Idf course module 2 overview of diabetes management
- 1. IDF BASIC DIABETES COURSE Module TWO An Overview of Diabetes Management
- 2. ON COMPLETING THIS COURSE YOU SHOULD BE ABLE TO: 1. Understand the importance of patient education in diabetes 2. Understand the importance of ongoing monitoring and assessment 3. Understand the action of insulin and other diabetes treatments 4. Understand the common complications of diabetes 5. Understand basics of gestational diabetes
- 3. AGENDA
- 8. BACKGROUND Diabetes Mellitus was first documented by the Ancient Greeks. However it was not until the 20th century that the role of insulin was discovered, and insulin was first used as a treatment by Dr Fredrick Banting and Charles Best in 1921.
- 9. Type 1 diabetes is an autoimmune disorder where insulin is not produced by the pancreas. Type 2 diabetes is a progressive disease, characterised by a lack of insulin sensitivity and an increase in insulin resistance in the body. Exogenous insulin injections may be required by some individuals with type 2 diabetes to enable glycaemic control Type 2 diabetes is also associated with a number of modifiable risk factors. These include unhealthy diet, lack of physical activity and sedentary lifestyle. Type 2 diabetes can be diagnosed from a standard oral glucose tolerance test involving a 75g carbohydrate based drink. In 2015, it was estimated that nearly 5 million people died as a result of diabetes. Sugar sweetened beverages have been shown to increase your risk of developing Type 2 diabetes.
- 10. The Diabetes Complication and Control Trial (DCCT 1993) and The United Kingdom Prospective Diabetes Study (UKPDS 1998) were two ground-breaking studies that truly identified the need for people with diabetes to obtain optimal control in order to prevent complications. The associated complications of diabetes are well documented: Microvascular involving small vessels - capillaries Macrovascular involving large vessels - arteries Neuropathic (nerve damage) Others - periodontal, soft tissue and psychological problems
- 11. common complications of diabetes
- 12. THE IMPACT OF MANY COMPLICATIONS CAN BE GREATLY REDUCED IF THEY ARE PICKED UP EARLY AND APPROPRIATE TREATMENT GIVEN. THEREFORE REGULAR SCREENING IS VERY IMPORTANT.
- 15. SELF MANAGEMENT EDUCATION IN DIABETES With the right education and regular access to health professionals, a person with diabetes can make the appropriate changes to their life and better improve control of their diabetes. The role of the diabetes educator is to encourage realistic behavior change by providing the right level and amount of education in any one time. Diabetes educators and health professionals engaging in diabetes education should remain unbiased and approachable. Gaining the trust of the person with diabetes is essential to them incorporating changes within their lives.
- 16. DIABETES SELF MANAGEMENT EDUCATION (DSME) (DSME) is an ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based research. The overall objectives of DSME are to support informed decision making, self- care behaviors, problem solving, and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life.
- 17. Diabetes self management support (DSMS) refers to the support that is required for implementing and sustaining coping skills and behaviors needed to self-manage on an ongoing basis. Patient-centred care refers to providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
- 19. ASSESSMENT AND MONITORING You will have already covered the symptoms of diabetes These symptoms may be a sign of suboptimal diabetes control, if reported by your patient. They are caused by hyperglycemia. During your consultation you may wish to ask if these symptoms are particularly noted on certain days or nights, or following certain foods etc.
- 20. Glycated haemoglobin is used to assess overall diabetes control. In poorly controlled diabetes more glucose molecules become attached to haemoglobin increasing the proportion that is glycated. Measurement of HbA1c reflects the level of glycaemic control of an individual over the past 8-12 weeks. It is generally accepted that a target HbA1c of 7.0% or 53mmols/mol would significantly reduce the risk of microvascular complications. However, consideration must be given to the social and medical circumstances of each individual (for example a higher target would be more appropriate in the elderly or those prone to unrecognized hypoglycemia). HbA1c
- 21. IDF GLOBAL GUIDELINES FOR HbA1CTARGETS Publication* Target IDF/ISPAD Diabetes in childhood and adolescents 2011 <7.5% or <58mmol/mol IDF managing older people with type 2 diabetes 2013 Functionally independent person: 7-7.5% or 53-59 mmol/mol Functionally dependant person: 7-8% or 53-64mmol/mol Global guidelines for managing type 2 diabetes 2012 <7% or <53mmol/mol
- 22. INSULIN
- 23. Normal Insulin Secretion In a person with a fully functioning pancreas a low level of insulin is released continuously. This is referred to as 'basal' insulin secretion. A post-prandial 'bolus' of insulin is released following a meal, as shown in this diagram.
- 24. The most physiological insulin replacement regimen is known as a basal bolus regimen. This can be given by multiple daily injections or by using an insulin pump. This replicates the normal function of the pancreas it can provide very good control of blood glucose levels. Unfortunately some insulin regimens may not be available to all people with type 1 diabetes. Basal Bolus Regimen
- 33. SICK DAY RULES 1. People with type 1 diabetes need to know how to manage their insulin treatment during periods of sickness. Unfortunately some health professionals give inappropriate advice during these times and this can be dangerous and lead to ketoacidosis. 2. During sickness, blood glucose levels are likely to rise with the body’s natural response to infection. 3. It is vital that people with type 1 diabetes DO NOT STOP TAKING INSULIN even if unwell. They may in fact need an increase in insulin dose if the illness is prolonged. 4. Encourage fluids to avoid dehydration. 5. If the person tests their blood glucose, they may need to check more frequently. 6. The person will need to check ketone levels (in urine or blood). 7. A person who has raised ketones and is vomiting should be admitted to hospital. 8. Follow your health care provider's sick day recommendations.
- 34. TYPE 2 DIABETES International recommendations agree that the initial treatment of type 2 diabetes should be lifestyle change, focusing mainly on healthy eating and increased physical activity. HEALTHY EATING PHYSICAL ACTIVITY ORAL MEDICATIONS
- 35. HEALTHY EATING In the management of type 2 diabetes, it is important to focus on achieving and maintaining a healthy body weight (ideally a body mass index between 20 and 25 (23 in some Asian populations). For many people, this will require weight loss. Achieving this will help reduce blood glucose levels. Healthy eating guidelines are presented in a variety of ways, such as a healthy food plate, pyramid, palm tree and even rainbow. You may have a local pictorial tool to help educate people with diabetes on this topic.
- 36. HEALTHY EATING The Basics. It is important to minimize intake of sugars and refined or other fast- acting carbohydrates, such as potatoes, white rice or white bread; it is also important to increase intake of fresh leafy vegetables, fruits and foods with healthy fats (such as nuts and fish). Given the socio-economic, cultural, educational and linguistic diversity of people with diabetes it is clear that one single approach cannot work in all practices. There is a clear need for a diversity of approaches to nutritional education or, at least, flexibility in attending to the very different needs of people with diabetes.
- 37. HEALTHY EATING Behavior change can be difficult, and rather than just providing patients with the knowledge, success may come around helping them to figure out some meal related positive changes. Once barriers to this change are identified, solutions will help to start the beneficial process.
- 39. PHYSICAL ACTIVITY For people who have not done exercise for some time, the idea of starting may be daunting. It is important to highlight that any increase in physical activity is better than none at all. Any increase in activity levels will help - this may require in depth exploring of a person lifestyle and capabilities. However it should be possible for most people to find a way of increasing their activity levels (eg walking to work/ taking the stairs instead of the elevator).
- 40. ORAL MEDICATIONS If, despite lifestyle modifications, a person’s diabetes remains suboptimally controlled, consideration should be given to treatment with Oral Hypoglycemic Agents (OHAs). There is general agreement that metformin is the first line treatment: it is safe, inexpensive, widely available and effective. It may be necessary to add other agents.
- 43. TYPE 2 DIABETES INTRODUCTION TO INSULIN We have already looked at insulin and the regimens used in people with type 1 diabetes. Sometimes, people with type 2 diabetes also require treatment with insulin, if their beta cell function is severely impaired. In type 2 diabetes insulin is often added to oral or injectable agents, initially as a single injection of intermediate-injecting insulin (for example NPH insulin). Take a look at these examples:
- 48. OTHER HEALTH CHECKS Due to potential complications associated with diabetes, some of which may be asymptomatic, it is vital that people with diabetes receive a number of health checks at least once a year.
- 49. FOOT CHECKS
- 51. RETINAL SCREENING Retinopathy is a microvascular complication in which capillaries in the retina are affected by long term hyperglycaemia, leading to leakage from the capillaries and ischaemia in the areas served by them. This ischaemia can stimulate formation of new blood vessels (neovascularisation). These new blood vessels are weak and liable to haemorrhage, causing sometimes permanent visual impairment. Up until this late stage, retinopathy does not cause any symptoms. Thus it is essential that everyone with diabetes is examined for the presence of retinopathy. This can be done by directly examining the retina using an ophthalmoscope or retinal photography, with the images transmitted to an expert to be assessed for the presence and extent of retinopathy. Many countries have national guidelines for eye screening. In 2015, IDF launched the eye health guide, to provide recommendations on the screening and treatment of retinopathy.
- 57. HYPOGLYCAEMIA Hypoglycemia (or hypos) can cause serious problems if left untreated, including coma, hypoxic brain injury and death. People should be advised to treat a hypo as quickly as possible with carbohydrate. Hypoglycemia is a common side effect of insulin use. It can be defined as a plasma blood glucose of <4.0mmol/l or 72mg/dl and is caused by too much insulin being in the bloodstream. This may result from too much insulin being injected for the carbohydrate taken in a meal, or from unplanned exercise, excess alcohol or poor injection sites causing delayed insulin absorption. Symptoms of hypoglycemia can vary between people and can change during a person`s life. Symptoms can be split into two categories: Neuroglycopeanic: The brain`s response to reduction in glucose Autonomic: The body`s fight or flight mechanism, mediated by adrenaline
- 60. HYPOGLYCEMIA SYMPTOMS • Trembling • Palpitations • Sweating • Anxiety • Hunger • Nausea • Tingling • Difficulty concentrating • Confusion • Weakness • Drowsiness • Vision changes • Difficulty speaking • Headache • Dizziness AUTONOMIC NEUROGLYCOPEANIC
- 61. IDF recommends 15-20g quick acting carbohydrates should be taken, followed by a further 20g of slower acting carbohydrate.
- 62. Recommended quick acting CHO: Recommended slower acting CHO: Glass of orange juice (150mls) 1 slice of Bread Half glass of fizzy soda (non diet version) Half a bowl of cereal (eg cornflakes) 6 glucose tablets Glass of milk (150mls) 3 teaspoons of table sugar in water 1 medium sized piece of fruit (eg apple, pear) 5 jelly based sugary sweets 1 pot of sugar-sweetened yoghurt
- 64. ACUTE HYPERGLYCAEMIA Acute hyperglycaemia (when blood glucose level s rise above 13mmol/l or 234mg/dl) can be associated with typical symptoms of hyperglycaemia (the symptoms of diabetes).Short periods of hyperglycaemia are not uncommon (for example after a high carbohydrate meal) and unlikely to be harmful. However prolonged hyperglycaemia increases the risk of infections and delayed healing and over time increases the risk of long term complications.
- 66. DIABETIC KETOACIDOSIS (DKA) DKA occurs when there is little or no insulin available in the body. This leads to glucose remaining in the blood stream and to hyperglycaemia and dehydration. Body fat is broken down rapidly for an energy source and as a result of this process, ketones are produced and build up in the blood stream. The excess of ketones causes acidosis and, along with the hyperglycaemia, can result in a coma or even death. DKA requires urgent hospital admission for treatment with intravenous insulin and fluids. While usually associated with type 1 diabetes, DKA can sometimes occur in type 2 diabetes during severe illness. DKA could be the first manifestation of Latent Autoimmune Diabetes of Adulthood (LADA),and should be treated with insulin.
- 68. HYPERGLYCAEMIC HYPEROSMOLAR STATE (HHS) This is an acute complication arising from decompensated type 2 diabetes, which is often triggered by an infection or other illness. HHS was previously referred to as hyperosmolar, non ketotic coma (HONK) or hyperglycaemic, hyperosmolar, non-ketotic syndrome (HHNS), however, not all cases result in coma. Prolonged severe hyperglycaemia leads to dehydration and a hyperosmolar condition (with typically a very high sodium level) but without acidosis. It often occurs in older people and can lead to focal or global neurologic deficits. It requires treatment with intravenous fluids and insulin.
- 69. GESTATIONAL DIABETES Gestational diabetes (GDM) occurs in women who develop resistance to insulin and subsequent high blood glucose during pregnancy. GDM usually occurs after the twenty-fourth week of pregnancy, as the level of "pregnancy hormones" is increased with the growing fetus. This results in an "insulin resistant" state in the mother's body and an increased requirement for maternal insulin production. As gestational diabetes normally develops later in pregnancy, the unborn baby is already well-formed but still growing. Uncontrolled gestational diabetes can lead to excessive growth of the baby and problems during delivery. All Women who had GDM should be screened for diabetes following the pregnancy. They should also be give lifestyle advise as they are at an increased risk of developing to type 2 diabetes later in life.