diabetes for all

1. IDF BASIC DIABETES COURSE
Module TWO
An Overview of Diabetes Management

2. ON COMPLETING THIS COURSE YOU SHOULD BE ABLE TO:
1. Understand the importance of patient education in diabetes
2. Understand the importance of ongoing monitoring and assessment
3. Understand the action of insulin and other diabetes treatments
4. Understand the common complications of diabetes
5. Understand basics of gestational diabetes

3. AGENDA

8. BACKGROUND
 Diabetes Mellitus was first documented by the Ancient Greeks.
However it was not until the 20th century that the role of insulin was
discovered, and insulin was first used as a treatment by Dr Fredrick
Banting and Charles Best in 1921.

9.  Type 1 diabetes is an autoimmune disorder where insulin is not produced by the pancreas.
 Type 2 diabetes is a progressive disease, characterised by a lack of insulin sensitivity and
an increase in insulin resistance in the body.
 Exogenous insulin injections may be required by some individuals with type 2 diabetes to
enable glycaemic control
 Type 2 diabetes is also associated with a number of modifiable risk factors. These include
unhealthy diet, lack of physical activity and sedentary lifestyle.
 Type 2 diabetes can be diagnosed from a standard oral glucose tolerance test involving a
75g carbohydrate based drink.
 In 2015, it was estimated that nearly 5 million people died as a result of diabetes.
 Sugar sweetened beverages have been shown to increase your risk of developing Type 2
diabetes.

10.  The Diabetes Complication and Control Trial (DCCT 1993) and The United Kingdom
Prospective Diabetes Study (UKPDS 1998) were two ground-breaking studies that truly
identified the need for people with diabetes to obtain optimal control in order to prevent
complications.
 The associated complications of diabetes are well documented:
 Microvascular involving small vessels - capillaries
 Macrovascular involving large vessels - arteries
 Neuropathic (nerve damage)
 Others - periodontal, soft tissue and psychological problems

11. common complications of diabetes

12. THE IMPACT OF MANY COMPLICATIONS CAN
BE GREATLY REDUCED IF THEY ARE PICKED
UP EARLY AND APPROPRIATE TREATMENT
GIVEN. THEREFORE REGULAR SCREENING
IS VERY IMPORTANT.

13. SELF MANAGEMENT EDUCATION
IN
DIABETES

15. SELF MANAGEMENT EDUCATION IN DIABETES
 With the right education and regular access to health professionals, a person with
diabetes can make the appropriate changes to their life and better improve control of
their diabetes.
 The role of the diabetes educator is to encourage realistic behavior change by
providing the right level and amount of education in any one time. Diabetes
educators and health professionals engaging in diabetes education should remain
unbiased and approachable. Gaining the trust of the person with diabetes is essential
to them incorporating changes within their lives.

16. DIABETES SELF MANAGEMENT EDUCATION (DSME)
 (DSME) is an ongoing process of facilitating the knowledge, skill, and ability
necessary for diabetes self-care.
 This process incorporates the needs, goals, and life experiences of the person
with diabetes and is guided by evidence-based research.
 The overall objectives of DSME are to support informed decision making, self-
care behaviors, problem solving, and active collaboration with the health care
team and to improve clinical outcomes, health status, and quality of life.

17. Diabetes self management support (DSMS)
 refers to the support that is required for implementing and sustaining coping skills and
behaviors needed to self-manage on an ongoing basis.
Patient-centred care
 refers to providing care that is respectful of and responsive to individual patient
preferences, needs, and values and ensuring that patient values guide all clinical
decisions.

19. ASSESSMENT AND MONITORING
You will have already covered the symptoms of diabetes
These symptoms may be a sign of suboptimal diabetes control, if reported by
your patient. They are caused by hyperglycemia. During your consultation you
may wish to ask if these symptoms are particularly noted on certain days or
nights, or following certain foods etc.

20.  Glycated haemoglobin is used to assess overall diabetes control.
 In poorly controlled diabetes more glucose molecules become attached to haemoglobin
increasing the proportion that is glycated.
 Measurement of HbA1c reflects the level of glycaemic control of an individual over the
past 8-12 weeks.
 It is generally accepted that a target HbA1c of 7.0% or 53mmols/mol would significantly
reduce the risk of microvascular complications.
 However, consideration must be given to the social and medical circumstances of each
individual (for example a higher target would be more appropriate in the elderly or those
prone to unrecognized hypoglycemia).
HbA1c

21. IDF GLOBAL GUIDELINES FOR HbA1CTARGETS
Publication* Target
IDF/ISPAD Diabetes in childhood and
adolescents 2011
<7.5% or <58mmol/mol
IDF managing older people with type 2
diabetes 2013
Functionally independent person: 7-7.5% or 53-59 mmol/mol
Functionally dependant person: 7-8% or 53-64mmol/mol
Global guidelines for managing type 2
diabetes 2012
<7% or <53mmol/mol

22. INSULIN

23. Normal Insulin Secretion
 In a person with a fully functioning pancreas a low level of insulin is released
continuously.
 This is referred to as 'basal' insulin secretion.
 A post-prandial 'bolus' of insulin is released following a meal, as shown in this
diagram.

24.  The most physiological insulin replacement regimen is known as a
basal bolus regimen.
 This can be given by multiple daily injections or by using an insulin
pump.
 This replicates the normal function of the pancreas it can provide very
good control of blood glucose levels.
 Unfortunately some insulin regimens may not be available to all people
with type 1 diabetes.
Basal Bolus Regimen

33. SICK DAY RULES
1. People with type 1 diabetes need to know how to manage their insulin treatment
during periods of sickness. Unfortunately some health professionals give
inappropriate advice during these times and this can be dangerous and lead to
ketoacidosis.
2. During sickness, blood glucose levels are likely to rise with the body’s natural
response to infection.
3. It is vital that people with type 1 diabetes DO NOT STOP TAKING INSULIN even
if unwell. They may in fact need an increase in insulin dose if the illness is
prolonged.
4. Encourage fluids to avoid dehydration.
5. If the person tests their blood glucose, they may need to check more frequently.
6. The person will need to check ketone levels (in urine or blood).
7. A person who has raised ketones and is vomiting should be admitted to hospital.
8. Follow your health care provider's sick day recommendations.

34. TYPE 2 DIABETES
International recommendations agree that the initial treatment of type 2 diabetes should be
lifestyle change, focusing mainly on healthy eating and increased physical activity.
 HEALTHY EATING
 PHYSICAL ACTIVITY
 ORAL MEDICATIONS

35. HEALTHY EATING
 In the management of type 2 diabetes, it is important to focus on achieving
and maintaining a healthy body weight (ideally a body mass index between
20 and 25 (23 in some Asian populations).
 For many people, this will require weight loss.
 Achieving this will help reduce blood glucose levels. Healthy eating
guidelines are presented in a variety of ways, such as a healthy food plate,
pyramid, palm tree and even rainbow.
 You may have a local pictorial tool to help educate people with diabetes on
this topic.

36. HEALTHY EATING
 The Basics. It is important to minimize intake of sugars and refined or other fast-
acting carbohydrates, such as potatoes, white rice or white bread; it is also
important to increase intake of fresh leafy vegetables, fruits and foods with
healthy fats (such as nuts and fish).
 Given the socio-economic, cultural, educational and linguistic diversity of people
with diabetes it is clear that one single approach cannot work in all practices.
There is a clear need for a diversity of approaches to nutritional education or, at
least, flexibility in attending to the very different needs of people with diabetes.

37. HEALTHY EATING
 Behavior change can be difficult, and rather than just providing patients with
the knowledge, success may come around helping them to figure out some
meal related positive changes.
 Once barriers to this change are identified, solutions will help to start the
beneficial process.

39. PHYSICAL ACTIVITY
 For people who have not done exercise for some time, the idea of starting may
be daunting.
 It is important to highlight that any increase in physical activity is better than none
at all.
 Any increase in activity levels will help - this may require in depth exploring of
a person lifestyle and capabilities.
 However it should be possible for most people to find a way of increasing their
activity levels (eg walking to work/ taking the stairs instead of the elevator).

40. ORAL MEDICATIONS
 If, despite lifestyle modifications, a person’s diabetes remains suboptimally
controlled, consideration should be given to treatment with Oral
Hypoglycemic Agents (OHAs).
 There is general agreement that metformin is the first line treatment: it is safe,
inexpensive, widely available and effective.
 It may be necessary to add other agents.

43. TYPE 2 DIABETES
INTRODUCTION TO INSULIN
 We have already looked at insulin and the regimens used in people
with type 1 diabetes.
 Sometimes, people with type 2 diabetes also require treatment with
insulin, if their beta cell function is severely impaired.
 In type 2 diabetes insulin is often added to oral or injectable agents,
initially as a single injection of intermediate-injecting insulin (for
example NPH insulin).
Take a look at these examples:

48. OTHER HEALTH CHECKS
Due to potential complications associated with diabetes, some of which may be
asymptomatic, it is vital that people with diabetes receive a number of health
checks at least once a year.

49. FOOT CHECKS

50. RETINAL SCREENING

51. RETINAL SCREENING
 Retinopathy is a microvascular complication in which capillaries in the retina are
affected by long term hyperglycaemia, leading to leakage from the capillaries and
ischaemia in the areas served by them. This ischaemia can stimulate formation of new
blood vessels (neovascularisation). These new blood vessels are weak and liable to
haemorrhage, causing sometimes permanent visual impairment.
 Up until this late stage, retinopathy does not cause any symptoms. Thus it is essential
that everyone with diabetes is examined for the presence of retinopathy. This can be
done by directly examining the retina using an ophthalmoscope or retinal photography,
with the images transmitted to an expert to be assessed for the presence and extent of
retinopathy.
 Many countries have national guidelines for eye screening. In 2015, IDF launched the
eye health guide, to provide recommendations on the screening and treatment of
retinopathy.

55. ACUTE COMPLICATIONS

57. HYPOGLYCAEMIA
 Hypoglycemia (or hypos) can cause serious problems if left untreated, including
coma, hypoxic brain injury and death. People should be advised to treat a hypo as
quickly as possible with carbohydrate.
 Hypoglycemia is a common side effect of insulin use. It can be defined as a
plasma blood glucose of <4.0mmol/l or 72mg/dl and is caused by too much
insulin being in the bloodstream. This may result from too much insulin being
injected for the carbohydrate taken in a meal, or from unplanned exercise,
excess alcohol or poor injection sites causing delayed insulin absorption.
 Symptoms of hypoglycemia can vary between people and can change during a
person`s life.
 Symptoms can be split into two categories:
Neuroglycopeanic: The brain`s response to reduction in glucose
Autonomic: The body`s fight or flight mechanism, mediated by adrenaline

60. HYPOGLYCEMIA SYMPTOMS
• Trembling
• Palpitations
• Sweating
• Anxiety
• Hunger
• Nausea
• Tingling
• Difficulty concentrating
• Confusion
• Weakness
• Drowsiness
• Vision changes
• Difficulty speaking
• Headache
• Dizziness
AUTONOMIC NEUROGLYCOPEANIC

61.  IDF recommends 15-20g quick acting carbohydrates should be
taken, followed by a further 20g of slower acting carbohydrate.

62. Recommended quick acting CHO: Recommended slower acting CHO:
Glass of orange juice (150mls) 1 slice of Bread
Half glass of fizzy soda (non diet version) Half a bowl of cereal (eg cornflakes)
6 glucose tablets Glass of milk (150mls)
3 teaspoons of table sugar in water 1 medium sized piece of fruit (eg apple, pear)
5 jelly based sugary sweets 1 pot of sugar-sweetened yoghurt

64. ACUTE HYPERGLYCAEMIA
 Acute hyperglycaemia (when blood glucose level s rise above 13mmol/l or
234mg/dl) can be associated with typical symptoms of hyperglycaemia (the
symptoms of diabetes).Short periods of hyperglycaemia are not uncommon
(for example after a high carbohydrate meal) and unlikely to be harmful.
 However prolonged hyperglycaemia increases the risk of infections and
delayed healing and over time increases the risk of long term complications.

66. DIABETIC KETOACIDOSIS (DKA)
 DKA occurs when there is little or no insulin available in the body. This leads to glucose
remaining in the blood stream and to hyperglycaemia and dehydration.
 Body fat is broken down rapidly for an energy source and as a result of this process,
ketones are produced and build up in the blood stream.
 The excess of ketones causes acidosis and, along with the hyperglycaemia, can result in
a coma or even death. DKA requires urgent hospital admission for treatment with
intravenous insulin and fluids.
 While usually associated with type 1 diabetes, DKA can sometimes occur in type 2
diabetes during severe illness. DKA could be the first manifestation of Latent Autoimmune
Diabetes of Adulthood (LADA),and should be treated with insulin.

68. HYPERGLYCAEMIC HYPEROSMOLAR STATE (HHS)
 This is an acute complication arising from decompensated type 2 diabetes, which is often
triggered by an infection or other illness.
 HHS was previously referred to as hyperosmolar, non ketotic coma (HONK) or
hyperglycaemic, hyperosmolar, non-ketotic syndrome (HHNS), however, not all cases result
in coma.
 Prolonged severe hyperglycaemia leads to dehydration and a hyperosmolar condition (with
typically a very high sodium level) but without acidosis.
 It often occurs in older people and can lead to focal or global neurologic deficits. It requires
treatment with intravenous fluids and insulin.

69. GESTATIONAL DIABETES
 Gestational diabetes (GDM) occurs in women who develop resistance to insulin
and subsequent high blood glucose during pregnancy. GDM usually occurs
after the twenty-fourth week of pregnancy, as the level of "pregnancy
hormones" is increased with the growing fetus. This results in an "insulin
resistant" state in the mother's body and an increased requirement for maternal
insulin production.
 As gestational diabetes normally develops later in pregnancy, the unborn baby
is already well-formed but still growing. Uncontrolled gestational diabetes can
lead to excessive growth of the baby and problems during delivery.
 All Women who had GDM should be screened for diabetes following the
pregnancy. They should also be give lifestyle advise as they are at an
increased risk of developing to type 2 diabetes later in life.