1. DIABETES, HYPERTENSION,
& STROKE
(THE SCIENCE OF WELLBEING, EFSS WEEKEND CLASSES)
©DR LEJU BENJAMIN MODI (MBChB)
FOR EFSS AUDIENCE (ON ZOOM/YOUTUBE)
09 – 10 SEPTEMBER, 2023

2. Disclaimer
The material shared in this presentation is
strictly for health awareness and information
purposes to the audience and must not be
used for making self diagnosis and/or
prescriptions!
This presentation does not contribute to any CPD
points.

3. The Epidemiologic Triangle/Triad
Communicable Vs Non-communicable diseases

4. DIABETES MELLITUS (DM): Outline
Diabetes Mellitus
o What it is
o Risk factors
o Signs/symptoms
o Diagnosis, complications and treatment
o Prevention

5. The Blue Circle…
o Universal symbol for diabetes mellitus
o Signifies the unity of the global
diabetes community in response to
the rising number of people affected
by diabetes
o November 14th is World Diabetes Day

6. Body sugar balance
o Insulin – increases cell uptake
of sugar from blood; promotes
storage of energy
o Higher levels immediately after a
meal
o Glucagon – increases
breakdown of energy stores,
hence, increasing blood sugar
levels
o Exercise/stress moments
o Starvation, etc.

7. Diabetes Mellitus (DM)
o Group of disease conditions (affecting conversion of food
to energy) involving inappropriately elevated blood
sugar (glucose) levels over prolonged time
o Due to either the pancreas not producing enough insulin
or the cells of the body not responding properly to the
insulin produced.
o Three main types – Type 1 (pancreas not producing insulin),
Type 2 (cells not responding well/resistance to insulin), and
Gestational DM (resistance to insulin in pregnancy)

8. DM Types
o Gestational DM – during
pregnancy in women
without previous DM
o Hormonal changes
o Weight gain
o Less response to insulin
o 5-10% women found to
have DM after pregnancy
(type 2)

9. Risk Factors for DM
Type 1 (non
modifiable):
o Genetics
o Autoimmune
disease of the
pancreas
Type 2
o Alcohol excess
o Drugs (steroids, etc.)
o Pancreatitis/ surgery
o Endocrine
(Cushing’s, etc.)

10. Signs & Symptoms of DM
Classic Signs and Symptoms are:
o Wight loss (mainly in Type 1)
o Increased urination (polyuria)
o Increased thirst (polydipsia), and
o Increased hunger (polyphagia)
Additionally:
o Blurry vision
o Headache, fatigue
o Slow healing of wounds/cuts, itching
skin
Symptoms may develop faster in Type 1
while gradually and more subtle in Type 2.

11. Diagnosis of DM
o History (family history; classic symptoms)
o Physical examination (eyes for vision, physical appearance/weight,
etc.)
Laboratory workups (ranges may vary by labs)
o Random Blood Sugar (RBS) ≥ 11.1 mmol/L (≥ 200mg/dL)
o Fasting Blood Sugar (FBS) ≥ 7.0 mmol/L (≥ 126mg/dL)
o Oral glucose tolerance test (OGTT; 2hrs glucose) ≥ 11.1 mmol/L
(200mg/dL)
o Glycated Haemoglobin (HbA1C) ≥ 6.5% – chronicity of high blood
sugars; monitoring treatment
Other workups as deemed necessary to rule out other conditions

12. o Complications can
only be slowed
down, not
prevented, with
appropriate
treatment.
o Other
complications/
emergencies
o Very low sugar
(hypoglycemia)
o Very high sugar
(hyperglycemia)

13. Diabetic foot – a common DM complication!
 May start with pain,
tingling
sensation/swelling; open
wound (ulcer)
 Associated loss of
sensation
 Meticulous treatment of
wound and DM needed
 Clean wound
(debridement)?
 Up to 50% get
amputated!

14. Gestational DM complications
 Some risk factors include
age 25+; family history;
overweight; previous
GDM
 Offer general advice,
discuss risks pre-
conception
 Screen with OGTT at
booking (16 – 18 weeks)
 Do FBS 6 weeks after
birth
Complications for Mother/baby
 Miscarriage
 Pre-term birth
 Pre-eclampsia (hypertension in
pregnancy)
 Congenital malformations
 Big baby (macrosomia)
 Worsening diabetic complications
(eyes, kidneys)

15. Treatment/Management of DM
Non-pharmacological
o Diet and weight control
o Exercise
o Surgery – weight loss surgery; pancreas/kidney transplant
Pharmacological
o Insulin derivatives – Type 1, tablets resistant Type 2, complicated DM (with
raised hyperglycemia – DKA, HHS)
o Oral tabs – Type 2
o Table sugar; Glucagon – in severe hypoglycemia
Other Care
o Prompt treatment of infections; avoid wounds/cuts
o Regular monitoring of blood sugars “whenever you have a needle in a
vein, do a blood glucose (unless recently done).”

16. Prevention of DM
Primary Prevention
o (Genetics??)
o Exercise
o Diet
Secondary prevention
o Early diagnosis and
treatment
Tertiary prevention
o Prevent injuries
o Continue treatment

17. Creating and maintaining a healthy
food environment – your role!

18. Conclusion
o Three main types of DM – Type 1, Type 2, and Gestational (during
pregnancy); caused by both modifiable and non-modifiable
factors (type 1)
o Type 1 – no insulin production by pancreas; self-destruction of
pancreatic cells the most common cause. Often early diagnosis,
loss of weight very common; treated with insulin injections.
o Type 2 – resistance to insulin, obesity the most common factor; later
(40s’ age) in life; oral medications; insulin if complicated/resistant
o Treatment slows down complications but cannot prevent them
o Other care of diabetic patients is important (avoiding cuts, early
treatment)
o Prevention lies in modification of modifiable risk factors (lifestyle)
o Screen for sugar levels, especially if family history strong

19. Reading materials
o https://www.slideshare.net/100002840600351/diabetes-mellitus-72487523
o https://www.yourhormones.info/media/nlhfrcax/signs-and-symptoms-
final.pngSSHepatitis Treatment Guidelines, 2020
o https://pdb101.rcsb.org/global-health/diabetes-
mellitus/monitoring/complications
o https://www.semanticscholar.org/paper/Primary-Prevention-of-Type-2-
Diabetes-and-Its-291-
Maiya/2dc744c4140fcef69dd9e008e4ad78b1186ca3d9/figure/0
o https://www.ezmedlearning.com/blog/type-2-diabetes-mellitus-
symptoms-medications
o https://link.springer.com/chapter/10.1007/978-3-030-71377-5_1
o https://www.pacecvi.com/blog/diabetic-foot-sores
o https://www.cdc.gov/diabetes/managing/eat-well/meal-plan-
method.html

20. Q&A ON DM?

21. HYPERTENSION (HIGH BLOOD
PRESSURE)
Hypertension (HTN)
o What it is
o Risk factors
o Signs/symptoms
o Diagnosis, complications and treatment
o Prevention

22. MAY 17TH = WORLD HYPERTENSION DAY

23. What is HYPERTENSION (HTN)?
 Blood pressure (BP) – amount of force exerted on the walls of
the blood vessels by circulating blood; from the pump (heart).
 BP is measured at two instances – force exerted at the time of
contraction of the heart to pump blood (Systolic BP), and at its
relaxation (Diastolic BP)
 Normal BP is <120/80 mmHg. Pre-HTN = 120/80 – 139/89. People
with pre-HTN have increased risk for HTN
 HTN is persistently elevated blood pressure averaging greater
than 139/89 mmHg (systolic/diastolic BP) on at least two
separate recordings at rest taken apart

24. o Broadly classified as Primary/Essential HTN (Unknown
cause, 95% cases), and Secondary HTN (due to other
potentially rectifiable causes, 5%); also systolic or diastolic
HTN
o Estimated 1bn people worldwide have HTN, with about
7.1m deaths attributable to HTN annually
o The World Health Organization estimates that the
prevalence of hypertension is highest in the African region,
with about 46% of adults aged 25 years and older being
hypertensive compared to 35% in the Americas and other
HIC, and 40% elsewhere in the world

25. Clinical classification

27. Risk Factors for HTN
Non Modifiable
o Family history (tends to run
in the family)
o Age (older age increases
risk)
o Sex (more males, earlier)
o Race (blacks)
Modifiable
o Stress
o Obesity (BMI > 30kg/m2)
o DM
o Nutrients (salt)
o Smoking
o Caffeine is controversial
o Kidney disease
o Endocrine causes
o Pregnancy, drugs (steroids), etc.

28. Signs & Symptoms of HTN
o None, early in the condition, except high BP (often
incidental finding) – means no early seeking of medical
help!
o With progress in the condition, morning headaches,
fatigue, dizziness, nausea/vomiting, feeling own
heartbeat (palpitations), flashing, blurred vision, and
nose bleeding (epistaxis)
o If left untreated, about 50% patients die of heart disease
(including heart failure), 1/3 die of stroke, and about 10 –
15% die of kidney disease/failure

30. Diagnosis/Tests
 BP reading
Other Tests:
 Ambulatory BP Monitoring (ABPM), 24hrs
 FBS
 Lipids
 Electrolytes
 Cardiac Echo
 Etc.

31. Complications of HTN – multi organ
Heart and Blood Vessels
 Heart muscle enlargement, abnormal heartbeats, heart attack
 Vessels rupture
Kidneys
 Damage to “filters”, leading to impaired kidney function
 End stage kidney disease
Nervous system
 Stroke, bleeding into brain tissue (if ruptured vessels)
Eyes
 Bleeding into retina, → impaired vision; extraocular muscles
paralysis (from nerve damage)

32. Management of HTN
o History – family history, previous HTN; signs/symptoms
reported, including for complications of HTN, etc.
o Physical examination – head to toe – BP measurement,
eyes, look for identifiable risk factors for HTN
o Some lab tests could be indicated to find cause of HTN
o Life style modifications (see next slide) as initial
management plan

33. DASH = Dietary
Approaches to
Stop Hypertension

34. Treatment
o Medications, if persisting with lifestyle changes. Goals are
to maintain BP <140/90, and prevent kidney and heart
morbidity and mortality
o Single drug or combination; dose adjustments, etc.
o Once started on medications, advisable to stay on it
lifelong, while BP monitoring continues
o Benefits of treatment include:
o Reduce stroke incidence by 35 – 40%
o Reduce heart attack by 20 – 25%, and
o Reduce heart failure by about 50%

35. Prevention of HTN
o Applicable to secondary HTN (modifiable risks mostly) –
lifestyle modifications above
o Medical checkups – BP check regularly
o Early treatment; staying on treatment

36. Conclusion
o Hypertension is persistently high blood pressure averaging
140/90mmHg or more
o Most cases (95%) have unknown cause
o Modifiable and non modifiable risk factors exist
o Initially has no signs/symptoms, could be associated with
headaches, vomiting/nausea, lethargy, etc.
o Untreated HTN has devastating multi organ complications,
including stroke
o Lifestyle modification before medications as management steps
o Once started on medications, better stay on them lifelong
o Screen for BP regularly, 3 yearly earlier, can do as regularly as can

37. Further Reading materials
o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8030060/#:~:text=T
he%20World%20Health%20Organization%20estimates,40%25%20el
sewhere%20in%20the%20world.
o https://www.foodafactoflife.org.uk/media/5575/high-blood-pressure-
ppt-1416he.pptx
o https://www.cdc.gov/globalhealth/healthprotection/ncd/training/files/S
ession1_PPT.pdf

38. Q&A ON HYPERTENSION?

39. STROKE (CEREBROVASCULAR
ACCIDENT, CVA)
Stroke
o What it is
o Risk factors
o Signs/symptoms
o Diagnosis, complications and treatment
o Prevention

42. Stroke
 Clinical syndrome of rapid onset of cerebral deficit lasting
more than 24hrs or leading to death with no apparent cause
other than a vascular one. Also termed “brain attack”.
 Symptoms lasting less than 24hrs = Transient Ischemic Attack
(TIA); has best outcomes
 Occurs due to blood supply problems in the brain – either
blood supply is blocked (ischemic, over 85% cases) or a
vessel ruptures (hemorrhagic), leading to death of brain tissue
 A medical emergency – treatment must be sought as fast as
possible, time is of the essence!
 World Stroke Day – 29th October

43. Two main types of Stroke
 Ischemic
(commonest;
~ 85% cases)
 Hemorrhagic
 TIAs (warning
signs!)

44. Incidence (WHO)
 Annually, 15 million people worldwide suffer a stroke. Of these, 5 million die and
another 5 million are left permanently disabled, placing a burden on family and
community.
 The Global Stroke Factsheet released in 2022 reveals that lifetime risk of
developing a stroke has increased by 50% over the last 17 years and now 1 in 4
people is estimated to have a stroke in their lifetime
 Stroke is uncommon in people under 40 years; when it does occur, the main
cause is high blood pressure. However, stroke also occurs in about 8% of
children with sickle cell disease.
 For every 10 people who die of stroke, four could have been saved if their
blood pressure had been regulated.
 Among those aged under 65, two-fifths of deaths from stroke are linked to
smoking.

45.  In Africa, data published within the past decade show that stroke
has an annual incidence rate of up to 316 per 100,000, a
prevalence of up to 1,460 per 100,000 and a 3-year fatality rate
greater than 80%.
 Moreover, many Africans have a stroke within the fourth to sixth
decades of life, with serious implications for the individual, their
family and society.
 Patients, providers, payers, policy-makers and the public, in
concert with scientists and funders, will need to maintain
prospective vigilance of the continental stroke burden, apply
vigour to unravelling the unique determinants of stroke in the
region, and prioritize the development of contextual preventive
and therapeutic solutions to avert and minimize the burden of
stroke

46. Non-modifiable Risks
 Genetics (higher
predisposition than
others)
 Age
Modifiable Risks
 Most risk factors
 Account for about
80% cases of stroke
 Include past TIAs,
drugs, etc.

48. Signs/Symptoms of Stroke
 The signs and symptoms of
a stroke often develop
quickly. However, they can
develop over hours or even
days.
 The type of symptoms
depends on the type of
stroke and the area of the
brain that’s affected.
 How long symptoms last
and how severe they are
vary among different
people.

49. The Signs and Symptoms may include:
• Sudden weakness
• Paralysis (an inability to move) or numbness of the face, arms, or legs,
especially on one side of the body
• Confusion
• Trouble speaking or understanding speech
• Trouble seeing in one or both eyes
• Problems breathing
• Dizziness, trouble walking, loss of balance or coordination, and
unexplained falls
• Loss of consciousness; incontinence (urine/faeces); etc.
• Sudden and severe headache

50. Diagnosis of Stroke
 History: smoking, previous experience (TIA), onset of symptoms,
family history, underlying chronic illnesses, remember FAST! Etc.
 Physical examination: heart rate; blood pressure; body weight
(BMI); head to toe; facial deviations, speech alterations/none,
sensory and motor function of extremities, etc.
 Laboratory tests: aim to identify risk factors – blood sugar,
lipids, ECG, etc.
 Urgent CT Scan of the Brain – gold standard – identifies type of
stroke (ischemic or hemorrhagic), determining treatment
approach
 MRI; Etc.

51. Treatment/Management of Stroke
Emergency!!! The golden hour rule – protect the airway, rush to the hospital!
Ischemic Stroke:
 Aspirin (blood thinner)
 Blood clot breaker (Tissue Plasminogen Activator, TPA)
 Vessel repair surgically (angioplasty, endarterectomy, etc.)
Hemorrhagic Stroke:
 Drugs that reduce blood pressure (minimize seizures, compression)
 If patient on drug thinners, give anti-blood thinners
TIAs:
 Observation as self-limiting
 Watch out for full stroke episodes

52. Complications of Stroke
 Contractures
 Memory loss; vision and
hearing impairment

53. Rehabilitation
 Speech therapy – help with producing/understanding speech
 Physical therapy – help relearn body movements and
coordination. Regular turning to prevent pressure sores.
 Occupational therapy - improve ability to carry out routine
daily activities: eating, dressing, bathing, etc.
 Psychosocial support – through groups, family members – very
important!

54. Prevention of Stroke (Modify Risks!)
 Healthy diet/weight; exercise regularly
 Stop smoking/don’t smoke!
 Moderate/stop alcohol intake
 Manage blood pressure/sugars (hypertension/diabetes)
well
 Preventive medications on prescription after TIA; take
your medicines!
 Check cholesterol
 Treat heart disease promptly/appropriately

55. Conclusion
 Stroke is mainly of two types – ischemic (due to blood vessel blockage;
most common, 85 of cases%) and hemorrhagic (due to blood vessel
rupture and bleeding into the brain).
 Transient Ischemic Attack (TIA) is a milder form of stroke, lasts less than
24hrs of symptoms; usually a ‘warning sign’ of future/completed stroke.
 Smoking, obesity, hypertension, and diabetes are major risk factors for
stroke – modify these! Other risks include trauma/stress, genes, and age.
 It is an emergency – be able to spot it by applying FAST; seek help
immediately. Survivor to stay on preventive treatment and other care.
 CT Scan of the brain is the mainstay for diagnosis, classification, and
determining form of treatment. Get it ASAP!
 Other care of a stroke patient, including physiotherapy, speech therapy,
occupational therapy, etc., is very important as is psychosocial support

56. Further Reading materials
o https://www.lompocvmc.com/blogs/2021/december/12-reasons-you-may-need-a-ct-
scan/
o https://www.slideshare.net/MrPramitKumarSah/stroke-presentation-77800548
o https://www.emro.who.int/health-topics/stroke-cerebrovascular-accident/index.html
o https://www.uclahealth.org/news/risk-stroke-up-worldwide-what-can-be-done-about-
it
o https://slideplayer.com/slide/3883478/
o https://www.neuroskills.com/brain-injury/stroke/what-are-the-signs-and-symptoms-
of-a-stroke/
o https://www.researchgate.net/figure/Frequencies-of-acute-complications-following-
stroke_tbl1_240116782
o https://www.who.int/srilanka/news/detail/29-10-2022-world-stroke-day-
2022#:~:text=Stroke%20is%20the%20leading%20cause,a%20stroke%20in%20the
ir%20lifetime.
o https://healthjade.com/human-brain/

57. Q&A on Stroke?

58. Thank you all for listening!