Download The goals of therapy

Management Of DM :
If We Consider to treat type 2 DM We Should Not depend on the first abnormal
reading but shoul d 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 :
1-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 ).
2-Drug Therapy
-DM1 : insulin .
-DM-2 :
 Oral hypoglycemic agents (sulphonylurea and meglitnides).
 Insulin sensitizers (Biguanides and thiazolidinedione )
 Insulin.
3-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 a car as an Occupation
because hypoglycemic patient is mentally not well oriented.
• Self assessment of blood glucose by Electronic-Meter-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 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 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 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 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 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 الشعير‬
we 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 .
•
•
•
•
•
•
•
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 ).
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.