Management of diabetes mellitus type 2 in primary health care setting

The lecture discusses the latest evidence in management of DM type 2 in PHC setting.

1. Management of Diabetes Mellitus Type 2 in Primary Health Care Setting Dr. Ahmed Khairi Mshari

2. The Author Ahmed Khairi Mshari Family Medicine Specialist MB ChB, FICMS Trainer, researcher and author in the field of Family Medicine Baghdad, Iraq Email: [email protected]

3. OBJECTIVES Discuss goals of DM2 management Review targets of optimal DM2 management Highlight the importance of Lifestyle Modification The role of Patient Education

4. Introduction Diabetes Mellitus is a chronic metabolic disorders characterized by abnormal metabolism of glucose with defects in insulin secretion, insulin action, or both In type 2 diabetes (DM2) , insulin is produced but cells are resistant to its action DM2 accounts for approximately 90-95% of individuals with diabetes DM2 is the most common endocrine problem encountered in PHC setting

5. Management of DM2 The goals of treatment are to: Alleviate symptoms Minimize complications Improve quality of life Reduce mortality

6. Management of DM2 Treatment should focus on simultaneous control of: Blood Glucose Level Blood Pressure Blood Lipid Level Body Weight

7. Targets of Optimal DM2 Management

8. Stepwise Approach to Management of DM2

9. Step 1 Lifestyle Modification

10. Lifestyle Modification Start a trial of Lifestyle Modification measures alone for 2-4 months, and continue throughout management Weight loss Nutritional therapy Regular exercise program Stop smoking If not reaching target level after 2-4 months trial, then we go to step 2:

11. Weight Loss Weight loss is the cornerstone measure of lifestyle change 80-90% of DM patients are overweight Calories restricted to 1600-1800 calories/day Weight loss should be gradual, not more than 1 kg/week Weight loss should be prolonged until the target goal BMI and waist circumference reached

12. Nutritional Therapy DM diet must compose of 45-60% carbohydrates , < 35% fats, and 10-15% protein Encourage complex carbohydrates such as whole grains, fruits, and vegetables Avoid simple refined carbohydrates, which are processed, such as sugar, white bread, flour, and cookies, pastries High fiber diet of about 10-15gms/day Reduce sodium in diet (less than 6 gm/day)

13. Regular Exercise Regular exercise is important for controlling weight and also to improve insulin sensitivity Exercise improve quality of life Brisk walk 30-60 min/day, 5 days/week The patient and the people in his environment must know the signs and symptoms of hypoglycemia, and must know how to react to it Exercise schedule should be appropriate for the individual's physical strength

14. Stop Smoking Message to stop smoking must be clear and direct Assist patient to specify a “stop date” Offer advice on how to cope with anxiety and cravings Frequent small snacks Use of nicotine patches or chewing gum Withdrawal symptoms will subside with time

15. Step 2 Use of Oral Hypoglycemics

16. Use of Oral Hypoglycemics Initiate therapy with one oral hypoglycemic drug , choice depends on body composition and severity of hyperglycemia If single drug is not effective enough, so, combination therapy with two or more drugs that work by different mechanisms may reduce blood sugar to target level A Biguanide with a sulfonylurea is the most widely studied combination If not reaching target level, refer for specialized consultation and/or management

17. Step 3 Specialized Management (Insulin Therapy)

18. Insulin Therapy When a person with DM2 has done well on oral agents, and is not at target blood glucose levels, Then: Add or change to Insulin therapy program to reach glycemic target Strict control of co-existing hypertension and dyslipidemia Continue wih lifestyle modification When target levels achieved, refer patient back to his primary care doctor for regular follow-up

19. Follow-up of DM2 Patient

20. Follow-up of DM2 Patient All DM patients should be evaluated on a regular basis The following parameters should be evaluated Annually: Physical examination : General Exam; such as, Blood pressure, Body Weight, Waist circumference... Systemic Exam; CVS (Peripheral pulses), Chest, Abdomen , Neurologic exam (especially lower extremities) Ophthalmic Examination; Visual Acuity, Fundus, Cataract… Foot exam; for sensation, infections , ulcers , callosity… Dental exam; to maintain proper oral hygiene Investigations; such as, FPG, RPG, HbA1C, Lipid profile, GUE, Urine ptn , S. Creatinin , ECG…

21. Referral to the Specialists Persistent hyperglycemia and/or other uncontrolled parameters (blood pressure, lipids) with above treatment Pregnancy and diabetes Diabetic ketoacidosis or hyperglycemic hyperosmolar coma Serious acute illness (chest pain, mental confusion) in addition to diabetes Switching from oral hypoglycemic medication to insulin Presence of microvascular changes (retinopathy, neuropathy, nephropathy)

22. Patient Education

23. Patient Education Diabetes is generally a chronic problem that require life-long management Treatment goals and plans should be patient-centered and sensitive to the individual preferences, needs and values Provision of health education is a key component of diabetes management from the time of diagnosis and subsequently as needed

24. Patient Education The main aims of diabetes education are to: enhancing knowledge changing attitudes and behavior developing skills required to: promote self-management achieve targets of metabolic control prevent or delay complications maintain quality of life

25. Content of Health Education Nature of DM disease: Chronic disease Require life-long treatment It is not curable but controllable Sigs and symptoms of acute problems (hypoglycemia, hyperglycemia) and chronic complication and how to deal with them Nature of t reatment Importance of adherence to established treatment

26. Content of Health Education Self-monitoring of blood glucose and BP Availability of glucometer and sphygmomanometer The correct use of these instruments The proper recording of results in a log book Interpret the results and make adjustments to treatment plans

27. Content of Health Education Adopting healthy lifestyle Healthful eating pattern Regular physical activity Stop smoking Avoid or limit alcohol

28. Content of Health Education Foot Care How to clean foot Nail cutting Search for skin infection and ulcer How to deal with mild lesions (corns, cracks) Proper shoes

29. Content of Health Education How to use insulin Dosage Injection technique Correct Insulin storage Make appropriate insulin dose adjustments for changes in day to day activity

30. references American Diabetes Association American Association of Clinical Endocrinologists International Diabetes Federation National NCD management Guidelines