PA M4 L1 Objective Objective • To know the general principles of management of diabetesmellitus. • To discuss/learn the issues regarding adjustment of one’s/ individualdaily life by setting specific targets that will enable living healthy in spite ofdiabetes. • To acquire the skill on self monitoring of blood glucose (SMBG), urinary glucose, protein and ketone body tests, etc. • To discuss/learn the basic principles of dietary modification in diabetes and to teach healthyeating. • Tomake/ advicerecommendations for intensity, duration and frequency of exercise for individualpatient. PB M4 L2 General Principles in Management of DM Management of diabetes mellitus, till date, in general aimed at supporting people to live with minimum or no risk of complication(s). • This is achievable through some specific goals of blood glucose, blood pressure, lipids, body weightetc. • The specific or set goals are termed as targets. "Treat to target" is the principle of management ofDM. • There are algorithms for initiation, maintenance and switching over to other regimen for Treat toTargets. Key points • Diabetes mellitus is a life-long disorder. Diabetic Education (DE) is an important component todevelop knowledge, skill and attitude of patient and family to take part inmanagement. • T1DM is a deficiency disorder from the onset and its management is ‘efficient replacement of the deficiency,’ and lifestyle is to be synchronized with insulinadministration. • T2DM is a more complex disorder, and here lifestyle modifications/interventions have the potentiality to correct some of factors which are not only proven as risk factors for developing diabetes but also responsible for deterioration in glycemic status and development of other co-morbidities e.g. hypertension, cardiovascular diseases, dyslipidemia etc. • A significant portion/numberof these T2DM patients can achieve and maintain the goals set for management with only lifestyle measures for a reasonable period (if diagnosed early). Drug therapy is added along with the lifestyle changes when the treatment target falls below that is to be achieved, or when there is compelling reason. The lifestyle modification becomes more important as because that needs to be synchronized withdrug. General Treatment Components of Diabetes mellitus DiabetesMellitus MNT Exercise Medication Monitoring Target N.B: MNT - Medical Nutrition Therapy E D U C A T I O N PB M4 L3 Aims and steps of Treatment of DM Aims and steps of treatment of DM are shown in tables below Aims of treatment of DM 1. To make the patient symptom-free 2. To maintain (near) normal blood glucose level round the clock or most of the time of the day 3. To prevent acute metabolic derangement, such as hypoglycemia, ketoacidosis, HHS etc 4. To prevent or delay chronic complications of diabetes, such as nephropathy, retinopathy, neuropathy etc 5. To ensure proper growth and development of children or young subjects 6. To maintain health of pregnant and lactating mothers 7. To support a productive and socially respectful life Steps of management of DM Steps 1. Confirmation of diagnosis 2. Analysis of factors to initiate treatment 3. Targets of treatment (glycemic & nonglycemic) 4. Selection & initiation of a treatment regimen 5. Monitoring & changing treatment regimen 6. Screening for complications & referral 7. Evaluation PB M4 L4 Step 1. Diagnosis and 2. Factor Analysis Step 1 and Step 2 of treatment of DM are shown tables below Step 1. Confirmation of Diagnosis by Test Tests for confirmation of diagnosis OGTT is the standard test for diagnosis. Other tests: FBG only, HbA1c, RBS can also be done. See details in Module 2 Step 2. Analysis of Factors Factors (patient factors may influence the choice of initial treatment regimen) 1. Type of DM 2. Associated conditions 3. History • Age of theperson • Bodyweight • Acute/chronic complications/illnesses, pregnancy/lactation, major surgeryetc. • Lifestyle of the person • Degree ofhyperglycemia • Previous anti-diabetic agents (if any) • Socio-economiccondition PB M4 L5 Step 3.Targets of Treatment Treat to targets is the most important agenda in management of DM. Treatment targets of DM are glycemic, lipid and others as follows: Blood (plasma) glucose (For adult) Parameter Target 1. Fasting /pre-meals < 6.0 mmol/L 2. Non-Fasting/post meals? < 8.0 mmol/L 3. HbA1c < 7.0 % Blood Lipids Parameter Target 1. LDL cholesterol < 100 mg/dl 2. HDL cholesterol > 40 mg/dl (male) & > 50 mg/dl (female) 3. Triglyceride < 150mg/dl Other Targets Parameter Target 1. Blood Pressure Systolic < 140 mm of Hg & Diastolic < 80 mm of Hg. 2. Body weight BMI < 25kg/M2 & Waist circumference (WC) < 90 cm (male) < 80 cm (female) 3. Diabetic Education Teaching, training & empowerment to take part in treatment Pa P-B M-4 L-6 Step 4: Selection & Initiation of a Treatment Regimen Key points on selection of regimen for treatment at diagnosis • • • • Severity of Glucose Intolerance is the primary determinant of initial treatment regimen in T2DM. Insulin is the single treatment option in T1DM In GDM if lifestyle fails to achieve the glycemic target only insulin is added. Principles of T2DM is mostly followed in other type of DM. Type Lifestyle based • lifestyle+ Insulin sensitizer Consist of (+ other)* Secretagogue based • Insulin secretagogue with lifestyle+ Insulin Insulin based • Insulin with lifestyle+ Insulin sensitizer (+ other) sensitizer (+ other) Used in T2DM & GDM T2DM All types of DM Termed Regimen A Regimen B Regimen C *Thiazolidinedione, alpha-glucosidase inhibitor, DPP-4 inhibitor, GLP-1 agonist, amylin analogue, SGLT2 inhibitors etc Which regimen to choose to start treatment of Type 2 DM? Lifestyle based Secretagogue based Insulin based Lifestyle+ Insulin sensitizer (+ other) • Insulin secretagogue with Lifestyle+ Insulin • HbA1c <8% • HbA1c 8 –<10 % • HbA1c > 10% • (FBG <11.1 mmol/L) • (FBG 11.1 -<16.7 mmol/L) • (FBG >16.7 mmol/L) sensitizer (+ other) When there is contraindication of secretagogue regime A or C can be used • Insulin with Lifestyle+ Insulin sensitizer (+ other) P-B M-4 L-7 Step 5: Monitoring & Changing Treatment Regimen Monitoring of DM Glucometer and SMBG Blood Glucose test is done by glucometer covering pre-meal, post-meal and critical periods in persons. Laboratory test HbA1c If all these facilities are unavailable, blood glucose measurement at laboratory can be done HbA1c should be tested at diagnosis and during follow up of DM because it helps in selection / change of a therapeutic regimen. Structured different pre-and post-meal blood glucose testing should be done so that it helps in decision making in treatment. See some examples below: SMBG of an Adult with Type 2 DM • All values (pre & post meals) are withintargets. • Existing treatment is continued • Provided any drug(s) of the regimen do not have any limitation inuse. SMBG of an Adult with Type 2 DM • All values (pre & post meals) are higher than targets but post meals are not higher than pre meal(<+4mmol/L) • Treatment priority will be to bring fasting blood glucose totarget • It is done by adding or increasing dose of long acting secretagogues /insulin. SMBG of an Adult with Type 2 DM • Fluctuating or Erratic values. • Priority will be to look into lifestyle (meals, physical activitiesetc). • Education (Diabetic Education) is to be strengthened in addition to treatmentregimen. Treatment Regimen and HbA1c in T2DM Regimen A Regimen B Lifestyle ± Metformin (± Others ) Lifestyle ± Secretagogue ± Metformin ± Others Continue Regimen A • so long HbA1c < 7% ( forAdult) • if not go to Regimen B Continue Regimen B • so long HbA1c < 7% ( forAdult) •or no contraindication of Secretagogue • if not go to Regimen C Regimen C Lifestyle ± Insulin ± Metformin ± Others Continue Regimen C • maintain HbA1c withintarget P-B M-4 L-8 Step 6: Complications Screening, Referral & Step 7: Treatment Evaluation Step 6. There are 2 basic components of diabetes management Screening and referral 1. Early detection of complication by routine screening. 2. Appropriate referral Step 7. The whole management strategy should be analyzed and evaluated from time to time so that the best treatment can be offered. Evaluation • Continuous evaluation is an integral step of DM management. • The whole management strategy should be analyzed and evaluated from time to time P-B M-4 L-9 Lifestyle Modification in DM The important issues of lifestyle of diabetics (also prediabetics): • Appropriate lifestyle of diabetics include their dietary habit, physical activity and exercise, regular monitoring of blood glucose, physical care such as foot and oral care, regular follow up etc. Lifestyle Management of DM include Diet • Healthy Dietary habit Physical activity • Regular Physical activity /exercise Monitoring • Regular monitoring of blood glucose, • Physical care such as foot and oral care, • Regular follow up etc. P-B M-4 L-10 MNT in DM MNT A proper diet is a fundamental element of therapy in all diabetic individuals. An appropriate dietarymanagement is called Medical Nutrition Therapy(MNT). Some important terms relevant to MNT • Diet: A proper diet is a fundamental element of therapy for all diabetic individuals . A diet recommended for adiabetic patient is, in fact, a ‘balanced diet’ for any one. • Balanced diet: A balanced meal is a combination of carbohydrates, fats, proteins and fibers appropriate for theindividual; at the same time, it should provide sufficient vitamins, minerals andmicronutrients. • Dietplan:Adietplanshouldbeindividualizedaccording tohis/herneeds; itmustbe simpletounderstand andeasy tofollow. • Dietician:Alldiabeticsshouldbereferredtoadieticianforcounselingatdiagnosisofdiabetesandalsosubsequently if they have problem with their dietadjustment. • Special diet: Special counseling is necessary in children and adolescents, pregnant and lactating women, and other conditions of acute or chronic illnesses where diet is of immenseconcern. Goals of MNT in Diabetes 1. To eat a balanced and regular meal 2. To achieve metabolic goals, e.g. blood glucose, lipid, hypertension etc 3. To attain and maintain desirable body weight. 4. To provide adequate nutrition for health and growth in pregnant and lactating mothers, and children 5. To prevent/delay complications of diabetes 6. To preserve the pleasure of eating Aspects of MNT in Diabetes 1. Calorie intake 2. Components of nutrients 3. Meal timing and consistency 4. Weight management P-B M-4 L-11 MNT: Calorie Requirement Calorie requirement of diabetes The daily calorie requirement is related to existing body weight and activity level but not on diabetic status. Calorie requirement is similar in diabetics and non-diabetics. Factors determining calorie requirement The daily calorie requirement is determined primarily by two factors a. existing body weightand b. activity level. Other factors that have influence on caloric requirements are lifestyle, pregnancy, lactation, other illnesses, and age, especially in growing period. Determinant of Daily Calorie allowance The following formula is used Daily calorie allowance (Kcal)=Ideal body weight (IBW) X Calorie factor (CF). • BW is obtained from standard height-weight charts. It can also roughly be calculated by subtracting 100 from height (in centimeters). • CF is obtained from a body weight-activity level chart (see below). Caloric Factor (CF) Activity Level Body Weight Sedentary Moderately Active Active Obesity 20 25 30 Over weight 25 30 35 Normal weight 30 35 40 Under weight 35 40 45 P-B M-4 L-12 MNT: Component of Nutrients Components of nutrients The impact of specific dietary composition on glycemic control and cardiovascular risk remains uncertain in diabetes Composition of macronutrient The optimal macronutrient composition should be individualized depending upon • weight lossgoal, • other metabolic needs (e.g. hypertension, dyslipidemia, nephropathy etc.)and • individual preference. Table: Distribution of macronutrient Carbohydrate Fat 50-60% of DCI 30% of DCI Fiber 20-35 grams (or 14 grams 1000/kcal) Saturated fats < 10% Trans-fat <1% Cholesterol < 300 mg Protein 10-20% of DCI P-B M-4 L-13 MNT: Carbohydrates, Fat & Protein Carbohydrates, fat & protein intake by diabetic person Carbohydrates (Intake of carbohydrates causes sudden rise in blood sugar level. Should be limited or avoided and Carbohydrates with lower glycemic index and glycemic load are to be selected.) Limit or avoid Carbohydrates: Refined or simple carbohydrates e.g.sugar, glucose, soft drinks, jam, honey, marmalade, sweets, cakes, chocolate etc. cause sudden rise in blood sugar level. Intake of these should be limited. Select Carbohydrates Un-refined complex carbohydrates such as bread, cereals, potatoes, rice etc. are more suitable, as they are digested more slowly in thebody andcauselessrapidriseinbloodsugarlevels. Carbohydrates with lower glycemic index and glycemic load are preferred. Fats intake (Fatty foods have high calorie which lead to weight gain and increase the risk of cardiovascular disease.) Fats solid at room temperature are high in saturated fat. It is abundantly present in cream, cheese, butter, ghee, animal fat, coconut oil, palm oil etc. Rich sources of trans fat are margarine, French fry, doughnut, pastry, pizza, pie, biscuit/cracker/cookie etc. Dietary cholesterol is high in egg yolk, butter, ghee etc. P-B M-4 L-14 MNT: Vitamins, Sweeteners & Alcohol Vitamin and minaral supplements • There is no sufficient or clear evidence of benefit from vitamin or mineralsupplementation in diabetes who do not have underlyingdeficiencies. • Routine supplementation with antioxidants or micronutrients (e.g. chromium, magnesium, vitamin D) or other herbs/supplements in diabetes is notrecommended. Alternative sweeteners • Sweetening agents, which provide sweetness but little calories, are now approved foruse. • Non-nutritive sweeteners include aspartame, neotame, saccharin, acesulfame and sucralose. These are preferred in diabetes. Reduced calorie sweeteners includesorbitol, mannitol etc. All are safe when consumed within acceptablelimit. Alcohol • Alcohol has various adverse effects indiabetes. • Daily intake should be limited to one dink (15-gram ethanol) or less in females and two drinks (30 gram) or less in males. • Alcohol should be avoided in pregnancy, liver disease, pancreatitis, advancedneuropathy and severehypertriglyceridemia. • Alcohol may cause delayed hypoglycemia, especially in those using hypoglycemicagents P-B M-4 L-15 MNT: Weight Management As most of the people with type2 diabetes and prediabetes are over-weight or obese, an important aim of MNT in this group is to achieve body weight goals. This can be achieved by calorie allowance as stated earlier. Caloric restriction and Increase in physical activity are the main strategies of weight loss. Caloric restriction • A moderate caloric restriction (250-500 calories less than average daily intake as calculated from food history) can be done. • A hypo-caloric diet, irrespective of weight loss, is associated with increased sensitivity to insulin and improvement in blood glucose level. Moderate sustained weight loss (5-10%, or 2-8 kg), irrespective of initial weight, in overweight/ obese individuals can have a lasting benefit on blood glucose, dyslipidemia and hypertension. Increase in physical activity • The dietary practice must be supported by an increase in physical activity Benefits of weight loss in overweight/obese • • • • • Decrease in mortality Normalization of blood glucose Maintenance of blood pressure at normal level Improvement in blood lipids (all components) Fall in cancer-death P-B M-4 L-16 Meal Timing, Composition and Planning The diet remains a big problem in diabetes care. One of the main reasons for this is lack of nutritional self-management training. Depending on the individual patient’s learning capabilities, clinical needs, level of motivation and lifestyle, different methods of teaching can be used: Meal timing Consistency with meal timing and day-to-day carbohydrate intake is very important, speciallyinthosetreatedwithanti-diabeticmedications,toavoiderraticbloodglucose. • Amealplanshouldbebasedontheindividual’susualfoodintake,integrating withlifestylepattern,activitylevel,drugs(ifused)andbloodglucoseresults Calorie distribution in meals Healthy food choice models System Model Remarks This classifies foods based on a traffic light system: Signal system Green - Healthy Food Items Yellow - Less Healthy Food Items Red - Least Healthy Food Items Potions of a foods: Foods with hight glycemic index Food (Sweets/fruits) - avoid Pyramid Grains - less Protein & dairy -moderate Vagitables /Fruits ( not sweet) maximum Potions of a plate: Plate Grain approximate25% Model Protein approximate 25% Rest with Vagitables/Fruits ( notsweet) Vegetable: As much asboth hands canhold. Hand Meat & Alternatives: The size of your hand (thickness ofyour little finger). jive Method Fruits & Grains & Starch: Amount of yourfist. Fats: Limit to the size of your thumb. Milk & Alternatives: Up to 250ml. P-B M-4 L-17 Anthropometric Measurement Body Mass Index (BMI) and Waist Circumference (WC) are 2 important measurements of overweight and obesity. Overweight/Obesity is a risk of diabetes and other non-communicable diseases like hypertension, dyslipidemia, ischemic heart disease, chronic respiratory disease and certain cancers. Correction of BMI and WC are incorporated as targets of treatment of T2DM BMI Weight and height measurements are required to determine BMI. The formula for calculation is as follows: BMI = Weight in Kg/Height in Meter BMI helps to diagnose and grade obesity using standard norm gram BMI (Kg/m2) Category Underweight <18.5 18.5 - 24.9 Normal 25 - 29.9 Overweight 30 - 39.9 Obese >40 Morbid Obese Waist circumference Waist circumference (WC) is a measure of central adiposity. Central adiposity rather than total adiposity is more related to cardio-metabolic risk. Adiposity is referred as ‘pear’ or ‘apple’ shaped. A person with pear shape have a higher WC and so greater risk of cardiovascular complications than apple shaped (higher gluteal fat) person Desirable Waist Circumference: for male <90 cm and for female <80 cm Hip Circumference (HC) and WC are used to calculate a parameter called 'Waist-Hip Ratio’ (WHR) or abdomino-gluteal ratio. The formula to have WHR is asfollows: WHR= WC(in cm)/HC (in cm) WHR is considered risky for developing cardiovascular and metabolic diseases if >0.9 for male and if >0.8 for female Waist or abdominal circumference is a measure at midway between the costal margin and the iliac crest; it is the smallest circumference at the waist. Hip or gluteal circumference is taken at the largest circumference at the posterior extension of the buttocks, measured over the greater trochanters P-B M-4 L-18 Exercise and DM Exercise Exercise is an important component of treatment of diabetes mellitus. In addition to physical fitness exercise helps in preventing atherosclerosis and thereby macroangiopathic complications in diabetes. It also improves mental well-being and quality of life. An exercise plan should be individualized according to his/her physical status, meals, drugs, profession, interest etc. To start with exercise one should be gradual in increasing the duration and intensity. For adults over the age of 18 years there should be ultimate target of doing aerobic exercise of moderate intensity for at least 150 minutes per week or vigorous intensity for at least 75 minutes per week, or equivalent combination of both types, spread over at least 3 days per week, with no more than 2 consecutive days without exercise. T2DM should perform anaerobic exercise involving all major muscle groups at least 2 days a week. Intensity of exercise Intensity of exercise is assessed by the Maximum Heart Rate (MHR).Formula for MHR is as follows. MHR = 220 - Age. Intensity of exercise is called a. Vigorous if Heart Rate achieved is > 70% of MHR ; b. Moderate if Heart Rate achieved is 50 - 70% of MHR; c. Low if Heart Rate achived is < 50% Prior to recommending any exercise programme one should be careful of a. Coronary Heart Disease, b. proliferative retinopathy, c. neuropathy, advance renal failure, d. hypoglycemia unawareness, etc. Exercise: Aerobic and Anaerobic Exercise: Aerobic • • • Aerobic exercise uses large group of muscles, can be maintained continuously, and is rhythmic in nature. This type of exercise overloads the heart and require oxygen to provide energy. Examples- Walking, running, treadmill, stair climbing, cycling, aerobic dancing, swimming, jogging etc. • • • • • • • Benefit of aerobic exercise Increases maximal oxygen consumption Improves cardiovascular and respiratory function Increases blood supply of muscles and ability to use oxygen Lowers resting systolic and diastolic blood pressure in people with hypertension Increases HDL Cholesterol and reduces LDL Cholesterol & Triglyceride Reduces body fat and improves weight control Improves glucose intolerance and reduces insulin resistance Exercise : Anaerobic • • • Anaerobic exercise is of short duration. This type of exercise can be supported by energy stored in the muscles and dose nor require oxygen. Examples- Weight lifting, strength training, sprinting at very fast speed etc. • • • • • Benefit of anaerobic exercise Increase muscular strength Improves flexibility of joints Reduces body fat and improves lean body mass ( muscle mass) Improves glucose intolerance and reduces insulin resistance Improves strength, balance and functional ability in older adults P-B M-4 L-19 Exercise Practical points on Exercise 1. Exercise recommendations for a person with diabetes are same as for a non diabetic. 2. Exercise program includes a proper warm-up and cool-down periods. • Warm-up should consist of 5 - 10 minutes of aerobic activity (e.g. walking) at allowed intensity level; it prepares heart for exercise. • After a short warm-up, muscles should be gently stretched for another 5 - 10 minutes; itprepares muscles for exercise without injury. This period is called ' stretchingperiod'. • The cool-down period also consists of 5 - 10 minutes of aerobic activity at a low intensity level after main activity session. It gradually brings heart rate down to pre-exerciselevel. 3. Person with T1DM who do not have any complications and satisfactory blood glucose profile can do all levels of exercise, including leisure activities, recreational sports and competitive professional performances. The emphasis must be given on adjusting therapeutic regimen with level of exercise and diet and avoiding hypoglycemia. 4. In children, extra attention needs to be paid to balance glycemic control with activity level and for this the support of parents, teachers and trainers may be necessary. Their meal and activity in school are impertinent. 5. Person with T2DM must view exercise as a vital component for management. Exercise along with a reduced calorie intake may enhance weight loss. Combination of diet, exercise and behavioral modifications is the most effective approach to weight control. Normally low to moderate intensity long duration exercise is recommended for weight loss. 6. The diabetic patient with peripheral neuropathy and loss of protective sensation should not engage in repetitive weight bearing exercise eg. prolonged walking, treadmill, jogging etc. as these activities may result in blistering, ulceration and fracture. Non-weight-bearing exercise, eg. swimming, cycling, rowing, chair exercise, arm exercise, yoga etc. may be better 7. Person with severe Charcot's joint should avoid weight-bearing exercise, as it can result in multiple fracture and dislocation of ankles and feet even without patient being aware of it. 8. In patients who have proliferative and moderate to severe non-proliferative diabetic retinopathy, strenuous activity may precipitate vitreous hemorrhage or fractional retinal detachment. These individuals should avoid anaerobic exercise and physical activities that involves straining, jarring or Valsalva maneuvers eg. weight lifting, boxing, heavy competitive sports etc. These persons may be recommended low impact exercise like swimming (but not diving), walking or stationary cycling. 9. Patient with stable coronary heart disease should perform exercise of moderate intensity. Person with uncontrolled hypertension should withhold exercise until control of blood pressure. 10. If a person develops symptomatic hypoglycemia or ketosis, exercise should be postponed. If blood glucose goes below 5.5 mmol/L the person should take extra 15 - 30 grams of carbohydrate before exercise. 11. One should not do exercise during any significant acute illness or uncompensated major chronic illness. 12. During pregnancy moderate exercise eg. walking at moderate speed for 30 minutes a day at a time or in divided fashion is advised. Vigorous exercise or exercises causing pressure in the abdomen should be avoided. P-B M-4 L-20 Summary There are 18 sections in module 4. I understand the following points. • Management of DM is aimed at supporting people to live with minimum or no risk of complication(s). • There is treatment goals/targets of blood glucose, BP, lipids, body weight etc • "Treat to target" is the principle of management of DM. There are algorithms for initiation, maintenance and switching over to other regimen. • Lifestyle- which includes dietary habit, physical activity and exercise, regular monitoring of blood glucose, physical care such as foot and oral care, regular follow-up etc. - is an essential component of DM management. Further Reading 1. Text Book of Diabetes, 4th edition, edited by Richard I G Holt, Clive S Cockram, Allan Flyvbjerg & Barry J Goldstein, Wiley-Blackwell, 2010. 2. Davidson's Diabetes Mellitus -Diagnosis &Treatment, 5th edition, edited by A P Hamel & R Mathur, Saunders, 2004. 3. Clinical Diabetes - Translating Research into Practice, 1st edition, V A Fonseca, Saunders, 2006. 4. Clinical Practice Recommendations, ADA ( American Diabetic Association), 2014. 5. Global Guideline for Type 2 Diabetes, Clinical Guidelines Taskforce, IDF ( International Diabetes Federation), 2012. 6. Comprehensive Diabetes Management Algorithm, AACE (American Association of Clinical Endocrinologist ) Task Force, 2013. 7. Patient's Guide Book, Diabetic Association of Bangladesh.
