Transcript Management : Of . DM

Management : Of . DM :
If We Consider to treat type 2 DM We
Should Not depend on the first abnormal
reading but should be confirmed by at least
2 abnormal reading because it may be a lab
mistake . while if the patient suspected to
have type 1 DM should be treated by insulin
therapy because if not treated early he
develop diabetic ketoacidosis and died .
The goals of therapy :
• To achieve a near normal body Weight .
• To achieve a near normal blood glucose .
Strategy Of Therapy :
• Non-pharmacological Management:
• Dieting to reduce hyperglycemia (low glycemic
index diets ).
• Dieting to reduce and maintain body weight
(reduction Of calorie intake ) .
• Life style Modification .(Muscular activity ).
Drug Therapy :
• DM1 : insulin .
• DM-2 :
• Oral hypoglycemic agents (sulphonylurea and
meglitnides).
• Insulin sensitizers (Biguanides and
thiazolidinedione )
• Insulin.
• Monitoring and follow up :
• Treatment Of patient with type II DM
need things which are milder and
important:
• Advise the patient about type of food,
Life style and physical activity .
• Educate patient who come for the first
time and who need insulin therapy about
the effect of high blood glucose and Low
glucose (hypoglycemia)
• Patient who are hypoglycemic should not drive
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a car as an Occupation because hypoglycemic
patient is mentally not well oriented.
Self assessment of blood glucose by ElectronicMeter-Finger prick .
Treatment with anti diabetic drugs:
Blood glucose monitoring is optional in many
patients with stable type 2 DM while it is more
useful in patient taking sulphonylureas
because the risk of hypoglycaemia is high also
during inter current illness and prescription of
corticosteroids and during changes in therapy .
• The blood glucose is usually measured before
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breakfast (typical target )
is 4-7 mmol/L = 72
- 126 mgldl ,and two hour after food is 4 – 10
mmol/L = 72 – 180 mgldl ).
Treatment with insulin which include: ( Like in
type 1 DM.)
Regular blood glucose monitoring should be
performed by all people treated by insulin to
adjust insulin dose and detect hypoglycemia .
Daily pre prandial and bed time measurement
are usually recommended.
Target blood glucose level are typically 5 – 8
mmol/L =
90 - 145mgldl.
• Diet and life style advice :
• Many patient with DM who come for the first
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time having mild DM, we can advice them
about diet and physical activity and many of
them return to normo glycaemia and survive
with out complications .
Diet and oral anti diabetic drug, which is also
known as oral hypoglycemic drug in past such
as sulphonylureas .
Diet and insulin
Approximately 50 % of new cases of diabetes
can be controlled adequately by diet alone . 20
– 30 % need Oral anti diabetic drugs and 20 –
30 % need insulin.
• Check List for follow up of patients with
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DM.
Things at least to be checked once a year which
include:
Body weight (body Mass index ).
Urinalysis for fasting specimen for glucose
(ketones , albumin for Both micro and macro
albumin urea .
Glycemic control (glycated HbAIc ) and
inspication of home blood glucose monitoring
record .
Blood pressure .
Hypoglycaemic episodes . (Number of server
and frequency of mild episodes ).
Plasma Lipids .
C.V.S. risk factors .
Eye examination :
• = visual acuities for near and distance vision.
• Ophthalmoscopy with fully dilated pupils.
Lower Limbs .
• Peripheral pulses .
• Tendon reflexes .
• Perception of vibration sensation and light
touch .
Feet :
• Callus skin indicate pressure areas .
• Ulceration , deformity .
• Need for chairopody .
Prognosis Of DM:
• Good management :
• Allows a normal Life .
• Symptom free .
• Good health .
• Escape long term complications of DM.
• Few patient die from acute complications
(ketoacidosis or hypoglycemia ).
• A Lot of patients suffer from chronic
complications.
• Factors associated with increased
mortality and morbidity in DM:
• Long duration of the disease .
• Early age at the onset .
• High glycated HbAIc .
• Which reflects poor control of Blood
glucose leading to chronic complications of
diabetes and the most common are what
is called triopathy (retino pathy , ncuro
pathy and Ne phro pathy) .it is well settled
especially in type IDM.
• Raised blood pressure .
• It has been found that controlling
hypertension become as important as
controlling of blood glucose in DM. the
recommended blood pressure is the
systolic is around 130mmHg. And
diastolic is 75 – 80 mmHg .
• Protein urea and micro albuminuria .
• Dyslipidemia .
• Obesity
Dietary therapy :
Aims of dietary management :
• Achieve good glycaemic control .
• Reduce hyperglycaemia and avoid
hypoglycaemia .
• Assist with weight management .
• Reduce the risk of micro and macro
vascular complication.
• The micro vascular complication can be
reduced by a low salt intake while macro
vascular complication is reduced by
avoiding cholesterol and saturated fat.
• Ensure adequate nutritional intake.
• Avoid atherogenic diet or those that
aggravate complications like high protein
intake in nephropathy .
• Recommended Composition Of Diet For
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people With Diabetes:
Carbohydrate 55% Of total Calorie Sucrose
up to 10% .
Fat
< 35%
Saturated
<10%
Polyunsaturated <10%
Monounsaturated 10 – 20 % .
Usually obtain from:
Olive , rapeseed , ground nut and sesame oil ,
(reduced in LDC and total cholesterol without
lowering H D L.
Protein 15% don`t exceed 1gm/kg body
weight.
• The quality of diet should also be
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considered:
Used CHO should be low in refined CHO and
high unrefined (fibrous) CHO .
Fat should mainly be unsaturated .
Alcohol should be discouraged :
It has bad effects as to the general population .
Contain calories and disturbs caloric intake .
Potentiate hypoglycemic effects by inhibiting
gluconeogenesis.
Predispose to lactic acidosis.
May induce disulfuram reaction effect when
taken with chloropropamide .
• Knowledge of CHO content of food:
• Low glycemic index food lead to slow
and gradual vise in blood glucose .
• For example., if we eat 50 gm of white
bread and measure the blood glucose
after tow hours and compare it with eating
50 gm of barely bread (‫ )خبز الشعير‬we can
find that blood glucose level for barely
bread is lower than white bread after 2
hours from eating so barely bread has
lower glycemic index than white bread
and for this reason it is more useful for
diabetic patient .
• Other foods with low glycemic index
include :
• Basmati rice .
• Beans , lentil ‫ العدس‬.
• Barley bread .
• Bulgar ‫البرغل‬.
While potato are not good for diabetic
patient because its glycemic index is high .
• Weight Management :
• The recommended daily energy = body
Wt × (33 – 42) Cal Average daily
requirement = 2000 – 3000 Cal
• Benefits of weight reduction in DM:
• Increase insulin sensitivity .
• Increase plasma insulin concentration .
• Decreased blood pressure .
• Improved Lipid profile .
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Diet for insulin treated :
Should contain 3 main Meals and 3 snacks .
Insulin and diet intake should be in conform .
A useful meal planning tool is it the plate model:
CHO (40 %) ]Rice , bread , beans , pasta ,
potatoes [
Vegetables and fruit (40 %) ] 5 portions per
day is necessary[.
Proteins (20%) ] Fish , eggs , meet , cheese ).
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Sweeteners :
• Are useful for diabetic patient : of 2 types
• Nutritive ( sorbitol , fructose ).
• Non nutritive Like saccharine and
aspartam which contain two amino acid
phenylanlaine which may harm to the
brain.
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