QAM 3. Go slow - Add 2 units every 3 rd day 4. Titrate - Constantly (diabetes is a progressive disease) 5. Rotate - Check injection sites and re-educate at every visit

COMPLICATIONS THE LEOPARD One of the big 5 cats of the world Nocturnal predator that stalks its prey by stealthy movements in the tall grass It spotted coat provides a perfect camouflage that allows the leopard to hunt from trees and pounce on unsuspecting pray

COMPLICATIONS OF DIABETES 1. Cardiovascular (MI, stroke and PVD) 2. CKD 3. Amputations : neuropathy and PVD 4. Retinopathy : blindness 5. ED/sexual dysfunction (male and female)

Control linked to complications Treatment control: good glycemic control reduced vascular complications Kumamoto UKPDS HbA1c 9 7% 8 7% Retinopathy 68% 21% Nephropathy 74% 34% Neuropathy - No Change

Microvascular Disease Peripheral Vascular Disease MI Stroke Heart Failure Cataract Extraction 0% UKPDS Fidnings - Risk Reduction with 1% decline in mean A1c -5% -10% -15% -14% -12% -16% -20% -19% -25% -30% -35% -31% -40% -45% -42%

IMPORTANT WAYS TO DIAGNOSE AND MANAGE DIABETIC COMPLICATIONS 1. Listen : classical symptoms of CAD often not present in diabetics 2. Look : shoes and socks off, injection sites 3. Ask : sexual dysfunction under reported by patients 4. Feel : Foot pulses, dry skin, mono-filament 5. Manage : Optometrist, podiatrist and optimize treatment

CONCLUSION : THE 5 PILLARS OF DIABETIC MANAGEMENT 1. Early diagnosis 2. Proper education 3. Motivation and re-education 4. Early, aggressive treatment (de-escalation vs. escalation) 5. Prevention and effective management of complications