Modul Diabetes Smt Vii_1

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Pesan-pesan :

Temen-temen ini ada 10 sub modul(diabetes) dalam 1 file

MODULE 1 :DIABETES MELLITUS - EPIDEMIOLOGY

MODULE 2 : DIABETES MELLITUS - Definition, Presentation, Diagnosis and

Classification

MODULE 3 : DIABETES MELLITUS - Aetiopathology

MODULE 4 : DIABETES MELLITUS-Management : Lifestyle modification

MODULE 5 :DIABETES MELLITUS – MANAGEMENT : Drug therapy

MODULE 6 : DIABETES MELLITUS – Acute Complications

MODULE 7 : DIABETES MELLITUS–Macro-vascular Complications

MODULE 8 : DIABETES MELLITUS–Micro-vascular Complications

MODULE 9 : DIABETES MELLITUS – Prevention

MODULE 10 : DIABETES MELLITUS – Children and Pregnancy

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(jadwal kuliah blok endokrin, terlampir di file lain)

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Makasii...

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MODULE 1 : DIABETES MELLITUS - EPIDEMIOLOGY

Overview Diabetes mellitus (DM), is now one of the most common non-communicable

diseases globally. It is the fourth or fifth leading cause of death in most high-

income countries and there is substantial evidence that it is epidemic in many

economically developing and newly industrialized nations. Complications

from diabetes are resulting in increasing disability, reduced life expectancy

and enormous health costs for virtually every society. Diabetes is undoubtedly

one of the most challenging health problems in the 21st century.

Goal To understand the meaning of prevalence rate of diabetes mellitus, why there are

differences of prevalence rate of diabetes mellitus in different places and in the same

place at different times. You will also learn how to estimate it.

Objectives After completion of this module, you should be able to :

1. Understand what is meant by prevalence rate of diabetes mellitus and

how it is estimated.

2. Explain why there are differences of prevalence rate of diabetes

mellitus in different places and in same place at different times.

3. Explain how to guess the risk factors for diabetes mellitus in a

population.

Teaching strategies Active learning with module task, group discussion, and expert lecture.

Suggested time Lecture: 1 hours

Who should teach

this module

Endocrinologist

Evaluation of

learning

Examination or assignment

References 1. Diabetes Atlas 2000, International diabetes Federation, Belgium.

2. Harrison‟s Principles of Internal Medicine 16th

edition, vol. 2, edited by Kasper DL

et al, Mc Graw-Hill, 2005, p 2153

3. Williams Textbook of Endocrinology 11th edition, edited by H.M. Kronenberg,

Saunders Elsevier, 2008, p 1329

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Activity 1.1

Understanding prevalence of diabetes mellitus from data of estimate.

Aim : This activity will help you to understand the meaning of prevalence of diabetes in a

population at a certain time.

REGION Number of

population

No. people with

diabetes

Prevalence of

diabetes

Africa 664021000 5.3%

Middle east and north africa 219781000 17007600 7.7%

South east asia 1219457000 3.6%

South and central america 462724000 22467400 4.9%

Western pacific 273794000 7.8%

North America and caribbean 233013000 8553300 3.7%

Europe 217888000 1.2%

TOTAL 3290678000 44097900 4.6%

N.B : IDF – International Diabetes Federation

The table above is an estimate of prevalence of diabetes mellitus by IDF in 7 different regions in

2009. Age of the population was 20 to 79 years. Study the table carefully and respond to the

following questions.

1. In the table there is a column for “No. of people with diabetes”. Fill up blank spaces in that

column.

2. Name the IDF region having the lowest number of population and what was the prevalence

of diabetes in that population in 2009?

Answer : Name of the IDF region ________________

Prevalence of diabetes mellitus was _______ %

3. Name the IDF region where our country is situated and make an estimate of diabetic persons

lived in that region in 2009?

Answer : Name of the IDF region ________________

Prevalence of diabetes mellitus was _______ %

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ACTIVITY 1.2

Understanding the risk factors of diabetes mellitus that determine prevalence of diabetes mellitus

that determine prevalence of diabetes in a particular population.

Aim : This activity will help you to understand the risk factors associated with increasing prevalence

of diabetes in Indonesia.

In the text, we have learned that variations in prevalence rate of diabetes in different countries, may

be due to genetic susceptibility and environmental risk factors such as change in diet, obesity, and

physical inactivity.

1. Now what is your opinion regarding the variations (increasing) in prevalence rate of

abnormal glucose tolerance in our country?

a. Genetic susceptibility for diabetes is more involved than environmental risk factors.

b. Environmental risk factors for diabetes are more involved than genetic susceptibility.

c. Genetic susceptibility and environmental risk factors are involved equally.

2. Name the 3 environmental risk factors mentioned above

a.__________________________ c._______________________________

b.__________________________

ACTIVITY 1.3

Understanding that duration of diabetes mellitus is a risk factor for increased prevalence of

complication of the diasease.

Aim : This activity will provide you the opportunity of looking into change in prevalence rate of

diabetic complications in a population with time.

Study the table 1.1 and, calculate the prevalence increased in retinopathy, nephropathy and stroke in

diabetes when the duration is > 15 years compared to 6-10 years.

Use the formula,

(Prevalence rate at > 15 years duration – prevalence rae at 6 – 10 years duration) x 100/ (Prevalence

rate at 6-10 years duration)

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Answer : prevalence increased in

1. Retinopathy ___________%

2. Nephropathy ___________% and

3. Stroke ________________% when the duration of diabetes became > 15 years compared to

6 – 10 years.

ACTIVITY 1.4

To understand risk factors for diabetes in a particular population from epidemiological study.

Aim : To make feedback in learning risk factors from an epidemiological survey.

There was a survey in Azimpur colony in Dhaka city in 1992. There lived 1247 persons in 135

families; 231 of them were under 20 years. Among the rest 1016 cases-the mean age was 37.5 years,

503 (49.5%) were male, 158 (15.6%) were obese, 201 (19.8%) had regular physical activity, 306

(30.1%) had hypertension, 71 (6.9%) were diabetic and 219 (21.6%) persons had known diabetic in

their first-degree relatives. The total population studid for diabetes mellitus (1016) was then divided

into 2 groups namely diabetic (71) and non-diabetic (945) to compare the parameters between the 2

groups. The result is summarized in the table below.

Parameter Total population Diabetic Non-diabetic

Number 1016 71 945

Mean age (years) 37.5 51 36.5

Sex (M:F) 503 : 513 37 : 34 466 : 479

Obese 158 (15.6%) 41 (57.7%) 117 (12.4%)

Physical activity 201 (19.8%) 23 (32.4%) 178 (18.8%)

Family history of DM 219 (21.6%) 44 (61.9%) 175 (18.5%)

Hypertension 306 (30.1 %) 34 (47.9%) 272 (28.8%)

N.B : Mean indicates „average‟. Frequency indicates „number per hundred‟

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In the left hand column of the following table there are remarks on the data on the above survey.

Write you opinions in the right hand column of the table.

Remarks Your opinion

Prevalence rate of diabetes in the colony

was 6.9%

Older people suffer from diabetes more.

Sex difference among diabetics and non-

diabetics was not marked.

Obesity was not a common finding in this

colony but diabetics were more obese.

Only about 20% of the colony people had

habit of regular physical activity; diabetics

performed more than the non-diabetics.

Family history of diabetes was common in

diabetic group.

Hypertension was more in diabetic group.

END-OF-MODULE TUTOR MARKED ASSIGNMENT

This part will help you to assess your learning of chapter 1 and help you to understand when you are

ready for chapter 2.

Task 1.1 : Calculation of prevalence of diabetes.

In the table below column 1 is showing the name of 6 divisions of Bangladesh. Column 2 is showing

the number of people aged between 45-70 years and Column 3 is showing the number of people

with diabetes mellitus.

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Calculate the prevalence rate of diabetes mellitus in each division and fill the Column 4.

Division No. of people aged

45 to 70 years

No. people with

diabetes

Prevalence

Dhaka 4036409 47356

Chittagong 3391205 41203

Sylhet 2764703 34705

N.B : Figures are arbitrary.

Write definition of prevalence of diabetes mellitus.

Task 1.2 : To understand that diabetics are more prone to morbidity than non-diabetics.

Diabetes mellitus is a serious disease. It increases the risk of developing certain morbidity many

times more than non-diabetics.

Fill-up the blanks in the following statements.

1. A diabetic has _______________times higher risk for stroke than a non-diabetic.

2. A diabetic has _______________times higher risk for heart attack than a non-diabetic.

3. A diabetic is ________________ times more prone to kidney failure than a non-diabetic.

4. A diabetic is_________________times more prone to eye problem than a non-diabetic.

5. A diabetic is _______________ times more prone to lower limb amputation than a non-

diabetic.

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Task 1.3 : Identifying the environmental risk of diabetes.

The left column of the table bellow contains risk factors of diabetes mellitus.

Mark „tick‟ in right column if you think it as an environmental risk factor.

Features Environmental risk factors

Aging

Obesity

Physical inactivity

Positive family history of DM

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MODULE 2 : DIABETES MELLITUS -

Definition, Presentation, Diagnosis and

Classification

Overview Diabetes mellitus (DM), a chronic, debilitating disease, is associated with a

range of severe complication. Demographic and epidemiological evidences

suggest that the incidence of diabetes is increasing worldwide. The

management of diabetes mellitus and the management of its complications are

major challenges for the future.

Goal To provide the opportunity of memorizing the different cutoff values for

raised bllod glucose at different investigation setting. The activities will

develop your skill to label individuals suffering from diabetes. It will also

familiarize you with clinical differentiation of different classes of diabetes,

particularly typ 1 DM vs type 2 DM.


1. define diabetes mellitus.

2. discuss about the a etiological factors and types of diabetes mellitus.

3. make distinction between type 1 DM and type 2 DM by observing

clinical presentations.

4. supervise the procedures for OGTT.

5. interpret blood glucose values at fasting, at random or during OGTT for

diagnosis of diabetes, IGT anf IFG.

Teaching strategies

Active learning with module task, group discussion, and expert lecture.


Who should teach

this module

Endocrinologist

Evaluation of

learning


References 1. Basic and Clinical Endocrinology 7th edition, edited by F. S. Greenspan and D. G.

Gardner, Lange medical book, 2004, p 658-689

2. Harrison‟s Principles of Internal Medicine 16th

edition, vol. 2, edited by Kasper

DL et al, Mc Graw-Hill, 2005, p 2152-2155

3. Standards of Medical Care in Diabetes – 2010, America Diabetes Association,

diabetes care, vol. 33, 2010, p S11-S61


Saunders Elsevier, 2008, p 1330-1331

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ACTIVITY 2.1

Understanding hyperglycemia and cuttoff values for diabetes mellitus for fasting blood glucose

and blood glucose level 2 hours after a standard oral glucose drink from laboratory reports.

Aim : This activity will help you practice understanding how laboratory values of blood glucose in

fasting and 2 hours after oral glucose drink are interpreted to label a person as a diabetic.

Departement Of Biochemistry

BIRDEM Hospital

Report Of OGTT

Date : February 24, 2004

SI.no Name VPG at 0 min VPG at 120 min

1 Mr. MA Karim 4.3 5.7

2 Mr. Abdul Alim 5.1 16.0

3 Mr. Kamaluddin 10.7 23.0

4 Mrs. Laila Begum 4.4 6.5

5 Master Zabed 18.3 23.5

N.B : VPG = Venous plasma glucose (mmol/L) and the assay is done by

Auto-analyzer by using glucose-oxidaze method

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In the left hand column, write whether the person is diabetic or not; in the right hand column, write

the reasons for the 4 reports (from sl.no 2-5) using the style shown for report of sl.no.1.

Mr. MA Karim is not suffering from

diabetes

Both the values are below the cutoff level

for a diabetic.

N.B. : Your tutor will provide feedback on this activity.

Activity 2.2

Typical presentation of diabetes mellitus in a case.

Aim : This activity will help you to understand the typical presentation of a diabetic by a case study.

Master. Zahid, a 17-year boy, 1st year student of HSC class, was brought at BIRDEM OPD with the

complaints of excessive urination and increased thirst and appetite with mild weight loss and general

weakness for last 15 days. On the previous day his fasting blood glucose was 18.3 mmol/L and 23.5

mmol/L 2hours after a 75 gram of glucose drink. At presentation, his pulse was 100 bpm and BP

120/70 mm of Hg, BMI 18.5, glycosuria and ketonuria were detected by urine examination.

a. Write down 3 presenting features of diabetes mellitus of Master Zahid.

1)

2)

3)

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b. What type of presentation it is – Typical or Atypical

We have learned that type 1 DM, where there is total lack of insulin from the beginning of disease,

always has a typical presentation.

c. What do you feel about the folloeing statement “A diabetic not belonging to type 1 DM has

the potentiality to have a typical presentation also.” Give your opinion.

Activity 2.3

Diagnostic tools used for diabetes mellitus.

Aim : This activity will make you understand which of the diagnostic tests are to be used for

determining diabetes in a person

In the left hand column, there is a statement regarding a particular tool; in the right hand column,

write down the appropriate figure (s) if you agree with the statement.

Blood glucose of a fasting sample can

indicate ascertain that one is non-diabetic.

Do you agree with the statement ?

If „yes‟ write down the value above which

a person is diabetic.

mg/dl

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Blood glucose of a random sample can

indicate that a person is likely to be a

diabetic if the value is either above or

below a certain range.


If „yes‟ write down the range.

To mg/dl

Blood glucose of an OGTT can certainly

tell us whether a person is diabetic, non-

diabetic or even pre-diabetic (IGT).


If „yes‟ write down of the range within

which blood glucose at 120th

minute the

level must be below 110 mg/dl).

To mg/dl

Feedback : If your are at liberty to suggest a test for diabetes for a gentleman who is not

symptomatic of diabetes, which test you will ask for ? Why ?

Name of the test Reason

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Activity 2.4 (a)

Classification of diabetes by case study

Aim : This activity will help you to understand the clinical classification based on presentations of

diabetes by case study.

Master. Zahid is a 17-year boy, 1st year student of HSC class, a newly detected diabetes with typical

features of diabetes mellitus for last 15 days only. On examination his pulse was 100 bpm and BP

120/65 mm of Hg, BMI 18.5. glycosuria and ketonuria were detected by urine examination. FBG

18.3 mmol/L.

To make an attempt to classify the type of diabetes of Master Zahid, how will you consider ecah of

the points mentioned in the left column of following table to go in favor of Type 1DM or type 2DM

Type 1 DM Type 2 DM

Presenting feature of DM-typical & of short duration

Age of onset

Body habitus (BMI)

High blood glucose + Ketonuria

Conclusion : Master Zahid‟s diabetes mellitus belongs to

Type 1DM rather than type 2DM

Type 2DM rather than type 1DM

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Activity 2.4 (b)

Classification of diabetes by case study.

Aim : This activity will help you understand the clinical classification based on presentations of

diabetes by case study.

Mr. Kamaluddin, a 48 years old gentleman was referred to endocrine OPD of BIRDEM Hospital by

his GP with a clinical diagnosis of Cushing‟s Syndrome. Endocrinologist confirmed the case as a

Cushing‟s syndrome due a cortisol secreting tumors in his right adrenal gland. During the diagnostic

work up n OGTT documented that he was a diabetic too, because blood glucose levels in both the

time poits were clearly above the expected level i.e. 10.7 mmol/L at 0 minute and 23.0 mmol/L at

120th

minute. On questioning he admitted that had typical features of diabetes.

Give your comment about the type of diabetes from which Mr. Kamaluddin was suffering.


This part will help you to assess your learning from the chapter 2. it will help you to understand

when you are ready to go for the chapter 3.

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Task 2.1 : Selecting investigation for diagnosis of diabetes mellitus.

Case :Your next-door neighbor Mrs. Khaleda wanted to know whether she was suffering from

diabetes or not ? She was from a diabetic family, but she did not haveany complaints suggestive of

diabetes mellitus. What would you ask her to do?

1. A blood sugar 2 to 3 hours after her lunch because lunch because lunch was her major

meal.

2. Blood glucose in the next morning before her breakfast.

3. An OGTT after taking proper preparations.

In the left hand column, give a written instruction to Mrs. Khaleda for the best; in the right hand

column, write the reasons for which you have selected this test.

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Task 2.2 : Understanding use of fasting blood glucose in diagnosis of diabetes mellitus.

Mark T (rue) or F (alse) for the following statements regarding a fasting blood glucose (FBG) :

1. FBG can label a person as diabetic if its value is 7.0 mmol/L.

2. FBG can label a person as IGT if its value is in between 6.0 & 7.0 mmol/L.

3. FBG can label a person as IFG if its value is > 6.0 & < 7.0 mmol/L and the person should

undergo an OGTT.

4. FBG cannot label a person as non-diabetic.

Task 2.3 : Use of presenting features of diabetes in its classification.

The left column of the table below contains presenting features of diabetes that are considered in

clinical classification. Write down the characteristic features for Type 1DM and Type 2DM in the

2nd

and 3rd

colums respectively.

Features Type 1DM Type 2DM

Age at diagnosis of DM

Body weight

Tpical symptoms

Insulin in treatment

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Task 2.4 : Respond to the following three short questions.

Question a

Name 3 clinical feature of diabetes mellitus that are called „typical feature‟ of diabetes mellitus.

i) ii) iii)

Question b

What is the minimum level of blood glucose that is required to initiate „typical feature‟?

Question c

Write down the values of fasting blood glucose in IFG/IGT and diabetic state.

For IFG :

For IGT :

For DM :

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MODULE 3 : DIABETES MELLITUS - Aetiopathology

Overview Diabetes mellitus (DM) primarily affects the carbohydrate metabolism; but it

also affects protein and fat metabolism. The disturbed metabolism is due to

defects in insulin secretion or insulin action or both.

Goal To provide you with the opportunity of understanding how blood glucose

level is maintained after taking food and in between meals, and how

biochemical abnormalities set in by the abnormalities (pathology) of secretion

and action of insulin in diabetes mellitus along with factor(s) responsible for

doing so.


1. describe the relationship between blood glucose and insulin in healthy

people.

2. discuss insulin actions.

3. discuss consequences of insulin lack and insulin resistance in diabetes.

4. identify the factors (modifiable & non – modifiable) associated in a

diabetic person.

5. describe pathogenesis of diabetes mellitus.



Who should teach

this module

Endocrinologist

Evaluation of

learning


References 1. Harrison‟s Principles of Internal Medicine 16th edition, vol. 2, edited by Kasper DL

et al, Mc Graw-Hill, 2005, p 2155-2158



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ACTIVITY 3.1

To understand utilization of blood glucose by cells and its relation with insulin secretion in non-

diabetic person.

Aim : This activity will provide you the opportunity to recall physiology of insulin and glucose

metabolism.

A. Name 4 types of cells that do not require insulin for entry of glucose

a. __________________ b. _____________________

c. __________________ d. _____________________

B. Fill up the gaps in the following sentences :

a) Following an overnight fast, the majority of glucose disposal occurs in insulin independent

tissues – the brain (~ ___%) and splanchnic organs (~ ___%) while in insulin –

dependent tissues it is only ____%.

b) Basal glucose utilization (~_____mg/Kg/Min) is precisely matched by glucose production by

liver.

C. Mark T(rue) or F(alse) on the statements

1. In between meals and throughout night when there is no glucose supply to blood from the

gut the following changes occur:

* Insulin secretion goes up.

* Hepatic glucose output (HGO) goes up.

* Glucose uptake is mostly by insulin independents cells

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2. Following ingestion of meal, when there is excess glucose supply to blood from the gut, our

body mechanism is adjusted to ensure euglycemia as:

* Insulin secretions goes up.

* Hepatic glucose output (HGO) goes up.

* Glucose uptake is mostly by insulin independents cells

D. Fill-up the gaps of the following statements :

1. Insulin stimulates_____________ syntheses in the liver and skeletal muscle and increases

_________ stock of liver and muscle.

2. Insulin increases _________ activity in fat and skeletal muscle thereby increases entry of

glucose into fat cells and skeletal muscle.

ACTIVITY 3.2

To understand that there are some factors, which contribute to the development of, type 2 DM by

increasing insulin resistance and their association with development of other disorders in the same

individuals.

Aim : This activity will help you to understand that type 2DM has multiple a etiological risk factors,

therefore during treatment plan you will see different approaches in subsequent chapters.

In the left hand column of the following table write 4 factors that contribute to the development of

insulin resistance and in the right hand column write 4 conditions that are contributed by insulin

resistance.

Left hand column

(Factors contribute to development of

insulin resistance)

Right hand column

(Conditions that are contributed by insulin

resistance)

1

21

2

3

4

ACTIVITY 3.3

To understand that pathway of development of type 1 DM is different from that of type 2DM.

Aim : This activity will help you to understand why there are differences in management of

diabetes. Management will be discussed in subsequent chapters.

Following etipathological factors lead to the pathway for development of either type 1 or type 2

DM, mark tick in the appropriate column.

Factors Type 1DM Type 2DM

1. Genetic susceptibility is linked with certain

types of HILA

2. Genetic susceptibility can be identified simply

by a positive family history of DM.

3. Autoimmune nature of the disease can be

identified by some markers in the serum.

4. Insulin lack is absolute from very beginning of

hyperglycemia.

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5. Insulin lack and insulin resistance may vary in

a patient with time.

6. Environmental factors like obesity, physical

inactivity have definite role in production of

this type of DM.


Task 3.1 : Read the case bellow and give your response

Aim : To acquire skill of identify risk factors of type 2 DM during case study.

Mr. N Ali, a 56-year-old manager of a private bank did OGTT by the advice of his personal

physician to whom he complained of general weakness for few months. OGTT documented diabetes

mellitus. Mr. Ali is father of 3 children – 2 daughters and a boy. His wife had diabetes during her 3rd

pregnancy (gestational diabetes mellitus), which became normal after delivery. Now-a-days Mr. Ali

has to spend more time in the bank for longer due to some audit problem. By nature Mr. Ali does

not go for exercise or sports and enjoys eating. For the last couple of years he is gaining weight. His

father, father in law, 1 brother and 1 sister are known diabetic.

The factors that might have contributed to causation of diabetes for Mr. Ali are given in the left hand

column of the table bellow. Fill-up other columns.

FACTORS YES NO IF YES : IS IT MODIFIABLE?

Age : 56 years

Sex : Male

Married

Father is diabetic

This part will help you to assess your learning from the chapter 3. It will help you to

understand when you are ready to go for the chapter 4

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Father-in-law is diabetic

Brother and sister are diabetic

Wife is diabetic

He has stress in working place

Weight gain

Sedentary life style

Task 3.2 : Fill up the gap

Aim : To test your memory on relationship between glucose and insulin in healthy person and on

insulin action

1. -cells show following insulin secretion pattern :

a) There is a continuo low-level secretion of insulin (approximately ____unit per hour) between

meals and throughout night.

It is called _________________________ insulin. So about ________ units of insulin is

secreted as basal, secretion.

b) Following meals there is sharp rise, which is called ______________ or __________

(________________) (also called 1st phase) insulin release. The rate and amount secretion is

influenced by _________________ and __________________ of meals.

2. In the liver insulin stimulates _______________________ and inhibits ___________________

and __________________ enzymes and therefore there is increased _______________ synthesis

and decrease in ___________ breakdown and _________________

Task 3.3

Mark T(rue) of F(alse) for the following statement on a etiology of type 2DM.

A. The basis of metabolic impairment i.e. hyperglycemia is a defective insulin response.

B. Al few patients may exhibit a severe impairment of insulin release and normal sensitivity.

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C. Another small group of patients demonstrates exaggerated insulin release.

D. Inheritance of the disease is multi-factorial.

E. Complete concordance in monozygotic twin for type 2DM has proven the weak genetic basis of

the disease

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MODULE 4 : DIABETES MELLITUS -

Management : Lifestyle modification

Overview Management of diabetes mellitus, tiil date is aimed at supporting people to

live with diabetes with or no risk of complication(s) and there is ample

evidence that such an aim is achievable by achieving some specific targets of

blood glucose, lipids, and body weight etc.

Goal To understand the role of diet , physical activity and sef monitoring blood

glucose in achieving the targets of diabetes management.


1. discuss the issue regarding adjustment of one‟s daily life by planning of

meal, daily activities including exercise with specific targets that will

enable living healthy in spite of diabetes.

2. acquire the skill to provide hands-on training of self-monitoring of blood

glucose (SMBG), urinary glucose, protein and ketone body tests, etc.

3. discuss the basic principles of dietary modifications in diabetes and to

teach healthy

4. make recommendations for intensity, duration and frequency of exercise

for individual patient.



Who should teach

this module

Endocrinologist

Evaluation of

learning


References 1. America Diabetes Association, diabetes care, vol. 33, 2010

2. Harrison‟s Principles of Internal Medicine 16th edition, vol. 2, edited by Kasper DL


26

ACTIVITY 4.1

Understanding recommendation of daily calorie intake for a diabetic.

Aim: This activity will heklp you to understand the ideal distribution of daily calorie intake from

carbohydrate, protein and fat for a diabetic.

Fill up the blanks:

A recommendation of daily calorie intae for a diabetic person by the WHO is as follows:

Carbohydrate ___________% of Daily Calorie Itake (DCI)

Fat ____________ % of DCI; saturated fat <10% and cholesterol ______ mg/day

Protein __________ % of DCI; from both plant and animal source.

ACTIVITY 4.2

To understand the principal sources of protein, fats and carbohydrate in our diet.

Aim: This activity will help you to understand the sources of proten, fat and carbohydrate in our

diet.

Give tick mark in the appropriate column.

Food Predominantly

Protein Fat Carbohydrate

Wheat

Egg, milk, meat

Fish

Rice

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Soft drinks, jam

Potatoes

Poultry

Honey

ACTIVITY 4.3

Understanding principles of dietary adjustment in the daily life of a diabetic.

Aim: This activity will provide you the opportunity ti recall some principles of dietary adjustments

for a diabetic.

A. Name 4 carbohydrate sources, which sharply raise the blood sugar in a diabetic patient.

a. ___________________ b. ___________________

c. ___________________ d. ___________________

B. Fill up the gaps in the following sentences:

A hypo-caloric diet is associated with ___________________ to insulin and improvement in

___________________ levels.

Moderate weight loss (5-9kg), irrespective of initial weight, has been shown to reduce

______________, ______________ and even hypertension if exist.

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ACTIVITY 4.4

Practice on anthropometric tools.

Aim: This activity will provide you the skill of calculating BMI and waist-hip ratio.

Name Height

(Meter)

Weght

(Kg) BMI

Waist

Circumference

Hip Circumference Waist-

Hip

Ratio


This part will help you to assess your learning from the chapter 4. It will help you to understand


Task 4.1: Give your response on the case described below.

Aim: To acquire skill of calculating BMI and recommending calorie requirement during case study.

Mr. Abdul Alim, former sportsman has joined in a multinational company as a business executive

for the last 2 years. He is now 28 years, 165 cm tall weighing 78 kg. He does not get time for any

exercixe. His eating habit is irregular due to office schedule. During annual medical check-up he

was diagnosed to be diabetic. He is from a diabetic family.

a) What is his BMI? _____________________

b) Is he over weight? _____________________

if „Yes‟ what would be caloric recommendation i) Iso-caloric or

ii) Hypo-caloric

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Task 4.2: Mark T (rue) or F(alse) for the following statements on exercise for type

2DM.

a) Improves cardiovascular / cardio – respiratory function

b) Increases blood supply to muscles and their ability to use oxygen

c) Lowers hearts rate and blood pressure at any level of exercise

d) Increases LDL cholesterol

e) Decreases blood triglycerides

f) Reduces body fat and improves weight control

g) Improves glucose tolerance and reduces insulin resistance

Task 4.3: Fill up the missing letters of following table.

Aim : To test your memory on Strategies for Medical Nutrition Therapy in diabetes.

Select the appropriate priorities

Strategy Type 1DM Type 2DM Obese Type 2DM Non-Obese

Consistency of day-to-day intake

Meal spacing

Fat Modication H H

Sucrose limitation M M

Exercise H

Exercise snack H L

Caloric restriction

Blood glucose monitoring H H

N.B : H – High priority, M – Moderate priority, L – Low priority

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MODULE 5 : DIABETES MELLITUS – MANAGEMENT :

Drug therapy

Overview Diet and exercise are the first line of treatment for all people with Type 2

diabetes, including the young. However, due to the natural history of Type 2

diabetes, 50–75% are unlikely to achieve normoglycemia through these

measures alone. The microvascular complications of diabetes are associated

with the duration of diabetes and poor control. Therefore, it is now well

accepted that oral agents should be commenced earlier when they are most

effective, rather than later in the treatment of people with Type 2 diabetes.

Goal To understand of the different oral agents and insulin used to treat diabetes

and why particular agents are chosen in preference to others.


1. describe the mechanism of action and maximum dose of

secretagogues, metformin, thiazolidinediones and alpha-glucosidase

inhibitors in treatment of T2DM.

2. identify appropriate time to commence drug treatment and type of

drug to be used in different clinical situations.

3. identify secretagogues failures (primary & secondary)

4. explain different insulin regimens and understand the principles of

insulin dose adjustment.

5. identify appropriate regimen of insulin to be used in different clinical

situations.

6. provide hands-on training on insulin administration to the patients and

their family members.



Who should teach

this module

Endocrinologist

Evaluation of

learning


References 1. Basic and Clinical Endocrinology 7th edition, edited by F. S. Greenspan and D. G.

Gardner, Lange medical book, 2004, p 689-711

2. Harrison‟s Principles of Internal Medicine 16th edition, vol. 2, edited by Kasper DL


3. America Diabetes Association, Diabetes Care, vol. 33, 2010



31

MODUL TASK

Activity 5.1

Recalling the memory on maximum dose, duration of action and frequency/day of commonly used

secretagogues in type 2 DM when appropriate lifestyle adjustment fails to achieve the glycemic

targets.

Aim : This activity will serve you to practice in using maximum dose of secretagogue to achieve

treatment targets and thereby enable you to pick up OHA failure cases in time.

Fill-up the gaps of the following table :

Drugs Max. dose / day Frequency/day Duration of action (hrs)

Glibenclamide mg

Gliclazide mg

Glimepiride mg

Repaglinide mg

Nateglinide mg

Activity 5.2

Understanding achievement of glycemic targets in a diabetic patient on oral antidiabetic agent(s) by

studying laboratory reports.

Aim : this activity will serve you to practice in identifying cases with OHA failure and to decide

change in management protocol in type 2 DM in time.

No Name Lifestyle as a

diabetic

Medication Blood glucose

Fasting &

Postprandial

HbA1c (%)

1. Mr. MA Satisfactory Glibenclamide (5 mg)

1.5 – 0 – 0

140 & 240 mg/dL 8.5

2. Mr. A Satisfactory Glibenclamide (5 mg)

2 – 0 – 1

Metformin (500 mg)

0 – 1 – 1

180 & 330 mg/dL 9.5

3. Mr. K Satisfactory Metformin (850 mg)

1 – 1 – 1

108 & 300 mg/dL 6.8

4. Mrs. L Satisfactory Glimepiride (4 mg)

2 – 0 – 0

Metformin (500 mg)

0 – 1 – 1

162 & 342 mg/dL 8.9

32

The above sheet contains reports of 5 different individuals- read them carefully and perform the

following activity.

In the left hand column, write whether the person has developed OHA failure or not; in the right

hand column, write the reasons for the 3 reports using the style shown for report of sl. No 1.

Mr. MA has not developed OHA failure The secretagogue he is taking can be further

increased to see whether he can achieve the

trgets or not.

N.B : You tutor will provide feedback on this activity.

Activity 5.3

To understand how to adjust dose(s) of insulin according to blood glucose profile.

Aim : This activity will serve you to practice in adjusting dose of insulin

No. Name & age Lifestyle as diabetic Medication Blood glucose

1. Mr. A, 52 yo Satisfactory Mixtard (30:70)

24 – 0 16

FBG 180; AL 315

2. Mr. K, 48 yo Satisfactory Actrapid 12-0-10

Insulatard 20 – 0 – 14

FBG 198; ABF 225

AL 324; AD 198

3. Mr. KR, 57 yo Satisfactory Humulin R 12 – 0 – 10

Humulin N 20 – 0 – 14

FBG 99; ABF 140;

AL 324; AD 144

The above sheet contains reports of 3 different individuals- read them carefully and perform the

following activity.

33

In the left hand column, write whether the person has achieved the target or not; in the right hand

column write the change you want to make for the 3 reports (from case no 2-3) using the style

shown for case no. 1.

Both the glucose values are above the targets. I like to increase the dose of the present

preparation of insulin in morning and at night.

Because intermediate acting insulin of Mixtard

will be able to bring the glucose values to

targets.

N.B : Your tutor will provide feedback on this activity.


Task 5.1 : Mark T(rue) or F(alse) for the following statements on drugs use for type 2 DM.

1. Insulin secretagogues are preferred as first line treatment in young, midlle-aged non-obese

patients.

2. Insulin action enhancers such as biguanides like metformin or the thiazolidinediones such as

Rosiglitazone or Pioglitazone are preferred as initial therapy in patients with evidence of

insulin resistance.

3. Combinations of insulin releasing and insulin action enhancing drugs may be used when

single agent does not work alone.

4. For most OHAs to have any significant effect, the presence of sufficient aounts of insulin or

the ability of the ß-cells to secrete endogenous insulin is must.

5. OHAs may be replaced by or used in combination with insulin after carefully considering all

aspects of the disease and features of therapy.

34

Task 5.2 : Fill up the missing points of following table.

Aim : To test your memory on selection of an oral agent for type 2 DM.

SELECTION ISSUES OF AN ORAL AGENT :

Metformins Sulfonylureas Repaglinide Thiazolidinedione α –

glucosidase

inhibitor

Favorable

points

Flexible meal

schedule

Elderly

Post meal

hyperglycemia

Elderly

Unfavorable

points

Lactic

acidosis,

hypoxia,

CHF Age >

80 y

Hypoglycemia

Weight gain

Heart disease

Liver disease

Task 5.3 : Recalling the memory on indication of different regimens of insulin.

Fill-up the gaps of the following table :

Insulin regimens Appropriate / effective in

One injection a day

Two injections a day

Multiple injections a day

35

MODULE 6 : DIABETES MELLITUS – Acute Complications

Overview Acute complications are caused either by hypoglycemia or hyperglycemia and

are a common cause of hospitalization. Hypoglycemia can cause loss of

consciousness and seizures. Hyperglycemia can result in diabetic ketoacidosis

or hyperglycemic hyperosmolar nonketotic syndrome. Short-term

complications are often preventable; therefore, people with diabetes need to

know the causes, signs and symptoms, treatment and prevention strategies to

minimize the risk of developing these complications.

Goal To identify DKA and HONK in persons known to have diabetes or even at the

time of detection of their diabetes. You will be able develop your skill of

identifying and managing hypoglycemia in diabetic patients.


1. identify a case of DKA along with its cause and/or precipitating

factor(s); thereby to initiate its treatment and hospitalization.

2. Identify a case of HONK along with its cause and/or precipitating

factor(s); thereby to initiate its treatment and hospitalization.

3. Diagnose and treat cases of hypoglycemia and teach the patient how to

prevent hypoglycemia.



Who should teach

this module

Endocrinologist

Evaluation of

learning


36



2. America Diabetes Association, Diabetes Care, vol. 33, 2010

Activity 6.1

To understand why a person may develop hyperglycemic crisis like DKA or HONK.

Aim : This activity will give opportunity to practice whom to suspect for DKA or HONK and

thereby arrange prompt transfer to hospitals.

The left hand column contains some clinical states of individuals; in the right hand column, write

whether he or she may develop DKA or HONK?

Mr. K, a 17 yo boy was suffering from type 1 DM. He was on split-mixed

regimen insulin, was playing cricket with his classmates. But was found

dehydrated and breathing rapidly at 1130 am.

Mr. L, a 71 yo man was brought to you by his grandson for drowsiness. The

grandson claimed that his grandpa was not suffering from DM.

Mrs. L, 35 yo lafy, 2nd

gravida was brought to you for fever, respiratory

distress and impaired level of consciousness. She was from a diabetic family

and prior to this conception her OGTT was normal.

Mrs. S, a 51 yo poor widow was on premixed insulin 24 – 0 – 18 iu, came to

you with an abscess in the thigh. She is running fever for last 3 days and she

is not taking insulin because she is unable to eat anything for 3 days.

N.B : Your tutor will provide feedback on this activity.

Activity 6.2

To recall the memory on diagnostic criteria of HONK

Fill up the blanks.

In HONK

a) Blood glucose is > __________ mg/dl

b) The effective serum osmolality __________ mOsm/kg H2O

c) Arterial blood pH > _________ & bicarbonate >________mEq/L

37

Activity 6.3

Mark T(rue) or F(alse) for the following statements on causation of DKA and/or HONK.

1. Undiagnosed diabetes

2. Omission of insulin dose

3. Injudicious reduction of insulin dose

4. Inter-current illness, especially acute infection.

Activity 6.4

Mark T(rue) or F(alse) for the following statements on causation of hypoglycemia in diabetic

patrients.

a) Doing more exercise than usual

b) Delay or omission of a snack or meal

c) Administration of too much insulin

d) Excess intake of insulin secretagagoues

e) Over indulgence in alcohol

f) Severe impairment of renal function.

Activity 6.5

Mark A(drenergic) or N(euroglycopenic) for the following statements on hypoglycemia in diabetic

patients.

Confusion

Nervousness, irritability, hunger

Convulsion

Palpitation, tachycardia

Tremor

Visual disturbances

Loss of memory

Behavioural abnormality

38


Task 6.1 Read the case below and give your response

Aim : To understand presentation and risk factors of HONK in type 2 DM by case study.

Mr. Z, a 61 yo retired officer is a known case of type 2 DM for last 15 years. He is on secretagogue

and metformin. His last follow-up in outpatient clinic 3 months ago documented satisfactory

glycemic status (FBG 113 mg/dl, AL 140 mg/dl, HbA1C 6.8%). Fifteen days ago he lost his wife in

a tragic car accident. Their only issue is studying in USA who could not manage to come home.

Except a teen-aged main servant there is none to look after Mr. Z at home. In the meantime, he

became irregular in diet and drugs, and progressively became weak. One morning he was found

unconscious and febrile in his bedroom where he is living alone.

On examination his pulse was 112/min, BP 140/80 mmHg, dehydrated, not icteric, no smell in

mouth (alcohol or poison) and instant blood glucose was 478 mg/dl. Acetone was not detected in

urine. No focal neurological deficit could be detected.

1. What is the possible cause of his unconsciousness ?

2. Do you need to hospitalize Mr. Z? Why?

3. Make a list of factors that you think might have contributed to this acute complication.

39

MODULE 7 : DIABETES MELLITUS –

Macro-vascular Complications

Overview Diabetes mellitus is a diasease associated with several macro-vascular

complications including coronary artery disease, cerebrovascular disease and

peripheral vascular disease etc. Hypertension and dyslipidemia are the two

prominent modifiable factors in the development of these forms of

complication in a diabetic person.

Goal To understand why and how to screen for hypertension and dyslipidemia in

diabetic person for prevention of macro-vascular complications. It will also

help you to learn how to screen for „high risk foot‟ and provide appropriate

care of foot in diabetics.


1. know the factors responsible for developing chronic complications.

2. understand pathology involved in developing chronic complications.

3. understand the hall marks of microangiopathy in retina.

4. memorize the indications of funduscopy and fluorescein angiogram.

5. understand diabetic nephropathy and its management.

6. understand diabetic neuropathy and its management.



Who should teach

this module

Endocrinologist

Evaluation of

learning


References 1. Harrison‟s Principles of Internal Medicine 16th

edition, vol. 2, edited by Kasper

DL et al, Mc Graw-Hill, 2005, p 2161-2166



40

Activity 7.1

To know the factors responsible for developing chronic complications of diabetes mellitus.

Aim : This activity will help you to memorize the factors responsible for developing

complications in a diabetic person.

Mark T(rue) and F(alse) for the following statements regarding complications in a diabetic.

1. Chance of complications increases with the duration of diabetes.

2. Diabetic control has no impact on reducing rate of complications in type 2 DM.

3. Genetic susceptibility to certain complications may be present.

4. Hypertension is a common risk factor for developing retinopathy, nephropathy, coronary and

cerebrovascular diseases.

5. Smoking, hypertension, hyperlipidemia, obesity and lack of exercise are risk factors for

coronary heart disease and cerebro-vascular diasease.

Activity 7.2

To understand pathology involved in developing chronic complications in diabetes mellitus.

Fill-up the gaps with appropriate word(s).

1. Hyperglycemia may cause increased_________________ leading to accumulation of

basement membrane______________and membrane_________________.

2. Hyperglycemia stimulates intracellular_________________ pathway leading

to_______________ and capillary endothelial cell__________________.

Activity 7.3

To understand the hall marks of micro-angiopathy in retina.

Mark T(rue) or F(alse) if the following are regarded as a hall mark of microangiopathy in eye of

a diabetic.

1. New vessel formation

2. Microaneurysm

3. Haemorrhage

4. Exudate

41

Activity 7.4

To memorize indications of funduscopy and fluorescin angiogram.

Fill up the gaps.

1. Funduscopy at least on detection of diabetes and _______________ year if not indicated

otherwise.

2. Fluorescein angiogram is done to evaluate ischemic retinal_______________;

____________ and unexplained reduction of vision.

Activity 7.5

To understand diabetic nephropathy and its management.

Fill up the gaps.

1. Diabetic nephropathy is defined by ____________________________________

and______________________________with or without__________________________.

2. Dietary protein restriction is done in diabetic nephropathy, because diet low in protein

reduces __________________________and___________________________.

3. During treatment of anemia in a patient with diabetic nephropathy, iron supplementation

often fails to correct anemia. Iron along with___________________________________

provides optimum response.

4. Renal replacement therapy in a diabetic should start_____________ than in a non-diabetic.

Activity 7.6

To understand diabetic neuropathy and its management.

Fill up the gaps.

1. Diabetic neuropathy is a descriptive term that denotes demonstrable (either clinical or sub-

clinical) evidence of ____________________ or ________________ neuropathy in a

diabetic individual.

2. Diabetic diarrhea is am example of _____________neuropathy where bacterial overgrowth

from stasis in small intestine may lead to passage of ____________ volume ____________

stool even in___________________.

42

3. In painful diabetic peripheral neuropathy the pain may be rekieved by _______________

after optimum ______________________ control.

END-OF MODULE TUTOR MARKED ASSIGNMENT

This part will help you tp assess your learning from the chapter 7. It will help you to understand


Task 7.1 : Mark T(rue) or F(alse) for the following statements on microvascular complications

in diabetes mellitus.

1. HbA1C is strongly related to chronic complications of diabetes.

2. Duration of diabetes is a dterminat of chronic complicxations.

3. Type 2 DM patients often have a long undiagnosed period after the onset of the disease. So a

significant number of a cases present with chronic complications, like retinopathy,

neuropathy or foot ulcer at the time of detection of diabetes.

4. Some degree of retinopathy is evident after 15 to 20 years in nearly all type 1 diabetics and

in more than 60% of type 2 diabetes.

Task 7.2 : Fill up the blanks.

A. Urinary Albumin Excretion (UAE) < 20 μg/minute is considered normal; a value of UAE

rate 20 to 200 μg/min is called____________________, while UAE rate > 200 μg/min or

300 μg/day is the______________________.

B. Criteria for good outcome after renal transplant include – age _______years, good ______

status and _________donor.

C. Non-invasive, reproducible and highly sensitive vibration threshold are measured

by_______________.

43

Task 7.3 : Fill up the missing values of the „Test of autonomic neuropathy‟ in the following

table.

Test of autonomic

neuropathy

Normal Borderline Abnormal

Valsava ratio

Heart rate variation

during deep breathing

Fall in systolic BP after

standing

(mmHg)

Rise in diastolic BP after

sustained handgrip

(mmHg)

44


Micro-vascular Complications

Overview Diabetes mellitus is a chronic, debilitating disease, which is associated with a

range of severe complications including renal disease, cardiovascular and

blindness. Early detection and meticulous management to prevent

complications is the major challenge of diabetic case.

Goal To understand the retinopathy, nephropathy, and neuropathy in diabetes

mellitus.


1. enumerate the microvascular complications of diabetes mellitus and

discuss their pathogenesis.

2. discuss on various types of diabetic retinopathies.

3. perform clinical examinations to detect and manage nephropathy.

4. perform clinical examinations to detect and manage peripheral and

autonomic neuropathy due to diabetes.



Who should teach

this module

Endocrinologist

Evaluation of

learning






45

ACTIVITY 8.1

To recall a list of macrovascular complications in diabetes mellitus.

Fill up the gaps with appropriate word(s).

1. _______________________disease is the most common cause of death in persons with type

2 diabetes.

2. ______________________ is the second most common vascular problem in diabetes.

3. Peripheral vascular disease (PVD) affecting the _______________ arteries supplying blood

to the limbs particularly the lower limbs is also common in diabetes and adds considerably to

the morbidity related to foot problems leading to _______________ amputations.

ACTIVITY 8.2

To understand the pathological changes in microvasculature system in diabetes mellitus.

Mark T(rue) or F(alse) for the following statements.

1. Atherosclerosis is several folds more frequent in persons with diabetes.

2. In diabetic people atheromatous lesions are usually less severe and localized.

3. High blood glucose level amages the endothelial cells lining the blood vessels making the

thick, harder, and less elastic. This makes it difficult for the blood to flow through.

4. People with diabetes have higher levels of fat in the blood. The fats or lipids in the blood

vessels may clot and restrict the flow of blod.

5. High blood glucose affects the RBCs and makes them less pliable, and increase the factors

that favour blood clotting.

ACTIVITY 8.3

To understand the changes in microvasculature system in hypertension & diabetes mellitus.


1. In larger arteries the internal elastic lamina is thickened, smooth muscle is hypertrophied and

fibrous tissue is deposited but in smaller arteries hyaline arteriosclerosis occurs in the wall,

the lumen narrows and aneurysm may develop.

2. Widespread atheroma may develop leading to coronary or cerebrovascular disease

particularly if other risk factors like smoking, hyperlipidemia are present.

46

3. Stroke is a common complication of hypertension and may be due to cerebral haemorrhage

or infarction.

4. Hypertension enhances the already existing retinal damage due to diabetes. It accelerates the

progression as well as increases the severity of existing diabetic retinopathy.

5. Hypertension may cause proteinuria and progressive renal failure by damaging renal

vasculature.

6. Diabetics are already at risk of kidney disease and added hypertension increases the risk of

kidney disease several folds.

ACTIVITY 8.4

To memorize features of dyslipidemia in diabetes mellitus.


Key features of dyslipidemia of diabetes mellitus include :

1. Hypertriglyceridemia

2. A rise in low density lipoprotein cholesterol (LDL)

3. A reduction in high density lipoprotein cholesterol (HDL).

ACTIVITY 8.5

To understand high risk foot.


A foot is leveled as “High Risk” is one or more of the following factors is/are present :

1. Loss of protective sensation

2. Abesnt pedal pulses

3. Severe foot deformity

4. History of foot ulcer

5. Previous amputation

ACTIVITY 8.6

To understand why diabetics are prone to high risk foot.


There are several reasons why foot of a diabetic person is vulnerable to lesions, these include:

47

1. Loss of sensation (___________________)

2. Poor circulation (__________________________________________________)

3. Higher likehood of developing ______________________________

END-OF MODULE TUTOR MARKED ASSIGNMENT


when you are ready to go for the next chapter.

Task 8.1 : Mark T(rue) or F(alse) for the following statements on hypertension in diabetes

mellitus.

1. Treatment is aimed to achieve BP < 130/90 mmHg and if proteinuria or chronic kidney

disease is present then, BP should be < 130/85 mmHg.

2. For mild hypertension, first line management is always non-pharmacological one.

3. Antihypertensive regimens should include ACE inhibitors or AngIIR blockers in order to

provide maximum cardio- and renoprotection in these patients.

4. Physicians must make every effort to decrease the blood pressure to as close as possible to

the target bt the least intrusive means possible. This will minimize drug-related side effects,

improve patient adherence, and reduce cardiovascular and renal events.


To test your memory on grading of foot lesion.

Wagner‟s classification of diabetic foot lesions

Grade Description of lesions

Grade 0 No ulcer & high risk foot

Grade 1

Grade 2 Deep ulcer but no bony involvement

Grade 3 Abscess with bony involvement

Grade 4

Grade 5

Task 8.3 : To understand dyslipidemia of diabetes mellitus.

Fill up the gaps with appropriate word(s).

48

1. The major production of HDL occurs in the ____________

2. Studies have reported that the HDL has a closer ________________ association with

atherosclerosis.

3. HDL shows an inverse relationship with plasma ____________ and ______________ levels.

4. The rate of LDL secretion from the liver is influenced by many factors, such as the

___________,____________ level, glucagon, time of the day, and he degree of adiposity.

5. High level of plasma LDL has been shown to be associated with _____________________

and macrovascular complications.

49

MODULE 9 : DIABETES MELLITUS – Prevention

Overview Diabetes mellitus, a chronic debilitating disease which is associated with a

range of severe complications. Prevention of the diasease and or it

complications is a challenge for diabetic health care delivery providers.

Goal To understand what are the different types of prevention strategies of diabetes.

It will also help you to learn ealy detection and achievement of targets of

treatment are important in secondary and tertiary preventions of diabetes

respectively.


1. enumerate the types of prevention applicable for diabetes mellitus.

2. discuss on primary, secondary, and tertiary preventions of diabetes

mellitus.

3. identify individuals with „high risk‟ of developing diabetes and help

them to do appropriate lifestyle adjustment toprevent or delay

development of diabetes



Who should teach

this module

Endocrinologist

Evaluation of

learning


References 1. Williams Textbook of Endocrinology 11th edition, edited by H.M. Kronenberg,


50

ACTIVITY 9.1

To recall three different types of prevention of diabetes mellitus.


a) __________________prevention refers to avoiding the onset of the diabetes.

b) __________________prevention means early detection of diabetes and propmpt initiation of

treatment.

c) __________________prevention aims to delay and/or prevent progression of complications.

ACTIVITY 9.2

To understand the primary prevention of diabetes mellitus.


1. Population approach of primary prevention includes :

a) Creation of mass awareness

b) Reinforcement of „lifestyle‟ changes by ensuring regular physical activity and practice of

medical nutrition therapy to modify the risk factors.

2. High risk group strategies of primary prevention is in fact clinical approach where physicians

perform following activities :

a) Detect the presence of established risk factors in an individual

b) Care of risk factors for diabetes through public health and clinical approaches.

3. Strategies for high-risk group for primary prevention include :

a) Individuals at risk of developing diabetes need to become aware of the benefit of modest

weight loss and participating in regular physical activity.

b) Younger individuals with a BMI ≥ 25 plus additional risk factors need to underho

screening to detect IFG or IGT.

ACTIVITY 9.3

To understand the secondary prevention of diabetes mellitus.


1. Early detection of diabetes to initiate its treatment thereby to halt or delay the complications

is the aim of secondary prevention.

51

2. Achievement of glycemic targets is not an element of secondary prevention.

3. Diabetes awareness in the community and among GPs to enhance the chances of routine

screening of population at risk is important. Those above 40 years, positive family history of

diabetes, overweight (BMI ≥ 25), high WPR, and other associated risk factors must be

routinely screened.

4. Studies documented that approximately 50% of type 2 DM patient already have

complications at detection of their diabetes.

ACTIVITY 9.4

To recall the targets of bood glucose, HbA1C, lipids, blood pressure and BMI for prevention for

diabetes mellitus.


A. Blood glucose

Fasting <__________ mg/dL

Post-prandial <___________mg/dL

Bed time < _________mg/dL

B. Blood lipids

LDL cholesterol < __________mg/dL

HDL cholesterol > __________mg/dL

TG < __________mg/dL

C. HbA1C < _______%

D. BMI ≤ _________ kg/m2

E. Blood pressure : Systolic < _________mmHg; diastolic < _________mmHg

ACTIVITY 9.5

Aim : To understand the tertiary prevention of diabetes mellitus.


1. In tertiary prevention attempts are directed to contain damage by aggressive therapy to arrest

or delay progression of complications.

2. Economic analysis from the different prevention programmes is not cost effective.

52

3. Comprehensive care of diabetes with patient‟s education and awareness about complications

can bring about a remarkable reduction in blindness, end stage renal disease (ESRD) and

amputation.



when you are ready to go for the next chapter.

Task 9.1 : Mark T(rue) or F(alse) for the following statements on risk factor for developing

diabetes mellitus.

1. Age > 40 years.

2. Positive family history of DM

3. Habitual physical activity

4. BMI above normal

5. Waist Hip Ratio above normal

6. Previously identified as IFG/IGT/GDM

Task 9.2 : Fill-up the missing points of following table.

Aim : To test your memory on primary prevention strategies.

1. Individual at risk of developing diabetes needs to become aware of the benefit of

____________________________ and participating _______________________.

2. Younger individuals with a BMI ≥ 25 plus additional risk factors need to undergo screening

to _______________________.

3. Cases having IFG or IGT and/or past history of GDM may even be suggested for

intervention with ____________________________ in addition to life style modification if

scope of regular monitoring is available.

Task 9.3 : To recall memory on some facts of prevention of diabetes mellitus.


1. The risk factors for type 2 diabetes are also the risk factors for other non-communicable

diseases like___________________, high blood pressure,______________, etc.

53

2. By creating awareness about the ills of such lifestyle, it may be possible not only to stem the

rising tide of diabetes but also to have ___________________ effects on some of these

associated diseases.

3. Creation of mass awareness can be done through :

a. Incorporation of ____________________in school text book curriculums.

b. Use of mass media such ________________, radio, television, etc.

4. Diabetic complications account for ___________% of diabetes related health care cost

(direct costs) and almost _______________% of indirect costs.

54


Children and Pregnancy

Overview Diabetes mellitus in childhood and adolescence is most often type 1 DM but

type 2 or secondary diabetes may also occur. Diabetes care in children

requires intensive individualized education of the children and the family

members. Pregnancy in women with diabetes is a high risk one. Care must be

given with an aim to make pregnancy as safe as in non-diabetic state for both

the expectant mother and the baby.

Goal To understand the management principles of diabetes in children and during

pregnancy.


1. enumerate the basic principles of management of diabetes mellitus in

children.

2. enumerate the basic principles of management of diabetes mellitus

during pregnancy.



Who should teach

this module

Endocrinologist

Evaluation of

learning


References 1. America Diabetes Association, Diabetes Care, vol. 33, 2010, p S39-S42

55

ACTIVITY 10.1

Aim : To recall the memory on the targets of management of diabetes in Children.


A. Targets of glycemic control in children

Fasting < __________mg/dL

Post prandial < _________mg/dL

Bed time < _________mg/dL

B. Targets of growth and development : within ± __________SD of growth chart

C. Targets of education includes providing skill of i)____________________ and ii)

__________________injection.

ACTIVITY 10.2

Aim : To understand the basic principles of management of diabetes in children.


A. To provide diabetic education to children and their parents.

B. To train them about home monitoring of blood glucose and insulin injection techniques.

C. To monitor physical growth and development.

ACTIVITY 10.3

Aim : To recall the memory on the targets of management of diabetes in pregnancy.


A. Targets of glycemic control in pregnancy

Fsting < ____________mg/dL

Post prandial < ___________mg/dL

HbA1C < _________%

B. Targets of total weight gain_________ kg

C. Avoid ________________ and __________________

ACTIVITY 10.4

Aim : To recall the memory on the problems of management of diabetes in pregnancy.


56

Pregnancy in diabetic women have the following poblems :

1. Pregnancy loss : abortion/intrauterine death

2. Congenital malformations of baby

3. Difficulties of diabetes control

4. Problems in neonates like hypoglycemia, repiratory distress, hypocalcemia, etc

5. Diabetes mellitus of the neonate

6. Maternal problems like pre-eclampsia, eclampsia, etc.


This part will help you tp assess your learning from the chapter 10.

Task 10.1 : Mark T(rue) or F(alse) for the following statements on risk factor for developing

GDM.

1. Age > 24 years.

2. Posirive family history of DM.

3. Habitual physical inactivity.

4. BMI above normal.

5. Waist Hip Ratio above normal.

6. Previosly identified as IFG/IGT/DM

7. History of abortion, still birth, infertility.


Aim :To test your memory on childhood diabetes.

School going children should be taught on :

1. Insulin injection and blood __________________monitoring.

2. How to recognizing __________________symptoms and self-management of the condition.

3. How to adapt with school programs, school meals, __________ and _____________.

4. Advise the parents on the gradual development of the child‟s independence and progressive

_________________of responsibility.

57

EVALUATION

The information in this chapter was :

The knowledge I have gained will improve my ability to treat patients :

Yes, definitely

Perhaps

Probably not

Definitely not

Do you have any suggestion for improving this chapter ?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Student‟s ID Signature

Too little

About right

Too much

Too simple

A bit complex

Too complex

Relevant to my practice

Not very relevant to my practice

Rather boring

Quite interesting

Very interesting

Too theoretical

Right amount theory for me

Insufficient in theory

Documents

Modul Diabetes Smt Vii_1