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
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The ELEPHANT – diet
The BUFFALO – exercise
The RHINO – diabetic management
The LION – medical treatment
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
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Greece
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France
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Spain
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North Africa
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East Basin
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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
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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
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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
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Injection sites
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Cancer screening
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Always check
Re-educate
Patients “forget”
Don’t feel? Don’t inject
Needles – correct length, change frequently
Colon
Breast
Uterus
Motivate
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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
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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
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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 3rd 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
UKPDS Fidnings - Risk Reduction with 1% decline in mean A1c
-20%
-25%
-30%
-35%
-40%
-45%
-42%
Heart Failure
MI
-31%
-12%
-14%
Cataract Extraction
-15%
Peripheral Vascular Disease
-10%
Microvascular Disease
-5%
Stroke
0%
-16%
-19%
IMPORTANT WAYS TO DIAGNOSE AND
MANAGE DIABETIC COMPLICATIONS
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Listen : classical symptoms of CAD often not present in diabetics
Look : shoes and socks off, injection sites
Ask : sexual dysfunction under reported by patients
Feel : Foot pulses, dry skin, mono-filament
Manage : Optometrist, podiatrist and optimize treatment
CONCLUSION : THE 5 PILLARS OF
DIABETIC MANAGEMENT
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Early diagnosis
Proper education
Motivation and re-education
Early, aggressive treatment (de-escalation vs. escalation)
Prevention and effective management of complications