Diiabetes prevention and management

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Diabetes Prevention and Management :1 Diabetes Prevention and Management Dr.Gyanendra Lamichhane LEI, Bhairahawa

Why are We Concerned about Diabetes? :2 Why are We Concerned about Diabetes? Every 24 hours... 3,600 new cases of diabetes are diagnosed. 580 people die of diabetes-related complications. 225 people have a diabetes-related amputation. 120 people with diabetes progress to end-stage renal disease. 55 people with diabetes become blind.

A Constellation of Complications :3 A Constellation of Complications Diabetes

MILD NPDR :4 MILD NPDR

Moderate NPDR :5 Moderate NPDR

Severe NPDR :6 Severe NPDR

PDR :7 PDR

Advanced Diabetic Eye Disease :8 Advanced Diabetic Eye Disease

Indicators of Good Health :9 Indicators of Good Health Blood pressure of 130/80 or lower Total cholesterol below 200 Hemoglobin A1c below 6.5% Feeling well and being active A waistline below 35 inches

Stay Healthy :10 Stay Healthy These are things all people have to do to stay healthy: Avoid smoking Get regular exercise Eat a balanced diet Weight management

Important for individuals with risk factors for Diabetes :11 Important for individuals with risk factors for Diabetes Obesity Sedentary lifestyle Family history of type 2 diabetes - Native American, Hispanic, African American, Asian American, Pacific Islander

Carbohydrate Metabolism :Glucose (G) Insulin I I I I I I I I G G G G G G G G I G G G Adipose tissue Liver Pancreas Muscle Gut I G Stomach Carbohydrate Metabolism Adapted from Kobayashi M. Diabetes Obes Metab 1999; 1 (Suppl. 1):S32–S40.Nattrass M & Bailey CJ. Baillieres Best Pract Res Clin Endocrinol Metab 1999; 13:309–329.

Metabolism without Diabetes :13 Metabolism without Diabetes Insulin Sugar SI SI SI SI S S Body Blood

Metabolism without Diabetes :14 Metabolism without Diabetes Insulin Sugar S S S S S S S Blood Body S

Metabolism with Diabetes :15 Metabolism with Diabetes Insulin Sugar SI SI SI S S S Body Blood S S S

Metabolism with Diabetes :16 Metabolism with Diabetes Insulin Sugar SI SI SI S S S Body Blood S S S S

Prevention of Diabetes :17 Prevention of Diabetes Type 1 diabetes - Currently there is no way to prevent . -- Has been made feasible by the unraveling of the immunogenetics of the disease and the identification of at-risk subjects --The risk of developing diabetes is clearly increased in families where a family member is affected by Type 1 diabetes Type 2 diabetes Maintaining an ideal body weight and an active lifestyle may prevent

Prevention of Diabetes(ADA Recommendation) :18 Prevention of Diabetes(ADA Recommendation) 1) Life style change 2) weight loss 3) Nutrition 4) Physical activities 5) Education

Prevention of Diabetes :19 Prevention of Diabetes Diabetes Prevention Program 1) Lifestyle changes Changes in eating habits Increase in physical activity 58% reduction in incidence of type 2 diabetes

Prevention of Diabetes :20 Prevention of Diabetes 2) Weight loss 5% to 10% weight loss Weight loss rate of 1 to 2 lb/week Decrease of 300 to 500 kcal/day = 1/2 to 1 lb weight loss/week Increased physical activity and/or decreased food intake

3) Nutrition :21 3) Nutrition ADA Nutrition Recommendations Total Daily Energy Intake Carbohydrate – 60-70% Protein – 15-20% Fat - 10% from polyunsaturated fats < 10% from saturated fats Fibers

Prevention of Diabetes :22 Prevention of Diabetes Healthy Nutrition Recommendations: Decrease total fat intake smaller amounts of high fat foods (ghee, butter, cheese) remove skin from chicken substitute with low calorie/low-fat foods (fruits /vegetables)

Prevention of Diabetes :23 Prevention of Diabetes Healthy Nutrition Recommendations: Increase fruits and vegetables Include dry beans and lentils Drink water & calorie free drinks Cut back on high calorie snacks Avoid Junk food ( burgers, sandwich)

Slide 24:24 . Avoid fatty acids. Increase dietary fiber reduces the speed at which carbohydrates are absorbed and increases tissue sensitivity to insulin

Slide 25:25 Biotin – It helps the body in metabolizing carbohydrates, proteins and fats. Chromium – It aids the metabolism of glucose. It is most effective if consumed as niacin. Vitamin E – It helps in improving insulin sensitivity. Magnesium – It helps in lowering blood pressure and reducing heart-attack risks by relaxing the muscle tissues.

Slide 26:26 . Omega 3 and Alpha Lipoic Acids - They are effective building blocks and anti-oxidants respectively. They reduce the risks associated with nerve damages by aiding balancing of blood sugar. Vitamin B6 – It helps in preventing neuropathy. Vitamin D – It helps in reducing insulin resistance and averting the risks of cataract. Zinc – It helps in improving the action of insulin

Prevention of Diabetes :27 Prevention of Diabetes Healthy Nutrition Recommendations: Rate your plate ¼ grains or starchy foods ¼ protein ½ non starchy vegetables Add 1 glass milk or small piece of fruit

Prevention of Diabetes :28 Prevention of Diabetes 4) Physical Activity Benefits: Increases insulin sensitivity Decreases weight Decreases blood pressure and cholesterol Decreases stress ( esp. by yoga and pranayam)

Prevention of Diabetes :29 Prevention of Diabetes Physical Activity Recommendations: 30 minutes/day for 5 to 7 days a week or 10 minutes of activity 3 times/day Physical activity causes sugar to be transported to your cells, where it's used for energy, thereby lowering the levels in your blood fat makes your cells more resistant to insulin. But when you lose weight, the process reverses and your cells become more receptive to insulin. How it helps??????????

Prevention of Diabetes :30 Prevention of Diabetes How to Get started ?????????? What activities can you do Start slow: What, when, where, how often, how long Challenging but not overly difficult Be flexible

Exercise Choices :31 Exercise Choices Choose an exercise that you enjoy and that fits your personality

5) Health education :32 5) Health education if significant health education is offered at the community level, then motivational interviewing and collaborative problem solving can be offered in the clinical setting All categories of health care professionals can play a crucial role in their communities by raising community awareness about the importance of programs

Slide 33:33 Treatment of Diabetes

Should understand that….. :34 Should understand that….. Multidisciplinary team management Physician alone usually is not able to meet the goal team usually is composed of a physician, a registered dietitian, a nurse clinician, a social worker, and the patient and the family Comprises of a) management of Diabetes proper (control of blood sugar) b) management of complications

Principles of management(Diabetes) :35 Principles of management(Diabetes) 3Ds Discipline Diabetic Diet Drugs---OHA / Insulin

A) Discipline :36 A) Discipline 1) Disease idea to the patient 2) Lifestyle change 3) Diet chart 4) Care of foot 5) A card containing identification and mentioned diabetic drug 6) Idea about hypoglycemic shocks

B) Diabetic Diet :37 B) Diabetic Diet 1) Restricted diet- sweet, sugar 2) Measured diet- first calculate total amount of calories required by a diabetic patient depending upon age and state of obesity CHO PROTEIN FAT (60%) (20%) (20%)

ADA Recommendation :38 ADA Recommendation

Treatment :39 Treatment Monitoring blood sugar Food---- A healthy diet, more fruits, vegetables and foods that are high in nutrition and low in fat and calories and fewer animal products and sweets.

C) Pharmacologic TherapyDRUGS :40 C) Pharmacologic TherapyDRUGS Selection of therapy should be individualized based upon potential side effects.

Slide 41:41 When diet, exercise and ideal body weight aren’t enough to maintain normal blood sugar level------------------ may need to start medication Some people who begin treatment with oral medications eventually need to take insulin. Unfortunately, insulin cannot be taken in pills form because enzymes in your stomach alter it, which makes it ineffective. Hence, insulin is taken with insulin syringe or insulin pump. Loss of weight not only helps in fitness but also in control of blood sugar levels. Losing 10% of initial body weight and regular exercise can immensely reduce the risk of diabetes

Type2 DM treatment Protocol :42 Type2 DM treatment Protocol weight Not obese Diet Sulphonylures Poor control Trail of insulin Obese Diet Metformin Metfornin plus sulphonylurea (OHA) (OHA)

Treatment contd…. :43 Treatment contd…. MedicationsWhen diet, exercise and maintaining a healthy weight aren't enough A) Insulin B) OHA A) insulin---- Everyone with IDDM DM with complications like ketoacidosis, nephropathy NIDDM failure to OHA NIDDM with stressful condition e.g. pregnancy, surgery ,infection 2injections 3 injections 4 injections (BB,BE) (BB,BE,BB) (BB,BL,BE,BB) Subcutaneous skin of thigh and abdomen

B) Oral Hypoglycemic agents(Sulfonylureas) :44 B) Oral Hypoglycemic agents(Sulfonylureas)

Oral Hypoglycemic agents :45 Oral Hypoglycemic agents Sulphonylurea— Stimulate the pancreas to make more insulin Biguanides--- works by inhibiting the production and release of glucose from liver, which means you need less insulin to transport blood sugar into your cells Metformin Alpha-glucosidase inhibitors block the action of enzymes in your digestive tract that break down carbohydrates. That means sugar is absorbed into your bloodstream more slowly, which helps prevent the rapid rise in blood sugar that usually occurs right after a meal. acarbose (Precose) and miglitol Thiazolidinediones--make your body tissues more sensitive to insulin and keep your liver from overproducing glucose. rosiglitazone

Primary Sites of Action of Oral Antihyperglycemic Agents :Glucose (G) Insulin I I I I I I I I G G G G G G G G I G G G Adipose tissue Liver Pancreas Muscle Gut I G Stomach Primary Sites of Action of Oral Antihyperglycemic Agents Adapted from Kobayashi M. Diabetes Obes Metab 1999; 1 (Suppl. 1):S32–S40.Nattrass M & Bailey CJ. Baillieres Best Pract Res Clin Endocrinol Metab 1999; 13:309–329.

Therapeutic Agents for Type 2 Diabetes :47 Therapeutic Agents for Type 2 Diabetes Mechanism of Action Agent Sensitize the body to insulin Thiazolidinediones, Biguanides Control hepatic glucose production Biguanides, Thiazolidnediones Stimulate the pancreas to Sulfonylureas make more insulin Meglitinides Slow the absorption of starches Alpha-glucosidase inhibitors Decreases hepatic glucose Insulin production and increases peripheral glucose uptake

Surgical Treatment :48 Surgical Treatment Transplantation Pancreas transplantation Islet cell transplantation for people whose kidneys are failing or who aren't responding to other treatments.

Management of Complications :49 Management of Complications Good control of Blood sugar is the first step

Retinopathy :50 Retinopathy Nonproliferative ,proliferative LASER Photocoagulation Advanced stage —surgery (vitreoretinal)

Laser Photocoagulation :51 Laser Photocoagulation

Vitrectomy – blood removal :52 Vitrectomy – blood removal

Diabetic Neuropathy :53 Diabetic Neuropathy Blood sugar control Symptomatic treatment painful neuropathy--TCA

Diabetic Nephropathy :54 Diabetic Nephropathy Control blood sugar Control blood pressure Low protein diet CRF- dialysis ,transplantation

Diabetic foot :55 Diabetic foot Good control of blood sugar Foot care Avoid trauma Prevention of infection

How Family and Friends Are Affected :56 How Family and Friends Are Affected Sometimes they may be upset when your changes affect them in ways such as not buying sweets or going for a walk instead of watching TV Eventually they come to accept the needed changes and feel better too.

Slide 57:57 THANK YOU