new layout - india diabetes educatorjournal ne · 1.1 million deaths attributable to diabetes in...
TRANSCRIPT
In Type 2 Diabetes,Start early with
Metformin Hydrochloride 1000 mg SR + Glimepiride 0.5 mg
Early uptitrate with
For
the
use
of
a R
egis
tere
d M
edic
al P
ract
ition
er,
Hos
pita
l or
Labo
rato
ry o
nly
Abridged Prescribing Information; COMPOSITION: Glycomet GP 0.5: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 500mg and glimepiride USP 0.5mg. / Glycomet GP 1: Each uncoated tablet contains metformin hydrochloride
BP (as sustained release) 500mg and glimepiride USP 1mg. / Glycomet GP 2: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 500mg and glimepiride USP 2 mg. / Glycomet GP 1/850: Each uncoated tablet contains metformin
hydrochloride BP (as sustained release) 850mg and glimepiride USP 1mg. / Glycomet GP 2/850: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 850mg and glimepiride USP 2mg. / Glycomet GP 3/850: Each uncoated tablet contains
metformin hydrochloride BP (as sustained release) 850mg and glimepiride USP 3mg. / Glycomet GP 0.5 FORTE: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 1000mg and glimepiride USP 0.5mg. / Glycomet GP 1 FORTE: Each
uncoated tablet contains metformin hydrochloride BP (as sustained release) 1000mg and glimepiride USP 1mg. / Glycomet GP 2 FORTE: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 1000mg and glimepiride USP 2mg. /
Glycomet GP 4 FORTE: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 1000mg and glimepiride USP 4mg. INDICATIONS: Glycomet GP is indicated for the management of patients with type 2 diabetes mellitus (T2DM) when diet,
exercise and single agent (metformin hydrochloride or glimepiride alone) do not result in adequate glycemic control. DOSAGE AND ADMINISTRATION: Dosage of Glycomet GP should be individualized on the basis of effectiveness and tolerability while not exceeding
the maximum recommended daily dose of glimepiride 8mg and metformin 2000 mg. Initial dose: 1 tablet of Glycomet GP should be administered once daily during breakfast or the first main meal. Do not crush or chew the tablet. In several cases the tablet may remain
intact during transit through the gastrointestinal (GI) tract and will be eliminated in feces as hydrated mass (ghost matrix). Patients should be advised that this is normal as all drug components has already been released during GI transit. CONTRAINDICATIONS: In
patients hypersensitive to glimepiride, other sulfonylureas, other sulfonamides, metformin or any of the excipients of Glycomet GP; pregnancy & lactation; diabetic ketoacidosis, diabetic pre-coma, in patients with renal failure or renal dysfunction, acute conditions with
the potential to alter renal function (dehydration, severe infection, shock, intravascular administration of iodinated contrast agents), acute or chronic disease which may cause tissue hypoxia (myocardial infarction, shock, cardiac/respiratory failure) hepatic
insufficiency, acute alcohol intoxication, alcoholism. WARNINGS: Keep out of reach of children. Patient should be advised to report promptly exceptional stress situations (e.g. trauma, surgery, febrile infections) blood glucose regulation may deteriorate and a
temporary change to insulin may be necessary to maintain good metabolic control. In case of lactic acidosis, patient should be hospitalized immediately. PRECAUTIONS: In the initial weeks of treatment, the risk of hypoglycemia may be increased and necessitates
especially careful monitoring. Serum creatinine levels should be determined before initiating treatment and regularly thereafter: at least annually in patients with normal renal function. Intravascular contrast studies with iodinated materials can lead to acute alteration of
renal function. In patients in whom such study is planned, Glycomet GP should be temporarily discontinued at the time of or prior to the procedure, and withheld for 48 hours subsequent to the procedure and reinstituted only after renal function has been re-evaluated
and found to be normal. Use of Glycomet GP should be discontinued 48 hours before any surgical procedure. ADVERSE REACTIONS: For glimepiride - Hypoglycaemia; temporary visual impairment; gastrointestinal symptoms like nausea, vomiting, abdominal
pain, diarrhoea may occur; increased liver enzymes, cholestasis and jaundice may occur; allergic reactions may occur occasionally. For metformin - Gastrointestinal symptoms like nausea, vomiting, abdominal pain or discomfort may occur.
For full prescribing information please write to: USV Ltd. Arvind Vithal Gandhi Chowk, BSD Marg, Station Road, Govandi East, Mumbai, Maharashtra - 400088. Updated on: 11th February 2015
Issue No. 2, May 2015Indian
JOURNAL
Diabetes
INDIATime inTime instst
A monthly journal that serves as a
reference source for patient care and
diabetes education
In this journal:
Diabetes – An Epidemic in
India
Role of Diabetes Educators
Post – Diagnosis
Latest Diagnostic Criteria for
Diabetes Mellitus
Counselling Tips
Recipe
•
•
•
•
•
Preface
USV as your reliable healthcare partner believes in supporting your endeavour to make India a Diabetes
Care Capital.
As per the International Diabetes Federation (IDF) 2014 data, 66.8 million Indians have diabetes and it
is estimated to rise to 79.4 million by 2030. The healthcare system in India needs to gear up to manage this
alarming increase in the prevalence of diabetes and consequently, its life threatening complications.
It is important to remain abreast with the changes in diabetes diagnostic criteria, identify and screen
high risk patients with help of various tools such as Indian Diabetes Risk Score (IDRS) to help early
diagnosis and educate patients with effective lifestyle changes.
An integral part of any diabetes care team is the Diabetes Educator who provides support to the patient
by encouraging them to talk about their disorder, providing information about the disorder. This journal
provides practical tips on how to communicate with diabetes patients equipping them to deal with the
condition and its associated complications.
A Diabetes Educator can bring the change by helping with risk profiling and early diagnosis,
encouraging self care behaviours among newly diagnosed cases and motivating the patient for regular
screening and improving the levels of diabetes care and patient compliance.
Glycomet GP presents – “Indian Diabetes Educator Journal” first time in India with an objective to
educate Diabetes Educators and physicians who work as a team to provide diabetes care using
“evidence based clinical data and guidelines” specific for India. We aim to encompass regional, cultural,
social and economic aspects of diabetes education to improve the quality of diabetes care in India.
We dedicate this book to all healthcare professionals who are working relentlessly towards making
“India a Diabetes Care Capital”
Sincere Regards,
Disclaimer: This Journal provides news, opinions, information and tips for effective counselling of diabetes patients. This Journal intends to
empower your clinic support staffs for basic counselling of diabetes patients. This journal has been made in good faith with the literature
available on this subject. Every effort is made to ensure the accuracy of information but USV Limited will not be held responsible for any
inadvertent error(s). Professional are requested to use and apply their own professional judgement, experience and training and should not rely
solely on the information contained in this publication before prescribing any diet, exercise and medication. USV Limited assumes no
responsibility or liability for personal or the injury, loss or damage that may result from suggestions or information in this book.
IndianDiabetes
JOURNAL
You can contribute your articles, opinion, cases, recipes & experiences by sending an email to:
Diabetes – An Epidemic in India
World Health Organisation (WHO) projects diabetes to be the th7 leading cause of death by the year 2030. The current
population of people with diabetes is 387 million which will
rise to 592 million by 2035. Diabetes affects one in 12 people
and half of this population is undiagnosed.
India contributed to highest regional mortality, with
1.1 million deaths attributable to diabetes in the year 2013.
1
IndianDiabetes
JOURNAL TABLE OF CONTENT
1. Diabetes – An Epidemic in India 1
2. Role of Diabetes Educators Post–Diagnosis 2
3. Understanding the Risk Factors of Diabetes 3
4. Identifying High Risk Populations 6
5. Latest Diagnostic Criteria for Diabetes Mellitus 10
6. Case of the Month 12
7. Busting the Myth 14
8. Counselling Tips 16
9. Expert Speak 18
10. Quiz 20
11. Recipe 21
11. Super Food 23
12. Conferences Updates 24
13. References 25
SR NO. PAGE NO.TOPICCOUNTRY/
TERRITORY
China
India
United States of America
Brazil
Indonesia
Mexico
Egypt
Turkey
Pakistan
Russian Federation
Table 1: Countries/territories for number of people with diabetes (20–79 years), 2014 and 2035
2014
(Millions)
96.2
66.8
25.7
11.6
9.11
9.01
7.59
7.22
6.94
6.76
COUNTRY/
TERRITORY
China
India
United States of America
Brazil
Mexico
Indonesia
Egypt
Pakistan
Turkey
Russian Federation
2035
142.7
109.0
29.7
19.2
15.7
14.1
13.1
12.8
11.8
11.2
(Millions)
1India also accounts for the majority of the children with type 1 diabetes.
Multiple factors such as genetic, environmental influences such as
obesity with rising living standards, steady urban migration, and
lifestyle changes contribute to the aetiology of diabetes in India.
Obesity has been implicated as one of the major risk factors for
diabetes. While Indians represent lower overweight and obesity
rates, yet, there is a higher prevalence of diabetes as against their
western counterparts indicating that diabetes occurs at a much lower body mass index (BMI) 2, 3among Indians as compared with Europeans.
There is a significant difference between the rural and urban infrastructure and access to
healthcare facility in India which is responsible for higher proportion of poor glycaemic control 4among rural diabetics and higher prevalence of diabetes complications.
Obesity has been
implicated as one of
the major risk factors
for diabetes.
The current population of
people with diabetes is 387
million which will rise to 592
million by 2035
2 3
Newly diagnosed people with diabetes if referred to a diabetes educator (DE) by their 5
physician, can help them modify their lifestyle and adopt healthy behaviour by :
1. Healthy eating
2. Being active
3. Monitoring blood sugar
4. Taking medication
5. Problem solving
6. Reducing risks
7. Healthy coping
Active participation by the patients in their own care, motivated by the DE, could go a long way
in keeping the patient euglycaemic; thus reducing the risk of progression to complications
among both type 1 and type 2 diabetics.
Involving family members
DE spends more time with the patient and their family members which gives him/her the
opportunity to identify other members of the family those may have diabetes and motivate
them for screening. This may help in reducing the number of undiagnosed cases. DE can
further encourage lifestyle changes to the entire family and help in deferring diabetes among
those at risk.
Prediabetics
DEs can influence those people who are identified as prediabetics with respect to necessary
lifestyle modifications and regular screening to delay diabetes in future.
Body Weight
1) Find out if the patient is in the safe zone of body weight. Being overweight puts an
individual at an increased risk of metabolic syndrome and diabetes.
Broca’s Index
Ideal body weight = Height in centimetres – 100 cm (for males)
• To lose weight gradually, advise on calorie reduction of
about 500 calories each day
• Advise regular physical activity. The American Heart
Association and the American Diabetes Association (AHA
and ADA) recommends at least 30 minutes of moderate
intensity physical activity of at least five days of the week
2) BMI, a ratio of weight to height, is considered one of the measures for assessing an
individual’s overall health risk. Getting the BMI into a healthy range is important to reduce
the risk of lifestyle diseases and diabetes. Since even non obese Indians are predisposed 2
to diabetes, the suggested cut offs for BMI is 22.9 kg/m in Asian Indians as against2
25 kg/m in Caucasians.
Ideal body weight = Height in centimetres – 105 cm (for females)
A DE should understand the link between various risk factors and diabetes so that they can
guide the high risk individuals to stay within the safe zones of each risk factors.
Prediabetes(impaired glucose
tolerance)
Hyperuricaemia (high uric acid,
or gout)
Hypertension (high blood pressure)
Syndrome X metabolic syndrome
Central obesity (fat accumulated around
the gut area)
Dyslipidaemia(high triglycerides, highcholesterol, low HDL)
Polycystic ovarian syndrome(a type of female infertility
characterised by weight gain,acne, male pattern hair loss,
hirsutism or excessive hair growth and irregular menstrual periods)
Figure 1: Metabolic syndrome
Role of Diabetes Educators Post–Diagnosis Understanding the Risk Factors of Diabetes
54
2BMI= weight in kg/height in m
3) Body fat around the waist (central obesity) is a common culprit of lifestyle diseases.
One is more predisposed to lifestyle diseases if your waistline is more than 35 inches/90
cm in males and 32 inches/80 cm in case of female.
Since an individual cannot change his/her height, he/she should take special care to keep
his/her weight and in particular, abdominal girth in the healthy range.
4) The waist-to-height ratio (WHtR) gives a more accurate assessment of health since the
most dangerous place to carry weight is in the abdomen. Fat in the abdomen, which is
associated with a larger waist, is metabolically active and produces various hormones that
can cause harmful effects, such as diabetes, elevated blood pressure (BP) and altered
lipid (blood fat) levels.
Blood Glucose Levels
DE can advise patients to get their ABCs checked regularly: HbA1C (blood glucose), blood
pressure and cholesterol. It is extremely important to maintain the levels within the desired
target range to live a healthy disease free life. This is possible by following a good diet and
exercise plan.
Figure 3: Fasting, OGTT and HbAC1 blood glucose levels in prediabetics
Blood Pressure Levels
DEs can influence high risk individuals on healthy lifestyle, cutting down on salt intake, regular
monitoring of BP and overall compliance to the recommendations made by the physician.
High
Pre-high
Normal
Systolic 140 or above OR
Diastolic 90 or above
Systolic between 121–139 OR
Diastolic between 81–89
Systolic 120 or less AND
Diastolic 80 or less
High
Borderline high
Desirable
240 or higher
200 to 239
Less than 200
Cholesterol Levels
Keeping cholesterol levels healthy is a great way to keep the heart healthy and lower the
chances of heart diseases or stroke.
Figure 4: Blood pressure levels
Figure 5: Cholesterol levels
Active participation of DE in patients care in both rural and urban India can help in handling
better the turmoil of diabetes currently prevalent in India, in a better way.
Figure 2: Waist to height ratio: The new determinant of health risk
Under 35: Abnormally thin35 to 42: Extremely slim42 to 49: Healthy49 to 54: Overweight54 to 58: Seriously overweightOver 58: Extremely obese
Under 35: Abnormally thin35 to 43: Extremely slim43 to 53: Healthy53 to 58: Overweight58 to 63: Seriously overweightOver 63: Extremely obese
WOMEN: Waist to height ratio
Men: Waist to height ratio
"If waist circumference measures more than half of height, then the person is too fat and has an increased risk of living a shorter life"
5 ft 10 inch(70 inch)
AverageHeight
• Waist in inches/height in inches *100 = WHtR• E.g., A male with a 32 inch waist who is 5’10” (70 inches) would divide 32 by 70, to get a WHtR of 45.7%
5 ft 6 inch66 inch
36inch
34inch
Fasting HbA1C
Prediabetes
Normal < 100 mg/dL
Normal< 5.7%
Impaired fasting glucose
100–125 mg/dL
Impaired fasting glucose
5.7–6.4%
Diabetes> 126 mg/dL
Diabetes³ 6.5%
OGTT
Normal < 140 mg/dL
Impaired fastingglucose
140–199 mg/dL
Diabetes > 200 mg/dL
Prediabetes
76
Identifying High Risk Populations
As DEs interact with people with diabetes day in and day out, they can always identify the high
risk population which accompany them. They may be their first degree relatives, family
members, friends, colleagues, etc. Lot of simple risk profiling tools are available such as IDRS
(Indian Diabetes Risk Score), FINDRISC, UK diabetes score etc.
The DE can screen following high risk individuals using above mentioned risk calculators. This
will foster early diagnosis and care.
It would be helpful if the registry of the prediabetes cases is maintained by the healthcare
providers. DE could participate in ensuring screening of this population and educating the high
risk cases with lifestyle modifications. IDRS can be employed for screening the high risk 6patients such as :
First degree relatives of diabetes patients
Those who delivered > 4 kg babies/diagnosed with gestational diabetes
Hypertensive patients (BP ³ 140/90 mmHg)
Patients with high cholesterol (HDL cholesterol level < 35 mg/dL and/or a triglyceride level
> 250 mg/dL)
Women with polycystic ovaries
Physical inactive
High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American,
Pacific Islander)
HbA1C ³ 5.7%, IGT or IFG on previous testing
Other clinical conditions associated with insulin resistance (e.g., severe obesity,
acanthosis nigricans)
2 2Overweight patients (BMI ³ 25 kg/m or ³ 23 kg/m in Asian Americans)
History of cardiovascular disease (CVD)
7,8Indian Diabetes Risk Score
•
•
•
•
•
•
•
•
•
•
•
Indian Diabetes Risk Score (IDRS) is an effective tool for identifying undiagnosed diabetic 7,8subjects in India and could make screening programmes more cost effective.
India has 66.8 million diabetes population with 35.6 million
undiagnosed cases. Thus, there is an urgent need for mass
screening programmes. However, universal screening may not be
cost effective as well as feasible.
Minimum score: 0; Maximum score: 100
Particulars Score
Age (years)
< 35 0
35– 49 20
³ 50 30
Abdominal obesity
Waist < 80 cm female; < 90 cm male 0
Waist ³ 80–89 cm female; ³ 90–99 cm male 10
Waist ³ 90 cm female, ³ 100 cm male 20
Physical activity
Exercise (regular) + strenuous work 0
Exercise (regular) or strenuous work 20
No exercise and sedentary work 30
Family history
No family history 0
Either parent 10
Both parents 20
Table 2: Indian Diabetes Risk Score
India has 66.8 million
diabetes population
with 35.6 mill ion
undiagnosed cases.
IDRS has two modifiable risk factors: Waist circumference and physical activity; and two non-
modifiable risk factors: Age and family history of diabetes.
Figure 6: IDRS and risk stratification
98
You may also refer to following web pages for various diabetes risk calculators.
• ADA Type 2 Diabetes Risk Test
h
• Diabetes UK has a 7 step model to find out the diabetes risk
• Diabetes Risk Assessment Calculator from Med India
• NHS Type 2 diabetes self-assessment
• Q diabetes Web Calculator - gives up to 10 years risk predictions of
diabetes for Indians
ttp://www.diabetes.org/are-you-at-risk/diabetes-risk-test/
https://riskscore.diabetes.org.uk/start
http://www.medindia.net/ patients/calculators/diabetes-
risk-assessment-calculator.asp
http://www.nhs.uk/tools/pages/diabetes.aspx
http://www.qdscore.org/
Diabetes
DEs can use this simple SMS based tool to check the falling risk of Diabetes of
people whom they interact with.
QDiabetes
1110
Latest Diagnostic Criteria for Diabetes Mellitus
Blood glucose confirmation is necessary for diagnosis of diabetes. The major objective of
diagnosing diabetes is to prevent premature mortality and complication-related morbidity.
Table 3: American diabetes association (ADA) recommends the followingdiagnostic criteria in the Standards of Medical Care, 2015
During an oral glucose tolerance test (OGTT); 75-g glucose load should be used
Significant revisions in the latest Standards of Medical Care published in 2015 by
American diabetes Association include:
1. The BMI cut point for screening overweight or obese Asian Americans for prediabetes and 2 2
type 2 diabetes is altered to 23 kg/m (versus. 25 kg/m ) in view of the evidence that this
population is at higher risk for diabetes even at lower BMI.
2. The physical activity section was revised to reflect evidence that all individuals, including
diabetics need to limit the amount of time spent being sedentary by breaking up extended
amounts of time (> 90 min) spent sitting.
3. Considering the rising use of e-cigarettes, the Standards clarified their stand that e-
cigarettes are not supported as an alternative to smoking or to facilitate smoking
cessation.
4. The new glycaemic targets recommended by ADA include pre-meal blood glucose target
of 80–130 mg/dL rather than 70–130 mg/dL to match the HbA1C targets.
5. Standards provide new recommendations on assessing a patient’s readiness for
continued glucose monitoring (CGM) and on providing ongoing CGM support.
6.
7. Based on 2013 American College of Cardiology/AHA guidelines on the treatment of blood
cholesterol statins are now advised based on risk instead of LDL cholesterol.
Based on randomised controlled trials the new hypertension treatment goals have shifted
from 80 mmHg to 90 mmHg. Lower diastolic targets may still be appropriate for certain
individuals.
Blood test Diagnosis of diabetes
HbA1C ³ 6.5%
Fasting plasma glucose (FPG) ³ 126 mg/dL
Two-hour plasma glucose ³ 200 mg/dL
8. Standards recommend screening lipid profile at diabetes diagnosis, at an initial medical
evaluation and/or at age 40 years, and periodically thereafter.
9. Standards emphasize that all patients with insensitive feet, foot deformities or a history of
foot ulcers must have their feet examination at every visit.
10. Standards now recommend a target HbA1C of < 7.5% for all paediatric age-groups;
however, individualisation is still encouraged.
1312
Patient who felt diagnosis of diabetes is the end of his world!
What role did a DE play?
Case history
Patient who in complete shock and denial of his diabetes diagnosis.
A 48-year-old gentleman recently diagnosed with diabetes was referred to the DE. During his
annual medical health check-up, the blood investigations for
diabetes were as follows:
• Fasting blood glucose (FBG): 163 mg/dL
• Post prandial blood glucose (PPBG): 200 mg/dL
• HbA1C: 9.4%
The patient was in a state of shock when informed about his
diabetes status. He was in deed very upset when he was referred
to the DE.
Intervention by DE
While sitting with the patient, the DE found him in complete denial regarding his diagnosis.
Patient had a pre conceived notion that all patients with diabetes need treatment with insulin
on a daily basis. He had a phobia for needles from a very young age and hence was disturbed
by the diagnosis.
DE reassured the patient that he will not need to immediately start
with insulin. Patient was educated that diabetes could be
managed with lifestyle modifications and oral anti
hyperglycaemic agents and patients who were compliant and
consistent in their care may have a good chance of not needing
insulin in their lifetime.
This piece of advice helped change the patient’s attitude towards
the diagnosis. He was now willing to make a plan to counter his high blood glucose levels. With
the help of the DE and his family’s support, a meal and activity plan
was designed for the patient.
He was started on DPP 4 inhibitor + metformin 50/500 1-0-1 and
metformin 500 0-1-0, twice daily by his doctor.
Case of the Month
Pat ien t had a p re
conceived notion that all
patients with diabetes
need treatment with
insulin on a daily basis.
DE should be in
constant touch with
the patients.
Patient was in constant touch with the DE. He has been very regular with his physical activity
and also participated in the half marathon. He also demonstrated good compliance with his
diet, medication and monitoring regime.
Over a period of three months, patient’s blood investigations showed drastic improvement.
His repeat investigations reported (in four months)
• FBG: 97 mg/dL
• PPBG: 138 mg/dL
• HbA1C: 7.3%
Weight dropped from 67.4 kg to 63 kg (Ideal body weight)
He now enjoys following a disciplined lifestyle thanks to the
support from his DE and his family. He is now motivated to
target an HbA1C levels of < 6.5%.
This case has been contributed by Certified Diabetes
Educator: Shweta Gosalia (Registered Nutritionist)
(NDEP Batch 2012–13)
1514
Busting the Myth
HbA1C < 6.5% is a fixed target for all patients with diabetes
HbA1C goals need to be individualised based on the patient’s age/life expectancy, duration of
diabetes, comorbid conditions, individual patient considerations,
hypoglycaemia awareness diabetes history, known CVD or
advanced microvascular complications.
Patients should discuss their HbA1C targets with their physician, as
an HbA1C level that is safe for one patient may not be safe for
another. HbA1C test must be recommended at least two times a year
in patients meeting treatment goals (and have stable glycaemic control) and quarterly in
patients whose therapy has changed or who are not meeting their glycaemic goals.
Physicians and DE should collaborate in setting realistic target goals of HbA1C. They should
be vigilant in preventing severe hypoglycaemia in patients with advanced disease and should
not aggressively attempt to achieve near-normal HbA1C levels in patients in whom such
targets cannot be safely and reasonably achieved. Severe or frequent hypoglycaemia is an
absolute indication for the modification of treatment regimes, including setting higher
glycaemic goals.
The ADA 2015 guidelines for HbA1C targets
Physicians and DE
should collaborate in
setting realistic target
goals of HbA1C.
In the above figure patient and disease factors have been used to determine optimal HbA1C
targets. Characteristics and predicaments toward the left justify more stringent efforts to lower
HbA1C; those toward the right suggest less stringent efforts and need for relaxation of goal 9HbA1C targets.
Figure 7: Approach to the management of hyperglycaemia
Morestringent HbA1C 7%
Lessstringent
Low High
Disease durationNewly diagnosed Long-standing
Life expectancy Long Short
Important comorbiditiesAbsent Few/mild Severe
Established vascular complications Absent Few/mild Severe
Patient attitude and expected
treatment efforts Highly motivated, adherentexcellent self-care capacities
Less motivated, nonadherentpoor self-care capacities
Resources and support system Readily available Limited
Usually notmodifiable
Potentiallymodifiable
PATIENT/DISEASE FEATURES
Risks potentially associated with
hypoglycaemia and other drug
adverse effects
HbA1C
£ 7%
Reasonable HbA1C goal. If implemented soon after the diagnosis of diabetes has been shown to reduce microvascular complications.
HbA1C
< 6.5%
HbA1C goal for selective patients like those with short duration of diabetes, long life expectancy and no significant CVD. Suggested only if achieved
without significant risk of hypoglycaemia or other adverse effects of treatment.
HbA1C
7 to 8%HbA1C goal in case of some circumstances as shown in Figure 7
Approach to the management of hyperglycaemia
1716
How can a DE help patients cope with diagnosis of diabetes and associated unavoidable lifestyle modifications?
When patient is diagnosed with diabetes and advised by the doctor on self-care, medications,
monitoring, exercise and diet, patient compliance with same is questionable. Studies have
shown that only 77% take insulin as prescribed; 45% (fewer than half) monitor blood glucose
as advised and 24% (less than a quarter) follow the instructions on exercise and weight loss.
Thus, a DE needs to step in here to bring about the behavioural change which is a time
consuming process. A DE is expected to spend up to 10 hours of counselling in the first year
following diagnosis to address variety of topics mentioned below.
Given below are few things a DE must consider while counselling a newly diagnosed diabetes
patient:
It is not your fault!
Emphasise the causes of diabetes such as inheritance, explaining that it means they were
born with a tendency to get the disease. Mention things that can trigger diabetes such as
stress, lack of activity and weight gain which indicates there are things that they can do to
make it better and live healthier.
Do not panic!
Patients may recall diabetic relative who had lost his leg or life to diabetes. Patients should
be explained that following a healthy lifestyle and being compliant to their treatment and
monitoring plan can help decrease their risk of complications.
Check patient’s understanding
Ask them what they know about diabetes, which will help correct their misconceptions and
help them .
You do not need special foods
People usually are keen to know what they can eat when
they go home and worry that they will never be able to
consume anything sweet again. Let them know they should
eat the same way everyone should eat. That means
controlling carbohydrates, portion sizes, fat and salt intake,
but also enjoying the occasional sweet treat. Use diabetes
as something that can motivate them (and their families) to
live the healthier lives that all of us should be living.
•
•
•
•
better
Counselling Tips•
•
•
Being active helps
You do not need to run a marathon. Whatever their activity level, encourage them to think
of how they can be more active. If they are not active, little changes can help them start,
from taking the stairs instead of the elevator to parking the car at the far end of the lot.
Make it clear that being active has big payoffs, helping them lower their glucose levels;
strengthen their heart, bones and muscles; lose weight and feel better.
Learning to master diabetes is critical
Regular follow-up with DE is vital. Diabetes education has been proven to help patients
with diabetes, manage their weight and reduce their cholesterol levels and BP; and that
the DE acts as part of the diabetes care team to help you manage diabetes.
You are not alone
It is important to remember is that a diabetes diagnosis is scary and can be overwhelming,
so be sure to reassure your patients that although they will have to make changes, you and
their other healthcare providers are there to help them. Encourage them to discuss
experiences, ask questions and even get involved with support groups – in person or online.
Ultimately, ensure that newly diagnosed diabetes patients leave the office feeling
empowered to manage diabetes.
Emphasis should be on regular blood glucose monitoring. Maintain the level of blood
sugars in the diabetes safe zone (80–120 mg/dL) consistently. Medication and diet should 2be altered accordingly. Reduce weight if overweight (BMI > 23 kg/m ) and keep the
waistline to < 35 inches (males) and < 32 inches (females). Patients must be asked to fit in
time for a little fitness every day and watch meal and carb portions.
Sleep for at least six hours every day.
Moreover, keep a positive attitude! Meditation and yoga are a good way to reduce stress.
The people who do best with diabetes are those who, first of all, accept it.
Remember the EUP principle.
E: Education
U: Understanding and
P: Practice
It must be remembered, that merely Educating the patient is not sufficient. We may teach, but
the patients may not Understand and the latter is obviously very important if we have to
achieve results. Unfortunately, as we all know even if they understand, patients may not
Practice what we teach. The true success of DEs only comes when their patients practice
what they have been taught.
1918
Diabetes is a lifelong disorder and if not managed well can lead to serious life threatening
complications. Management is the key in reducing the risk of progression to complications.
Since there are fewer doctors in comparison to the number of patients, it is sometimes very
challenging for the doctor to spend so much time educating the patient on the finer aspects of
managing the disorder. The DE plays a very vital role in the counselling of people with
diabetes and helps bridge the gap between the patient and the doctor. When a patient is just
diagnosed with diabetes, we see different reactions from patients. They are upset and angry
and often question “Why Me?” or they are in complete denial refusing to follow any treatment.
They also at times refuse to monitor their blood glucose levels as they do not want “Bad News”
and feel ignorance is bliss.
Food is something which is very dear to all of us and when they are diagnosed, the first thing
that comes to their mind is that they have to give up most of their favourite things and the world
comes crashing down for them. They have a barrier to insulin as they are under the impression
“once on insulin, always on insulin” and that insulin is the step to the grave. There are several
myths and misconceptions in the patient's and relative's mind which need to be addressed.
In my practice, the treating and me work as a team. We first listen to the
patients concerns, understand his/her lifestyle and challenges in implementation of the
proposed plan, educate him/her about his/her condition and set achievable and realistic goals
in agreement with the patient. We then work closely with the patient and his/her family in
achieving the set goals.
physician patients
Expert SpeakPatient feels more empowered and becomes the core member of the diabetes care team. We
are in close touch with the patient between the two clinic visits educating him/her on the
various aspects of diabetes like lifestyle, foot care, eye care, hypoglycaemia and exercise. We
keep the physician posted on the patients progress, make modifications wherever necessary
and track compliance to treatment and lifestyle. This helps the physician see more patients,
more effectively. We also ensure compliance to doctor visits and monitoring.
In one of the studies we conducted on 126 type 1 and type 2 patients over six months, it was
observed that structured counselling by a DE in a physicians practice helped improve the
HbA1C by 2.05% (p = 0.0000), fasting blood glucose levels dropped from 165 mg/dL to 117
mg/dL (p = 0.000) and compliance to doctor visits almost doubled up. The study indicated a
significant reduction in body weight, body fat, HbA1C, fasting blood glucose and compliance to
lifestyle, self-monitoring and medical management reinforcing the importance of a DE as a
vital member of the diabetes care team.
As rightly said by the Father of Diabetes, “The one who knows the most, lives the longest.” As it
is a well-established fact that education improves knowledge and awareness, we have a very
important role to play in the life of a patient with diabetes. It gives me immense satisfaction of
touching one more life and making a difference when I see positive outcomes in my patients.
Ms. Sheryl Salis
RD, CDE, CPT, ND, M.D (A.M), MDHA]
Registered Nutritionist, Wellness Coach, Naturopath, Doctor of Alternative
Medicine, Certified Diabetes Educator, Certified Insulin Pump Trainer and
Health Writer.
Founder and Director of Nurture Health Solutions, a proprietary firm providing
Nutrition, Diabetes and Lifestyle Consultation Services.
2120
1. Pair with the most appropriate diagnosis:
Quiz
Blood report Diagnosis
i) HbA1C: 9.2% a. Well controlled diabetes
ii) HbA1C: 6.2% b. Uncontrolled diabetes
iii) FPG: 128 mg/dL c. Prediabetes
Answer:
1- [i) b, ii) c, iii) a];
2- [i) False, ii) True, iii) True, iv) False];
3- v).
2. True or false
i) The latest diagnostic criteria mention HbA1C ³ 7%for diagnosis of diabetes.
ii) Lifestyle modification alone can correct impaired glucose tolerance.
iii) All first degree relatives of type 1 diabetes patients should be screened for diabetes.
iv) Indian patients that are not obese do not need screening for diabetes.
3. Which of the following statement is correct?
i) More than half diabetics in India are undiagnosed
ii) Indians rate poorly on self-monitoring of blood glucose
iii) Rural India has higher prevalence of diabetics
iv) None of the above
v) All of the above
Recipe
As the United States Department of Agriculture (USDA) meal plate recommendation is to fill
half the plate with fruits and vegetables, this fibre rich salad packed with nutrients is a perfect
meal for patients with diabetes, hypercholesterolemia, and obesity. Here is a healthy and tasty
salad that will not only stimulate your taste buds but also improve blood glucose levels, aid
weight loss and keep you full longer. Apple cider vinegar added to this salad, as a dressing,
enhances these beneficial properties.
Ingredients Amount
thShredded cabbage 1/4 katori
thShredded red, green, yellow bell pepper 1/4
thGrated carrot 1/4 medium
Diced cucumber medium
Alfa alfa sprouts 1 teaspoon
Flax seeds 1 teaspoon
Paneer cubes
For dressing
Apple cider vinegar 1 teaspoon
Olive oil 1 teaspoon
Salt and pepper According to taste
katori
th1/4
th1/4 katori
GA
RD
EN
FR
ES
H S
AL
AD
2322
Method of preparation:
Toss all the ingredients in a bowl except paneer, flax seeds and alfa alfa sprouts.
Serve the veggies in the vessel, add vinegar and garnish with paneer, alfa alfa and flax seeds.
Nutritional value per serving:
Energy (Kcal) 140
Carbohydrate (gms) 8.0
Protein (gms) 8.0
Fat (gms) 10.0
Nutritional benefits:
Bell peppers (Green/Red/Yellow): Good source of vitamins and fibre
Alfa alfa sprouts: Low calorie, high in fibre and protein
Cabbage: Good source of vitamins and fibre
Carrot: Good source of vitamins, antioxidants and fibre
Flax seeds: Good source of heart friendly omega 3 fatty acids and fibre
Apple cider vinegar: Delays gastric emptying in patients with diabetes reducing PPBG
levels. Boosts immunity and regulates blood pressure
•
•
•
•
•
•
Apple Cider Vinegar (ACV)
Benefits of ACV:
• Improves insulin sensitivity
• Anti glycaemic effect – reduces hyperglycaemia
• Favourably influences HbA1C values
• Delays gastric emptying
• Aids in weight loss
• Reduces LDL (bad) cholesterol
Recommended Dosage:
10 ml of ACV with a glass of water can be taken fifteen minutes before meals or can be taken at 10bed time to reduce fasting blood glucose levels. It can also be used as a salad dressing.
Super Food
Figure 8: A healthy plate recommended for diabetics by ADA
2524
Conferences Updates
Conference
A Symposium on Diabetes
th7 international symposium
on the diabetic foot
American diabetes
association 75 scientific
sessions 2015
DNSG 2015 –rd33 International
Symposium on Diabetes
and Nutrition
Annual meeting of
American Association of
Diabetes Educators
Australian Diabetes
Educators Association
(ADEA) Annual meeting
Second Dr. Mohan’s
International Diabetes
Update – For Diabetes
Educators
th
Address
Athens, Greece
The Hague, The
Netherlands
Boston,
Massachusetts,
United States
Toronto
New Orleans,
Los Angeles
Adelaide convention
centre, South
Australia
Hotel ITC Grand
Chola, Chennai
Website
http://www.atiner.gr/diabetes.htm
http://diabeticfoot.nl/
http://professional.diabetes.org/Congr
ess_Display.aspx?
TYP=9&CID=95010
http://www.dnsg2015.ca/S1/
http://www.diabeteseducator.org/Prof
essionalResources/AnnualMeeting/C
orporateOpps/
http://www.ads-adea.org.au/
http://diabetesupdate.in/
Dates
4–7 May, 2015
20–23 May, 2015
5–9 June, 2015
9–12 June, 2015
5–8 August, 2015
26–28 , 2015
2 August, 2015
August
References
1. International Diabetes Federation, IDF diabetes Atlas, sixth edition. 2013. Available at: thwww.idf.org/diabetesatlas. Last accessed on: 5 March, 2015
2. Rao CR, Kamath VG, Shetty A, et al. A cross-sectional analysis of obesity among a rural population
in coastal southern Karnataka, India. Australas Med J. 2011; 4(1):53–57.
3. Mohan V and Deepa R. Obesity and abdominal obesity in Asian Indians. Indian J Med Res. 2006;
123(5):593–96.
4. Anjana RM, Ali MK, Pradeepa R, et al. The need for obtaining accurate nationwide estimates of
diabetes prevalence in India – rationale for a national study on diabetes. Indian J Med Res. 2011;
133:369–80.
5. Mohan V, Shah S and Saboo B. Current glycaemic status and diabetes related complications
among type 2 diabetes patients in India: data from the A1chieve study. J Assoc Physicians India.
2013; 61(1):12–5.
6. American Association of Diabetes Educators (AADE) Learn about AADE's Seven Self-Care
Behaviors. Avai lable at: ht tp:/ /www.diabeteseducator.org/DiabetesEducat ion/
PWD_Web_Pages/Learn_about_AADExs_Seven_Self-Care_Behaviors.html. Last accessed on: th9 April, 2015.
7. Mohan V, Deepa R, Deepa M, et al. Simplified Indian Diabetes Risk Score for screening for
undiagnosed diabetic subjects. J Assoc Physicians India. 2005; 53:759–63.
8. Joshi SR. Indian Diabetes Risk Score. JAPI. 2005; 755–757.
9. Riddle M, Brown C, Frias J, et al. Pramlintide improved glycaemic control and reduced weight in
patients with type2 diabetes using basal insulin. Diabetes Care. 2007; 30(11); 2794–2799.
10. Johnson CS, White AM and Kent SM. Preliminary evidence that regular vinegar ingestion
favourably influences haemoglobin A1C values in individuals with type 2 diabetes mellitus.
Diabetes research and clinical practice. 2009; 84:e15 – e17.
Ms. Sheryl Salis
RD, CDE, CPT, ND, M.D (A.M), MDHA]
Registered Nutritionist, Wellness Coach, Naturopath, Doctor of Alternative
Medicine, Certified Diabetes Educator, Certified Insulin Pump Trainer and
Health Writer.
Founder and Director of Nurture Health Solutions, a proprietary firm providing
Nutrition, Diabetes and Lifestyle Consultation Services.
Content Contribution by Nuture Health Solutions
26
NOTES
In Type 2 Diabetes,Start early with
Metformin Hydrochloride 1000 mg SR + Glimepiride 0.5 mg
Early uptitrate with
For
the
use
of
a R
egis
tere
d M
edic
al P
ract
ition
er,
Hos
pita
l or
Labo
rato
ry o
nly
Abridged Prescribing Information; COMPOSITION: Glycomet GP 0.5: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 500mg and glimepiride USP 0.5mg. / Glycomet GP 1: Each uncoated tablet contains metformin hydrochloride
BP (as sustained release) 500mg and glimepiride USP 1mg. / Glycomet GP 2: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 500mg and glimepiride USP 2 mg. / Glycomet GP 1/850: Each uncoated tablet contains metformin
hydrochloride BP (as sustained release) 850mg and glimepiride USP 1mg. / Glycomet GP 2/850: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 850mg and glimepiride USP 2mg. / Glycomet GP 3/850: Each uncoated tablet contains
metformin hydrochloride BP (as sustained release) 850mg and glimepiride USP 3mg. / Glycomet GP 0.5 FORTE: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 1000mg and glimepiride USP 0.5mg. / Glycomet GP 1 FORTE: Each
uncoated tablet contains metformin hydrochloride BP (as sustained release) 1000mg and glimepiride USP 1mg. / Glycomet GP 2 FORTE: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 1000mg and glimepiride USP 2mg. /
Glycomet GP 4 FORTE: Each uncoated tablet contains metformin hydrochloride BP (as sustained release) 1000mg and glimepiride USP 4mg. INDICATIONS: Glycomet GP is indicated for the management of patients with type 2 diabetes mellitus (T2DM) when diet,
exercise and single agent (metformin hydrochloride or glimepiride alone) do not result in adequate glycemic control. DOSAGE AND ADMINISTRATION: Dosage of Glycomet GP should be individualized on the basis of effectiveness and tolerability while not exceeding
the maximum recommended daily dose of glimepiride 8mg and metformin 2000 mg. Initial dose: 1 tablet of Glycomet GP should be administered once daily during breakfast or the first main meal. Do not crush or chew the tablet. In several cases the tablet may remain
intact during transit through the gastrointestinal (GI) tract and will be eliminated in feces as hydrated mass (ghost matrix). Patients should be advised that this is normal as all drug components has already been released during GI transit. CONTRAINDICATIONS: In
patients hypersensitive to glimepiride, other sulfonylureas, other sulfonamides, metformin or any of the excipients of Glycomet GP; pregnancy & lactation; diabetic ketoacidosis, diabetic pre-coma, in patients with renal failure or renal dysfunction, acute conditions with
the potential to alter renal function (dehydration, severe infection, shock, intravascular administration of iodinated contrast agents), acute or chronic disease which may cause tissue hypoxia (myocardial infarction, shock, cardiac/respiratory failure) hepatic
insufficiency, acute alcohol intoxication, alcoholism. WARNINGS: Keep out of reach of children. Patient should be advised to report promptly exceptional stress situations (e.g. trauma, surgery, febrile infections) blood glucose regulation may deteriorate and a
temporary change to insulin may be necessary to maintain good metabolic control. In case of lactic acidosis, patient should be hospitalized immediately. PRECAUTIONS: In the initial weeks of treatment, the risk of hypoglycemia may be increased and necessitates
especially careful monitoring. Serum creatinine levels should be determined before initiating treatment and regularly thereafter: at least annually in patients with normal renal function. Intravascular contrast studies with iodinated materials can lead to acute alteration of
renal function. In patients in whom such study is planned, Glycomet GP should be temporarily discontinued at the time of or prior to the procedure, and withheld for 48 hours subsequent to the procedure and reinstituted only after renal function has been re-evaluated
and found to be normal. Use of Glycomet GP should be discontinued 48 hours before any surgical procedure. ADVERSE REACTIONS: For glimepiride - Hypoglycaemia; temporary visual impairment; gastrointestinal symptoms like nausea, vomiting, abdominal
pain, diarrhoea may occur; increased liver enzymes, cholestasis and jaundice may occur; allergic reactions may occur occasionally. For metformin - Gastrointestinal symptoms like nausea, vomiting, abdominal pain or discomfort may occur.
For full prescribing information please write to: USV Ltd. Arvind Vithal Gandhi Chowk, BSD Marg, Station Road, Govandi East, Mumbai, Maharashtra - 400088. Updated on: 11th February 2015