Non-pharmacological Management of Diabetes Mellitus.pptx

Diabetes mellitus DM, is a metabolic disorder of biomolecules characterized by chronic hyperglycemia due to defects in insulin synthesis or utilization or both

DM requires lifelong therapy. A multidisciplinary approach is needed to control glycemia, as well as to limit the development of its devastating complications and manage such complications when they do occur.
Increases cost of living and reduces life expectancy

1. Non-pharmacological Management of Diabetes Mellitus Dr Samson Ojedokun Department of Chemical Pathology LAUTECH Teaching Hospital Ogbomoso Nigeria 1

2. Outline Introduction Prevalence Classifications Risk factors Pathophysiology Management Conclusion References 2

3. Introduction Diabetes mellitus DM, is a metabolic disorder of biomolecules characterized by chronic hyperglycemia due to defects in insulin synthesis or utilization or both DM requires lifelong therapy. A multidisciplinary approach is needed to control glycemia, as well as to limit the development of its devastating complications and manage such complications when they do occur. Increases cost of living and reduces life expectancy 3

4. Prevalence About 422 million people worldwide have diabetes, the majority living in low-and middle-income countries, and 1.5 million deaths are directly attributed to diabetes each year. Both the number of cases and the prevalence of diabetes have been steadily increasing over the past few decades In the past 3 decades, the prevalence of type 2 diabetes has risen dramatically in countries of all income levels. 4

5. It was reported that worldwide, 1 in 10 adults has diabetes. Data predicted that there would be a global increase in the number of adults with diabetes from 537 million in 2021 to 786 million by 2045, a 46% rise. In 2015, diabetes was the sixth leading cause of death in lower-middle-income countries.  The WHO predicts diabetes to become the seventh leading cause of death in the world by the year 2030. 5

6. The WHO estimated a 4.3% prevalence of diabetes in Nigeria in 2016, Some local studies conducted in Nigeria found a prevalence between 0.8% and 11%. A previous study reported that about 4.7 - 6million Nigerians had type 2 diabetes  It was estimated that diabetes killed more than 40,000 Nigerians in 2015 and there are millions who are diabetic but are yet to be diagnosed and treated. 6

7. Classifications The most common is type 2 diabetes, usually in adults, Type 2 diabetes mellitus consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. Type 1 DM can occur at any age. Although it frequently arises in juveniles, it can also develop in adults. Due mainly to absolute deficient in insulin production. 7

8. Secondary diabetes Diseases of the pancreas that destroy the pancreatic beta cells ( eg , hemochromatosis, pancreatitis, cystic fibrosis, pancreatic cancer) Hormonal syndromes that interfere with insulin secretion ( eg , pheochromocytoma) Hormonal syndromes that cause peripheral insulin resistance ( eg , acromegaly, Cushing syndrome, pheochromocytoma) Drugs ( eg , phenytoin, glucocorticoids, estrogens) Gestational diabetes 8

9. Subtypes Severe autoimmune diabetes (SAID) - corresponding with type 1 diabetes and latent autoimmune diabetes in adults (LADA Severe insulin-deficient diabetes (SIDD) Severe insulin-resistant diabetes (SIRD) Mild obesity-related diabetes (MOD) Mild age-related diabetes (MARD) 9

10. Risk factors Age greater than 45 years Weight greater than 120% of desirable body weight Family history of type 2 diabetes in a first-degree relative ( eg , parent or sibling) Hispanic, Native American, African American, Asian American, or Pacific Islander descent History of previous impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) 10

11. Hypertension (130/80 mm Hg or above) or dyslipidemia (HDL cholesterol level < 40 mg/dL or triglyceride level >150 mg/dL) History of gestational diabetes mellitus or of delivering macrosomic baby Polycystic ovarian syndrome (which results in insulin resistance) 11

12. Pathophysiology Type 1 DM is the culmination of lymphocytic infiltration and destruction of insulin-secreting beta cells of the islets of Langerhans in the pancreas. As beta-cell mass declines to 80-90%, insulin secretion decreases until the available insulin is no longer adequate to maintain normal blood glucose levels, hyperglycemia develops and diabetes may be diagnosed. Exogenous insulin is needed to reverse this catabolic condition, prevent ketosis, decrease hyperglucagonemia, and normalize lipid and protein metabolism. 12

13. Type 2 diabetes is characterized by a combination of peripheral insulin resistance and inadequate insulin secretion by pancreatic beta cells. Insulin resistance, which has been attributed to elevated levels of free fatty acids and proinflammatory cytokines in plasma, leads to decreased glucose transport into muscle cells, elevated hepatic glucose production, and increased breakdown of fat. 13

14. © emedicine 14

15. Management Presentation Diagnosis Treatment Pharmacologic Non-pharmacological 15

16. Presentation Polydipsia Polyuria Nocturia hyperphagia Tiredness, fatigue, lethargy Weight loss Blurry vision Pruritus vulvae, balanitis Mood change, irritability, difficulty concentrating, apathy 16

17. Diagnosis Glycemia Normal Impaired (prediabetes) Diabetes Symptomatic Random Plasma glucose or 2hrs PP ≥11.1mmol/l Fasting plasma glucose ≥7.0mmol/l 17

18. Asymptomatic (Pre-diabetes) IFG; FBG ≥6.0mmol/l but < 7.0mmol/l IGT; FBG < 7.0mmol/l and 2hrs PP 7.8 – 11.1mmol/l HBA1C 5.7−6.4% (39−47 mmol/mol) OGTT Indication: FBG 6.1 – 7.0mmol/l IFG 6.1 – 6.9 2hrs <7.8 IGT <7.0 2hr 7.8 – 11.0 Diabetes ≥7.0 2hrs ≥ 11.1 18

19. WHO Diagnostic Criteria Diabetes: FPG ≥126 mg/dL (7.0 mmol/L) OR OGTT 2-hour PG ≥200 mg/dL (11.1 mmol/L) Impaired fasting glucose (IFG): FPG 110 mg/dL to 125mg/dL (5.7 to 6.9mmol/L) AND OGTT 2-hour PG < 140mg/dL (< 7.8mmol/L) Impaired glucose tolerance (IGT): FPG < 126 mg/dL (< 7.0 mmol/L) AND OGTT 2-hour PG 140mg/dl to 200mg/dl (≥7.8 and < 11.1mmol/L) 19

20. Treatment Pharmacologic Involve mainly the use of OHA and Insulin therapy. Non-pharmacological Non-pharmacological management mainly involves diet and lifestyle modification 20

21. In new cases of DM, adequate glycemic control can be obtained by non-pharmacologic control in approximately 50% while 20-30% will require OHA or insulin. Regardless of etiology, the choice of treatment is determined by the adequacy of residual B-cell function which varies in the patient. The goals are to eliminate symptoms and to prevent, or at least slow, the development of complications. 21

22. Microvascular ( ie , eye and kidney disease) risk reduction is accomplished through control of glycemia and blood pressure macrovascular ( ie , coronary, cerebrovascular, peripheral vascular) risk reduction, through control of lipids and hypertension, smoking cessation metabolic and neurologic risk reduction, through control of glycemia. 22

23. Patient Education: With each healthcare system encounter, patients with diabetes should be educated about and encouraged to follow an appropriate treatment plan. Adherence to diet and exercise should continue to be stressed throughout treatment because these lifestyle measures can have a large effect on the degree of diabetic control that patients can achieve. 23

24. Healthy Diet: Carbohydrate 45-60% Sucrose up to 10% Fat <35% Polyunsaturated <10% Monounsaturated 10-20% Saturated <10% Protein 10 -15% Fruit/vegetables 5 portions daily Salt, not more than 6g sodium daily 24

25. Weight management: Reduction of energy intake Increase energy expenditure Modest weight losses of 5-10% Risk factor reduction greater with losses of 10-15% of body weight 25

26. Mediterranean-style diet Esposito et al reported greater benefit from a low-carbohydrate, Mediterranean-style diet than from a low-fat diet in patients with newly diagnosed type 2 diabetes mellitus. High-protein versus high-carbohydrate diet A study by Larsen et al concluded that the long-term therapeutic effect of a high-protein diet is not superior to that of a high-carbohydrate diet in the treatment of type 2 diabetes mellitus 26

27. Exercise/physical activity: Walking, gardening, swimming or cycling Adult 18-64yrs 2.5hrs weekly buildup or 75mins vigorous exercise Aerobic (moderate-intensity) 10mins daily or 30mins at least 5days 27

28. Alcohol: Both beneficiary and harmful just as with CVDs It reduces hypoglycemia awareness by suppressing gluconeogenesis due to its high-calorie content. Not to exceed 14U women and 21 U men weekly 28

29. Bariatric Surgery In morbidly obese patients, bariatric surgery has been shown to improve diabetes control and, in some situations, normalize glucose tolerance. It is certainly a reasonable alternative for carefully selected patients. 29

30. Conclusion For people living with diabetes, lifestyle modification are primary preventive tools pivotal to reducing long term complications and avoiding side effects of pharmacological therapy. There is a globally agreed target to halt the rise in diabetes and obesity by 2025 and this could be achieve through advocacy and awareness on the of unhealthy lifestyle. 30

31. References Davison's Principles & Practice of Medicine, 22 nd Edition pg 797-836 World Health Organization, diabetes mellitus https://www.who.int/health-topics/diabetes#tab=tab_1\2022 World Health Organization 2022 World Diabetes Day https://www.afro.who.int/countries/nigeria/news/stakeholders-call-increased-access-diabetes-education#:~:text=The%20World%20Health%20Organization%20(WHO,use%20and%20harmful%20use%20of Diabetes Mellitus, Medscape e-library https://emedicine.medscape.com/article/117739-overview#a2 31

32. Thank you all 32