Hong Kong Reference Framework
for Diabetes care for Adults in the
Primary Care Settings
MANAGEMENT OF DIABETES
USING THE REFERENCE
FRAMEWORK
OUTLINE OF PRESENTATION
1)
Reference Frameworks - Core Document
2)
Reference Frameworks – Modules
3)
Implementation issues
2
1
3
CORE DOCUMENT - TABLE
OF CONTENT
Chapter
1
Epidemiology
2
Population-based Intervention and Life Course
Approach
3
Role of Primary Care in the Management of Diabetes
4
Patient Education
5
Aim of the Framework
6
Prevention of Type 2 Diabetes
7
Early identification of People with Diabetes
8
Clinical Care of Adults with Diabetes
9
Patient Empowerment
10
Future Direction to Promote the Use of the
Framework
4
2
MODULES
Module
1
Framework for population approach in the prevention
and
d control
t l off di
diabetes
b t across th
the lif
life course
2
Early identification of people with diabetes
3
Dietary intervention for people with diabetes
4
Recommending exercise to people with diabetes
5
Glucose control and monitoring
6
Drug treatment for hyperglycaemia
7
Drug treatment in type 2 diabetes with hypertension
8
Lipid management in diabetic patients
9
Diabetic nephropathy
10
Diabetic eye disease
11
Diabetic foot problems
5
Type 2 diabetes is a progressive disease:
early identification and intervention is critical
6
Macrovascular complications
Microvascular complications
-cell function
Insulin
resistance
Blood
glucose
–10
Prevention
IFG/IGT
0
Diagnosis
Treatment
10+
Years
Type 2 diabetes
IFG: impaired fasting glucose
IGT: impaired glucose tolerance
Adapted from DeFronzo RA. Med Clin N Am 2004;88:787–835.
3
7
The need of early diagnosis and
optimise management
At
diagnosis of type 2 diabetes:
 50% off patients
ti t already
l
d have
h
1
complications
 Over 80% of patients are insulin
resistant2
 Up to 50% of -cell function has already
b
been
llostt3
1UKPDS
Group. Diabetologia 1991;34:877–890. 2Haffner S, et al. Diabetes Care 1999;22:562–568.
3Holman RR, Diabetes Res Clin Pract 1998;40:S21–S25.
Prevention and early detection is important
Population approach vs. risk based approach
Recommendations
Grades
Implement interventions to reduce
overweight and obesity at all stages of life to
reduce future risk of diabetes
A
Advise individuals at increased risk of
developing Type 2 diabetes and patients with
i
impaired
i d glucose
l
tolerance
t l
(IGT) to
t
maintain optimal body weight and practice
healthy lifestyles
A
Test individuals known to be at high risk of
developing diabetes
B8
4
Framework for Population Approach in The Prevention
and Control of Diabetes Across the Life Course
(MODULE 1)
9
Framework for Population Approach in The Prevention
and Control of Diabetes Across the Life Course
10
5
Early Identification of People with
Diabetes (MODULE 2)
Risk-based screening for type 2 DM:
1. age ≥45 years old
1
ld
2. One or more risk
factors:
 family history of DM
 overweight or obese
 previous impaired
glucose tolerance or
impaired fasting
glucose
 women with GDM
 hypertension
abdominal
bd
i l
circumference:
≥80cm(women)
≥ 90cm (men)
 metabolic syndrome
 clinical cardiovascular
disease / risk factors
 polycystic ovarian
syndrome
 long term systemic
steroid therapy

12
6
2011 ADA Diagnostic Criteria for DM
1. Fasting plasma glucose  7.0 mmol/l. Fasting is defined as no
caloric intake for at least 8 hours.
hours.*
2. 2 hours plasma glucose  11.1 mmol/l during an OGTT. The
test should be performed as described by the World Health
Organization, using a glucose load containing the equivalent of 75
gram anhydrous glucose dissolved in water.
y p
of hyperglycaemia
yp g y
or
3. In a ppatient with classic symptoms
hyperglycaemic crisis, a random plasma glucose  11.1 mmol/l
(200 mg/dl).
4. HbA1c 6.5 %. The test should be performed in a laboratory
using a method that is NGSP certified and standardized to the
DCCT assay.
Recommendations on initial treatment
Grades
Achieve optimal blood glucose control in all diabetic
patients and to reduce microvascular and
macrovascular complications
A
The target blood pressure in people with diabetes is
below 130/80 mm Hg
A
Use lipid modifying drug treatment to control
dyslipidemia in diabetic patients
A
Advise all patients on maintaining optimal body weight
(or reducing body weight if overweight/ obese) and
adopting healthy eating habit
A
Advise people with diabetes to increase level of physical
activity and take up regular exercises
B
Include smoking cessation counseling and other forms
of treatment as a routine component of diabetes care
B
7
Dietary Intervention for People with
Diabetes (MODULE 3)
Key to Healthy Eating:
 Eat regular meals and consistent portions
 Follow a balanced diet:
 different food groups
 less fat, sugar and sodium
 Eat more fibre-rich foods:
 soluble fibre: e.g. oatmeal, fruits, dried
beans
 insoluble fibre: e.g. whole wheat bread, fruits
and vegetables
 Use healthy cooking method
 cut down fat, sugar and sodium in diet
 Follow own meal plan
15
Meal Planning Approach





Carbohydrates can affect blood glucose levels
and should be evenly distributed in meals and
snacks for blood glucose control
~ 50% of total daily calorie intake from CHO,
spread out 3-5 small meals a day
Mostly complex CHO, high fibre foods
Simple sugar and food with high sugar content
should provide no more than 10% of total calorie
intake
For a 1800 kcal diet, the daily CHO intake should
be 200 gram of CHO = 20 portions
8
Meal Planning Approach (2)
Carbohydrate Exchange System:
 Example 1: Each contains 10g of carbohydrates
and can be exchanged:
 1 slice of wheat bread (thin cut, trimmed crust)
 4 soda crackers
 1 small fruit (e.g. small orange, kiwi, or pear)

Example 2: Each contains 50g of carbohydrates:
 1 bowl of cooked rice
 1 bowl of cooked spaghetti
17
 1 medium-sized baked potato
(1 bowl= 300 ml)
9
Recommending Exercise to People with DM
(adopted from Department of Health Exercise
Prescription) (MODULE 4)
Physical
Activity
P fil
Profile
Recommendations*
Frequency
• Moderate to vigorous aerobic exercise spread out
at least 3 days per week
• Resistance exercise at least twice per week
Intensity
• Aerobic exercise at least at moderate intensity
• Additional benefits from vigorous aerobic exercise
• Resistance exercise should be moderate
Time
• Perform 20 to 60 minutes of aerobic exercise per
day accumulated to total of 150min per week
20
• For resistance exercise, should perform 3 sets of
8-10 repetitions on 8-10 exercise involving the
major muscle groups
10
Recommending Exercise to People with DM
Physical
Activity
Profile
Recommendations*
Type
Recommends aerobic exercise of any form that:
 uses large muscle groups
 causes sustained increase in heart rate
Brisk Walking, swimming or cycling are good
choices
Recommends resistance exercise that:
 uses large muscle groups
 involves a combination of exercises
E.g. dumbbell, leg extension, abdominal curls
*Exercise prescription should be tailored to patients with
co-morbidities
21
Exercise Prescription to Patients with
Diabetes – special considerations (1)


Gradual progression of intensity is
advisable
Exercise stress testing



not a routine
may be considered in sedentary adults at high
risk for CHD and would like to undertake more
intense activities
Vigorous activity should be avoided in
presence of ketosis but it is not
contraindicated in simply high blood
glucose
22
11
Exercise Prescription to Patients with
Diabetes – special considerations (2)



In patients taking insulin or sulphonylureas,
exercise can cause hypoglycaemia
 Advised on identification and management of
hypoglycaemia
 Added carbohydrate if pre-exercise glucose
level <5.6mmol/l
Proliferative or severe non-proliferative DM
retinopathy – contraindicated for vigorous
exercise or resistance exercise
Peripheral neuropathy - comprehensive foot care
recommended
Glucose Control and Monitoring
(MODULE 5)
HbA1c
 measures glycaemic effect on haemoglobin over
preceding 2 to 3 months
 strong predictive value for DM complications
 goal of <7% in general. In selected patients 6.5% as
 measured half yearly as an indicator for blood glucose
control, more frequent for unstable cases
 limitations:
 conditions affecting red blood cell lifespan may
alter HbA1c levels
 not a measure for glycaemic variability or
24
hypoglycaemia
12
Glucose Control and Monitoring
Self-monitoring of blood glucose (SMBG):
 Recommended in patients using insulin and have
been educated about insulin titration or those at
risk of hypoglycaemia
 In patients not using insulin: SMBG is likely to be
an effective self-management tool and improve
glycemic control if results are reviewed and acted
upon by health care providers and/or patients
themselves
 American Diabetes Association suggested:
 3.9 to 7.2 mmol/L for Preprandial fasting
25
 <10mmol/L for Postprandial 1-2 hours.
26
UKPDS: over 10 years every 1% fall in HbA1c is associated with a
reduced relative risk of complications
Reductio
on in relative risk (%)
correspond
ding to a 1% fall in HbA
A1c
Any
diabetesrelated
endpoint
Diabetesrelated
death
Allcause Myocardial
mortality infarction
Peripheral
vascular
Stroke disease‡
Microvascular
disease
Cataract
extraction
0
–5
–10
–15
–20
–25
21%
21%
*
*
14%
14%
*
*
12%
†
19%
*
–30
37%
–35
–40
43%
–45
*
*
–50
*p<0.0001 vs baseline; †p=0.035
‡Lower extremity amputation or fatal peripheral vascular disease
Adapted from Stratton IM, et al. BMJ 2000;321:405–412.
13
10-Year Follow-up of Intensive Glucose Control in Type 2 Diabetes: N
Engl J Med 2008; 359:1577-1589
Rury R. Holman, F.R.C.P., Sanjoy K. Paul, Ph.D., M. Angelyn Bethel, M.D., David R. Matthews,
F.R.C.P., and H. Andrew W. Neil, F.R.C.P.
27
Conclusions
Despite an early loss of glycemic
differences, a continued reduction
in microvascular risk and emergent
risk reductions for myocardial
infarction and death from any
cause were observed during 10
years of post-trial follow-up. A
continued benefit after metformin
therapy was evident among
overweight patients.
Drug Treatment for Hyperglycaemia
(MODULE 6)
28
14
29
30
Stepwise strategy can delay patients achieving goals and
increase complications
HbA1c(%)1
10
Diet and
exercise
OAD
monotherapy
OAD
monotherapy
uptitration
OAD
combination
OAD +
basal insulin
OAD +
multiple daily
insulin injections
9
Mean
8
7
6
Duration of diabetes
Complications2
1Adapted
OAD = oral anti-diabetic
from Campbell IW. Br J Cardiol 2000;7:625–631.
2Stratton IM, et al. BMJ 2000;321:405–412.
15
31
The case for early combination therapy: reaching and
maintaining glycaemic goals
Diet and
exercise
HbA1c(%)1
10
OAD
monotherapy
9
OAD
Up titration
OAD +
basal insulin
OAD + multiple daily
insulin injections
OAD
combination
8
Mean
7
6
Duration of diabetes
Complications2
1Adapted
OAD = oral anti-diabetic
from Del Prato S, et al. Int J Clin Pract 2005;59:1345–1355.
2Stratton IM, et al. BMJ 2000;321:405–412.
Drug Treatment in Type 2 DM with
Hypertension (MODULE 7)
Target BP < 130/80mmHg
 Angiotensin-converting
A i t
i
ti
enzyme iinhibitor
hibit
(ACEI) and Angiotensin Receptor Blockers
(ARB)



confirmed to confer additional vascular and
renoprotective effects
should be included in the anti
anti-hypertensive
hypertensive
regime, especially for those with diabetic
nephropathy
32
16
Drug Treatment in Type 2 DM with
Hypertension
Combination
Specific
benefits
Disadvantages
Specific
benefits
Disadvantages
Diuretic
+
-blocker
Possibly
aggravate
ACE inhibitor + calcium- Calcium-channel blocker
-h
hyperglycaemia
l
i in
i Type
T
channel blocker
has a neutral effect on
2
diabetes
lipid and glucose
metabolism.
Diuretic + calciumDiuretic
reducesof
mild
Combination
calcium-channel blocker
ankle
swelling
due with
to
channel
blocker
-calcium-channel
ACEI or ARB is effective
blocker
in the treatment of diabetic
hypertension.
yp
High risk of
Diuretic
inhibitor -blocker
ACE inhibitor
preventsMay aggravate
or ‘first dose’
-blocker+ +ACE
calciumcounteracts
hypotension
with ACE
activationdue
of angiotensinprovoke
cardiac failure
channel blocker
tachycardia
to
inhibitor
in
patients
overaldosterone
system
due
to
(both are negative
calcium-channel
treated
with
diuretics
diuretic-induced
inotropes)
blocker’s vasodilator
extracellular fluid volume
action,
33
contraction,
and helps to
Effective
anti-anginal
retain potassium
therapy
Lipid Management in Diabetic Patients
(MODULE 8)
At least annual screening, more frequent if needed
Optimal treatment target of various lipid
components:
 LDL-Cholesterol:
< 2.6 mmol/L
<1.8 mmol/L (for patients with pre-existing
cardiovascular diseases)
 HDL-Cholesterol:
>1.0 mmol/L for male
>1.3 mmol/L for female
34
 Triglyceride (TG):
<1.7 mmol/L
17
Management of Diabetic Dyslipidaemia (adopted
from ADA) – in order of priorities
I. LDL-Cholesterol lowering
 HMG-CoA reductase inhibitor (statin)
II. HDL-Cholesterol raisingg
 behavioural interventions
 fibrates (gemfibrozil, fenofibrate)** or nicotinic acid
III. Triglyceride lowering
 glycaemic control
 fibrates
 Statins moderately effective at high dose in hypertriglyceridemic
subjects who also have high LDL cholesterol
IV. Combined hyperlipidemia
 First choice - Improved glycaemic control plus high dose statin
Second choice - Improved glycaemic control plus statin* plus fibrates*
(gemfibrozil, fenofibrate)
Third choice - Improved glycaemic control plus statin * plus nicotinic 35
acid* (glycaemic control must be monitored carefully)
Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes: N Engl J
Med 2008; 358:580-591
Peter Gæde, M.D., D.M.Sc., Henrik Lund-Andersen, M.D., D.M.Sc., Hans-Henrik Parving, M.D., D.M.Sc., and Oluf
Pedersen, M.D., D.M.Sc.


Targets:
 HbA1c < 6.5%
 Fasting total chol < 175 mg/dl (4
(4.5
5
mmol/l)
 Fasting TG < 150 mg/dl (1.7 mmol/l)
 SBP < 130 mm Hg
 DBP < 80 mm Hg
Patients were treated with blockers of the
renin–angiotensin system because of their
microalbuminuria, regardless of blood
pressure, and received low-dose aspirin as
primary prevention.
Conclusions
In at-risk patients with type 2 diabetes,
intensive intervention with multiple drug
combinations and behavior modification
had sustained beneficial effects with
respect to vascular complications and on
rates of death from any cause and from36
cardiovascular causes.
18
The major diabetes complications
Acute complications
Hypoglycaemia
Diabetic ketoacidosis
Hyperosmolar hyperglycaemic state
Chronic complications
Microvascular
Nephropathy
Neuropathy
Retinopathy
Macrovascular
Cardiovascular complication (IHD)
Cerebrovascular cx (stroke)
Peripheral Vascular disease (PVD)
Detection and treatment of long term complications
Recommendations
Grades
Check the presence of microalbuminuria and serum creatinine in all
Type 2 diabetic patients, starting from diagnosis and should review
y
annually
D
Treat diabetic patients with microalbuminuria with ACE inhibitors
or Angiotensin Receptor Blockers (ARB) to reduce the progression
to diabetic nephropathy if there are no contraindications
A
Perform eye examination in patients with Type 2 diabetes shortly
after the diagnosis of diabetes. Retinal photography is the evidencebased best p
practice and should be carried out by
y experienced
p
personnel in screening for DM retinopathy.
B
Foot care education is recommended as part of a multi-disciplinary
approach in all patients with diabetes
B
Screen all patients with diabetes for foot disease annually, and refer
to specialist promptly if complication is detected
D
19
Diabetic Nephropathy (MODULE 9)

Measure random urine albumin:creatinine
ratio (ACR) yearly



Overt DM nephropathy
p
p
y




> 2.5-25 mg/mmol in men/ 3.5-25 mg/mmol
in women, with confirmation by 2 out of 3 
Microalbuminuria
>25 mg/mmol  overt diabetic nephropathy
Perform USG to exclude non-DM causes
Test urine microscopy
Refer to specialists if indicated
Treatment: ACE and ARB
Screening and Management of Diabetic Renal Disease
40
20
Diabetic Eye Disease (MODULE 10)

An initial dilated and proper eye examination
shortly after the diagnosis of diabetes


Retinal photography by experienced personnel in
a programme of systematic screening is the
evidenced-based best practice



visual acuity (with pin-hole if necessary), lens opacity and
retinopathy.
should be repeated annually.
Less frequent examinations (every 2-3 years) may be
considered following one or more normal eye examinations.
For patient with background retinopathy, more
frequent examinations should be done if the
patient is at high risk of development of diabetic
retinopathy
Screening and Management of Diabetic Eye Disease
42
21
Diabetic Foot Problems (MODULE 11)
43
44
Summary
1.
Early intervention and glycaemic control is
associated with a long
long-lasting
lasting ‘legacy’
legacy effect in
reducing later complications
2. Treatment should be individualised over time to
maintain an optimal control of all clinical
parameters.
3. Multidisciplinary team approach is needed to
provide ongoing education to reduce risks,
risks
assess patients’ needs, monitor treatment
responses and adherence, identify treatment
barriers such as patients’ concerns and
misperceptions.
22
Challenges on implementation



Setting the standards is easy
D
Developing
l i
and
d implementing
i
l
ti
service
i models
d l
to realize the frameworks is difficult
Structural problems in health care system
 Public sector :heavily skewed towards
secondary/tertiary care
 Private sector : lack of allied health
support
 Financing: whether patients are willing to
pay for care of chronic diseases
45
Initiatives



Service gaps are being identified in the adoption
of the reference frameworks
New service delivery models of care, the
“Community Health Centre” will be explored to
foster the provision of more comprehensive and
multidisciplinary primary care services
Patient education and empowerment are crucial.
The patient’s version of the Reference
Frameworks and other education materials are
available at the website of the PCO.
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One page summary on HT and DM reference framework
Your support will be crucial
in the promotion of reference
frameworks!
THANK YOU!
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