Presentation title
Routine Care
Programme
1
Principles of care
2
Insulin therapy
3
Blood glucose testing
4
Dietary advice
5
Use of HbA1c
6
Quality of care indicators
7
Monitoring growth in childhood
Slide no 3
Principles of Care
• Goals of care include:
• Eradicate symptoms.
• Prevention of acute complications
• Hypoglycaemia
• Diabetic ketoacidosis
• Optimum growth and pubertal development
• Ensure good psycho-social adaptation and function
• Prevention of long term complications
Slide no 4
Components of care
• Education
• Insulin
• Diet
• Monitoring
• Support of the child and
family
FOOD
INSULIN
Management - who?
Multi-disciplinary team
• Medical personnel
• Diabetes educator
• Dietician
• Social worker
• Psychologist
Presentation title
Insulin therapy
Slide no 7
Insulin
• Human insulin
• Produced by recombinant DNA technology
• Usually U-100 concentration
• Beware of older U-40 insulins
• Different types classified by their duration of action
Slide no 8
Short acting regular insulin
• Onset=30-60 minutes
• Peak=2-4 hours
• Duration=4-8 hours
• Given 30 minutes before meal
Actrapid, Humulin R
Slide no 9
Rapid acting analogues
• Onset: 15 minutes
• Peak: 30 min-3 hours
Insulin profile
• Duration: 3-5 hours
NovoRapid®, adolescents aged 13–17 years
132
0
120
Serum insulin
(pmol/L)
• Given 15 minutes before food
NovoRapid®, children aged 6–12 years
0
108
0
960
HI, adolescents aged 13–17 years
840
HI, children aged 6–12 years
720
600
480
360
240
120
0
-30
0
30 60 90 120 150 180 210 240 270 300 330
Time (min)
NovoRapid, Humalog, Apidra
Slide no 10
Intermediate-acting insulin
• Onset: 2-4 hours
• Peak: variable
• Duration: 10-18 hours
• Not related to meals
• Usually twice daily
• Sometimes 3-4 times/day
NPH, Insulatard, Monotard,
Protaphane, Humulin N
Slide no 11
Insulin profiles
Aspart, lispro, glulisine
Plasma Insulin Levels
Regular
NPH
Detemir
0
2
4
6
8
10
12
Hours
14
16
18
20
22
24
Slide no 12
Mixing insulin
• Fixed ratio combination insulin
• Combination of short and long acting insulin
• Most commonly 30% and 70% combination
• E.g. Actraphane, Mixtard 30
• Two peaks of action
• Often used in twice daily regimens
• Self-mixed combinations
• Mixed regular/rapid insulin with NPH in syringes
• Create own mix to suit patient
Slide no 13
Insulin therapy
• No perfect insulin preparation
• Choice of insulin individualised to give as physiological
insulin profile as possible
• Be careful of the concentration of insulin (U-100, U-40)
• Need proper storage of insulin
• Compliance with treatment regimen is key to success
Slide no 14
Insulin regimens
Twice daily regimen
Multiple daily injections
• Mix of short acting and
long acting before
breakfast and supper
• Intermediate or long acting
insulin twice daily
• Short acting insulin with
each meal
Slide no 15
Insulin regimens
MDI with
Lantus-Levemir
CSII
Presentation title
Blood glucose testing
Slide no 17
Blood glucose testing
• Treating diabetes dependent on blood glucose changes
during the day
• Identify times when at risk for hyper- or hypoglycaemia
• Blood levels related to
• Insulin regimen and doses
• Pattern of eating
• Activity / illness
• Blood glucose information is used to help patient
and family learn – not done for staff!
Slide no 18
Interpretation
Timing of test
Interpretation
Fasting glucose
Evening dose of long acting insulin
After breakfast level
Dose of rapid insulin at breakfast
After lunch level
Dose of rapid insulin at lunch (midday meal)
After supper level
Dose of rapid insulin at supper
Pre-lunch level
Dose of insulin at breakfast, effect of mid
morning snack and morning long-acting insulin
Pre-supper level
Dose of insulin at lunch, effect of mid afternoon
snack and morning long-acting insulin
All levels
Affected by snacks and exercise
Needs records of insulin, food, activity, etc.
Slide no 19
Patterns of testing (1)
• Pre- and post-meals, bedtime (7 tests/day)
• Pre-meals, bedtime (4 tests/day)
• Pre-breakfast, pre- and post-selected meal for 1 week
(3 tests/day)
• Change selected meal weekly
• When symptoms of hypoglycaemia occur
• When a top-up dose of insulin is needed for extra food
or during illness
Slide no 20
Patterns of testing (2)
• Strips are expensive
• Patterns determined by
•
•
•
•
Availability of strips
Insulin regimen
Level of control
Patient factors
• Pattern changed to get useful information
• Needs patient records of food and insulin for readings
to be valuable!
Presentation title
Dietary advice
Date
Slide no 22
Principles
• Need to have a healthy diet
• Amount and proportions appropriate for age and growth
• Carbohydrate content of food matched with insulin
regimen
• Understanding of how to match insulin with food is key
• Best done with the assistance of a dietician
Slide no 23
Dietary review
•
•
•
•
•
Taken at diagnosis
Review regularly (annually)
Correct food, correct amount and correct times
Review food patterns, activities and insulin regimen
Growth and stage of puberty influence diet
Presentation title
Use of HbA1c
Slide no 25
What is HbA1c
• Red blood cells contain Haemoglobin
(Hb)
• Glucose sticks onto Hb  HbA1c
• Slow and irreversible
• HbA1c reflects average blood glucose
over 2-3 months
• High glucose = increased HbA1c
• Non diabetics: 4-6% (normal range)
Slide no 26
What does it tell us
• Measure of the average
blood glucose
• Correlates with risk of longterm complications
• Rising HbA1c requires
action
• Ideal HbA1c <6.5%
fix slide pix
Add EAG table vs A1c???
A1c vs estimated average
glucoses
28
Presentation title
Quality of care indicators
Slide no 30
Patient indicators
Indicator
Measurement
Growth
Height, weight and BMI
Puberty
Age at menarche, breaking voice
Acute
complications
No of admissions for DKA
Social adjustment
Schooling/vocational training/employment
Frequency of severe hypoglycaemia
Number of clinic visits in last 12 months
Number of hospitalizations in last 12 months
Missed school days due to diabetes
Food security
Interruption in insulin therapy in last 12 months
Slide no 31
Clinic indicators
Indicator
Measurement
Prevalence
Number of children in your clinic
Acute complications
Frequency of severe hypoglycaemia
Frequency of severe hypoglycaemia in <5 year
old children
Supplies
Interruptions in insulin therapy
Prevention of
microvascular
complications
% of patients tested for proteinuria
% of patients tested for HbA1c
% of patients with recorded BP
% of patients with recorded lipids
Slide no 32
Remember
• Vital to measure regularly the progress of diabetes
• Basic patient indicators measured at every visit (e.g.
once a month)
• Measurement of growth a very good indicator of the
quality of care
• Each visit an opportunity for repeated information and
education
Presentation title
Monitoring growth in childhood
Date
Slide no 34
Growth
• Growth follows a predictable pattern over time
• Growth can be affected by diabetes, i.e. insufficient
insulin dosing can cause stunted growth even if blood
glucose levels seem fine
• Type 2 diabetes, overweight contributes to the diabetes
• Normal growth indicator of adequate diabetes care
Slide no 35
Growth charts
200
78
+3
+2
190
74
+1
180
0
170
-1
66
62
-3
150
58
140
54
130
50
120
Height (in)
Height (cm)
70
-2
160
46
110
42
100
38
90
34
80
30
70
2
4
6
8
10 12
Age (y)
14
16
18
20
Females
200
78
190
74
+3
70
+2
170
+1
66
0
160
62
-1
-2
150
58
-3
140
54
130
50
120
46
110
42
100
38
90
34
80
30
70
2
4
6
8
10 12
Age (y)
14
16
18
20
Height (in)
180
Height (cm)
• Can use population specific charts
• Center for Disease Control (CDC)
charts
• Charts specific for boys and girls
and for different age ranges
• Height, weight, BMI
Males
Slide no 36
Measurements
• Measure height and weight at each clinic visit, once
every three months, at least twice a year
• Record in medical chart and plot on growth chart
• Standing height without shoes
• For young children under 2.5 years, total body length
should be measured
• Measure weight to nearest 0.1 kg if possible
Slide no 37
Measuring equipment
Questions
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