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Diabetes:
Dr. S. A. Rizwan, M.D.,
Assistant Professor,
Dept. of Community Medicine,
VMCHRI, Madurai
At the end of this lecture you should be able to
 Describe the burden of diabetes at the global and regional level
 Describe the epidemiological features of diabetes
 Discuss the trends in diabetes prevalence over the years
 List out the strategies needed for prevention of diabetes
 Appraise the diabetes scenario in India
3
4
6
IDF Diabetes Atlas, 2015
Type 1 DM
Type 2 DM
Gestational Diabetes
LADA (latent autoimmune
diabetes in adults)
MODY (maturity-onset
diabetes of youth)
Secondary DM
7
IDF Diabetes Atlas, 2015
 Type 2 diabetes and cardiovascular
share a common antecedent.
 The concept The Metabolic
Syndrome
 Clustering of central obesity with
several other major cardiovascular
disease risk factors
8
9
American Diabetic Association
10
Fasting
Plasma
Glucose
Post
Prandial
Plasma
Glucose
100 200
100 200
126110
140
Normal
Impaired
Fasting
Glucose
Impaired
Glucose
Tolerance
Diabetes
Mellitus
OR
11
FPG
PPPG
100 200
100 200
126110
140
12
FPG
PPPG
100 200
100 200
126110
140
13
FPG
PPPG
100 200
100 200
126110
140
14
FPG
PPPG
100 200
100 200
126110
140
16
IDF Diabetes Atlas, 2015
17
IDF Diabetes Atlas, 2015
18
IDF Diabetes Atlas, 2015
19
The Lancet 2011 378, 31-40DOI: (10.1016/S0140-6736(11)60679-X)
20
21
IDF Diabetes Atlas, 2015
23
IDF Diabetes Atlas, 2015
Indian J Med Res 125, March 2007, pp 217-230
24
Indian J Med Res 125, March 2007, pp 217-230
25
27
28
29
30
Overweight
and obesity
Physical
inactivity
High-fat and
low-fiber diet
Ethnicity
Family
history
Age
Low birth
weight
Urbanisation
31
 Non Modifiable
 Genetic factors
 Age
 Ethnicity
 Modifiable
 Obesity and physical
inactivity
 Metabolic factors: IGT, IFG
and GDM
Host factors
 Age
 Sex
 Genetic factors: HLA DR3 and
DR4
 Defective immune response
 Central Obesity
Environmental factors
 Sedentary life style
 High saturated fat intake
 Malnutrition- failure of β cells
 Excessive alcohol
 Viral infections (Mumps, Rubella)
 Chemical agents- Alloxan,
streptozotocin, cyanide
 Environmental stress
32
Dietary factors
 Characteristics of fat intake
 Dairy
 Glycemic load
 “Western diet”
 Fast food intake
 Soda intake
 Alcohol intake
33
Indian J Med Res 125, March 2007, pp 217-230
34
35
IDF Diabetes Atlas, 2015
Short term effects
of diabetes
36
 Ketoacidosis
 Recurrent or persistent infections (including
tuberculosis)
 Both hyperglycaemia and hypoglycaemia may
cause coma
Long term effects
of diabetes
1. Microvascular
2. Macrovascular
37
Prevalence &
timeline
38
Continuum of CVD
risk
39
 Aging of the population
 Urbanization especially in the developing countries
 More sedentary lifestyle
 Food consumption patterns
 More foods with high fat content
 More refined carbohydrates
41
 To reduce human suffering
 Improve Quality of Life
 Reduce the number of hospitalization
 Reduce mortality from diabetes
 Prevent sudden cardiac death
42
The human and economic costs of diabetes could be significantly
reduced by investing in prevention, particularly early detection, in
order to avoid the onset of diabetic complications
At least 50% of all people with diabetes are unaware of their
condition
43
IDF Diabetes Atlas, 2015
 Primary
 Includes activities aimed at preventing diabetes from occurring in
susceptible populations
 Secondary
 Early diagnosis and effective control of diabetes in order to delay the
progress of the disease
 Tertiary
 Prevent complications and disabilities due to diabetes
44
 “There is an urgent need to take the prevention of
cardiovascular disease more seriously. The only
sensible strategy is the population approach to primary
prevention” - Beaglehole, the Lancet 2001; 358: 661-3
Why primary
prevention?
45
M. V. Hospital for Diabetes & Diabetes Research Centre
 Behavioral interventions: including changing diet and
increasing physical activity
 Pharmacological interventions: utilizing
pharmaceutical agents to improve glucose tolerance
and insulin sensitivity
Strategies
46
 Population strategy
 Primordial prevention (prevention of emergence of risk
factors)
 Maintain body weight through adoption of healthy
nutritional habits and physical exercise
 High risk strategy
 Sedentary life style, obesity
 Avoid alcohol
 Smoking
 High blood pressure
 Elevated cholesterol and triglyceride levels
Approaches
47
 All of those components are risk factors for
CVD and can be targeted in life style
interventions to prevent Type 2 diabetes
Metabolic
syndrome
prevention
48
 Diet and physical activity reduce the incidence of Type
2 diabetes.
 Diet and exercise for 5 years in men with IGT reduced
the incidence of Type 2 diabetes by 50%
- Eriksson et al, Diabetologia 1991; 34: 891-8
 Reductions in the incidence of diabetes in subjects
with IGT who were randomized to diet, exercise, or
combined diet-exercise treatment groups
- Pan et al, Diabetes Care, 1997; 20: 537-44
Behavioral
interventions
49
 The evidence for the ability of
pharmacological interventions to prevent
Type 2 diabetes awaits confirmation
 Metformin Pharmacological
interventions
50
Evidence from
studies
51
Control Diet Exercise D&E
Pan et al, Diabetes Care, 1997; 20: 537-44
Evidence from
studies
52
Study Year Interventions Outcome
DaQing
(China)
1997 Diet, physical
activity or both
(control group:
general)
Reduction in diabetes
incidence 31% in diet group,
46% in physical activity and
42% in diet and physical
activity compared to control
group
Finnish
Diabetes
Prevention
Study
2001 Diet and physical
activity (control
group: general
advice)
Reduction by 58% of the risk
of diabetes compared to
control group
Diabetes
Prevention
Program
(USA)
2002 Diet, physical
activity,
metformin and
placebo
58% reduction in incidence
of diabetes with lifestyle
intervention, 31% with
metformin
STOP-NIDDM 2002 Acarbose or
placebo
32% patients randomised to
acarbose and 42%
randomised to placebo
developed diabetes
 The purpose of secondary prevention
activities such as screening is to identify
asymptomatic people with diabetes
Why secondary
prevention?
53
 Population screening
 Selective screening
 Opportunistic screening
Approaches
54
 Urine examination
 Test for glucose, 2 hours after a meal
 Lack of sensitivity
 Not appropriate for case finding
 Blood sugar testing
 “Standard oral glucose test”
 2hr value after 75 g oral glucose
 Measure fasting, random, post prandial
Strategies
55
Indian Diabetes
Risk Score
56
Interpretation:
Total score
< 30 - low risk
30-50 - medium risk
> 60 - high risk
Factors Score
Age
<35 0
35-49 20
>50 30
Abdominal obesity (WC)
<80 cm (F), <90 (M) 0
80-89 cm (F), 90-99 (M) 10
>90 cm (M), >100 (M) 20
Physical activity
Vigorous labour 0
Mild to moderate 20
No exercise 30
Family history
None 0
One parent 10
Both parents 20
J Assoc Physicians India 2005; 53 : 759-63.
 Includes actions taken to prevent and delay
the development of acute or chronic
complications
Why tertiary
prevention?
57
 Strict metabolic control, education and
effective treatment
 Screening for complications in their early
stages when intervention is more effective
Approaches
58
 Screening for diabetic retinopathy is cost-effective
where subsequent treatment, such as laser treatment,
is available and affordable
 Where there is no access to laser treatment, good
metabolic control aimed at delaying the progress of
diabetic eye disease is likely to be cost-effective
Screening for
eye problems
59
A number of interventions have been found to
be effective in preventing foot problems
 Education
 Pressure-relieving interventions
 Multidisciplinary clinics Managing foot
problems
60
 Renal failure in diabetes can be detected very
early by screening for ‘microalbuminuria’
 However, effective treatment must be
available in order to follow on from the
detection of this early sign of renal failure
Screening for
renal problems
61
 The same basic improvements in diet and
physical activity that prevent type 2 diabetes
are likely to prevent CVD complications
 Also, a wide range of drugs has now been
proven to be effective in reducing the risk of
CVD in people with diabetes, and in treating
diabetes-associated CVD once it is present
Macrovascular
complications
62
Evidence from
studies
63
Strategy Complication Reduction
Lipid control
 Coronary heart disease mortality
 Major coronary heart disease
event
 Any atherosclerotic event
 Cerebrovascular disease event
↓ 36%¹
↓ 55%¹
↓ 37%¹
↓ 62%¹
Blood Pressure Control
 Cardiovascular disease
 Heart failure
 Stroke
 Diabetes-related deaths
↓ 51%²
↓ 56%³
↓ 44%³
↓ 32%³
Blood Glucose Control  Heart Attack ↓ 37%³
1 The 4S Study, 2 Hypertension Optimal Treatment (HOT) Randomised Trial, 3 UKPDS
 Standardized data collection on disease magnitude, risk factors and mortality statistics.
 Clear action plan with specific targets, and well defined evaluation.
 Initiating community-based interventions for primary prevention.
 Advocacy for influencing policies.
 Advocacy for the rights of people with diabetes for quality care at all levels.
 Establishing acceptable standards for health care for people with diabetes.
 Establishing an effective referral system and defining the role of each level of health
care.
 Educating the population about this important global epidemic
 Provision of appropriate training for health care providers
 Coordination of prevention efforts
64
 Type 2 diabetes prevention must be integrated in a major program
addressing the prevention of other lifestyle related disorders like CVD and
some cancers
 Primary prevention is of the essence especially in resource-constrained
countries
 Diabetes prevention is an inter-sectoral effort requiring cooperation and
coordination
 Diabetes prevention should be addressed within the context of health
system reform ensuring the availability of acceptable health care standards
 Culturally appropriate and economically feasible interventions should be
adopted
65
 Type 2 diabetes is a major challenge to human health
 Type 2 diabetes can be prevented
 Primary prevention is a suitable and affordable choice
 There is strong evidence that lifestyle interventions are effective in
diabetes prevention
 Barriers for prevention should be addressed
66
67
Clinical services
 Glycemic control
 BP control
 Lipid management
 Annual eye examinations
 Foot care
 Kidney disease testing
 Flu immunization
 Preconception care
 Diabetes education
 Case Management
 Targeted Screening
Promotion of behaviors
 Education and awareness for:
• Physical activity
• Reduced Tobacco
• Healthy diet
• Regular doctor visits
• Self monitoring
• Self mgt education
68
Population targeted policies
• Health care access legislation
• Drug and supply reimbursement
policies
• Population registry and feedback
systems
 Taxation
 Food and Menu labeling
 Engage Private Industry
 Crop subsidy policies
 Incentives/promotion for community availability and affordability of foods
 Incentives/promotion for community support for physical activity
 Regulation of foods in public areas
 School food and physical education policies
69
It is the corner stone of DM management
It covers:
 Self care
 Changing behavior to prevent and control of
complications
 Encourage interaction with health care
providers
Education of
diabetic patients
70
 Nature of disease, types
 Clinical presentation, diagnosis, complications
 Types of treatment, side effects
 Exercise, self monitoring , avoidance and
recognition of hypoglycemia, and hyperglycemia
 Foot care
 Pregnancy and OC
 Avoidance of smoking
 CV RFs
 Need for follow up
 Self management skills and attitudes
Contents of
Educational
Program
71
 Patients should be educated to practice self-care
 This allows the patient to assume responsibility
and control of his/her own diabetes management
 Self-care should include:
 Blood glucose monitoring
 Body weight monitoring
 Foot-care
 Personal hygiene
 Healthy lifestyle/diet or physical activity
 Identify targets for control
 Stopping smoking
Diabetic Self-Care
72
 Individual counseling
 Group teaching
 Educational materials: posters, pamphlets,
books
 Special educational programs are needed for
special groups as children and pregnant
women
Types of education
methods
73
 Basic understanding of DM and its
managements
 Training in educational methods
 Training of dietetics and nurses
Education of
Health
Professionals
74
 Prevention or modification of dietary habits
and other life-style characteristics that link
with DM
Education of the
community
75
 Economic problems: unavailability of needed resources
 Socio-cultural problems
 Lack of data, knowledge and skills
76
Obesity is not
considered
negatively
Fad Food
Culture has
caught up
Changing diet
is very
difficult
No value given
to physical
exercise
No time for
physical
exercise at
work
Fatalism
77
Dietary
counselling
Patient
education
Physical
activity
Medication
compliance
Aggressive
follow-up
Sudden
death
assessment
78
 India’s response to the growing burden of
non-communicable diseases
National programme
for prevention and
control of diabetes,
cardiovascular
disease and stroke
79
c.
Objectives
80
AWARENESS SCREENING
CASE
MANAGEMENT
IN PHC
PRE–DIABETES
& LIFE STYLE
MODIFICATIONS
Plan of action
81
Guidelines
Trainings
Detection
camps in Sub
centres &
Main Centres
Detection /
Screening
Camps at
institutions
Regular, fixed
day weekly
NCD clinic at
PHC
Preparation of
Patient
Treatment
Cards
BCC
Activities
Key interventions
82
Key Area Activities
Health
Promotion
 Public awareness through multi-media
 Counseling for healthy lifestyle (Balanced diet,
regular exercise, avoid alcohol and tobacco)
Early
Diagnosis
 Screening of persons above 30 years and all
pregnant women for diabetes and hypertension at
all levels; facilities up to Sub-centre level
Case
Management
 Facilities for diagnosis and treatment (NCD Clinic)
at CHC level & above
 CCU at District Hospital and above
 Treatment of cancer at District Hospital & above
Capacity
Building
 Infrastructure Development & Equipment
 Training of human resources at all levels
Management
& Monitoring
 NCD Cell at National, State & District level
 Surveillance, monitoring & evaluation
 Regular review meetings
Activities at
different health
care facilities
83
Tertiary centres
Comprehensive care, research,
training, telemedicine
District Hospital
Diagnosis & management of difficult
cases, CCU, dialysis, training
CHC
Early detection & appropriate
treatment, health promotion
a) Screening for undiagnosed cases
b) Foot care
c) Lipid lowering agents
d) Metformin
85
a) FPG >126
b) PPPG >100 & <140
c) PPPG >140 & <200
d) FPG <110
86
a) USA
b) China
c) Russia
d) Canada
87
a) 8.8%
b) 6.5%
c) 12.0%
d) 3.0%
88
a) 70 million
b) 50 million
c) 100 million
d) 40 million
89
a) Retinopathy
b) Stroke
c) Coronary heart disease
d) Peripheral vascular disease
90
a) Primordial
b) Primary
c) Secondary
d) Tertiary
91
a) Separate centre will be set up for stroke, DM
b) Will be implemented in 10 districts in 5 states
c) CHC has facilities for diagnosis and treatment of CVD,
diabetes
d) Sub-centre will provide facilities for diagnosis and
treatment
92
This presentation is available on
Email your queries to sarizwan1986@outlook.com

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Diabetes Prevention Strategies for India

  • 1. 1
  • 2. Diabetes: Dr. S. A. Rizwan, M.D., Assistant Professor, Dept. of Community Medicine, VMCHRI, Madurai
  • 3. At the end of this lecture you should be able to  Describe the burden of diabetes at the global and regional level  Describe the epidemiological features of diabetes  Discuss the trends in diabetes prevalence over the years  List out the strategies needed for prevention of diabetes  Appraise the diabetes scenario in India 3
  • 4. 4
  • 5.
  • 7. Type 1 DM Type 2 DM Gestational Diabetes LADA (latent autoimmune diabetes in adults) MODY (maturity-onset diabetes of youth) Secondary DM 7 IDF Diabetes Atlas, 2015
  • 8.  Type 2 diabetes and cardiovascular share a common antecedent.  The concept The Metabolic Syndrome  Clustering of central obesity with several other major cardiovascular disease risk factors 8
  • 15.
  • 19. 19
  • 20. The Lancet 2011 378, 31-40DOI: (10.1016/S0140-6736(11)60679-X) 20
  • 22.
  • 24. Indian J Med Res 125, March 2007, pp 217-230 24
  • 25. Indian J Med Res 125, March 2007, pp 217-230 25
  • 26.
  • 27. 27
  • 28. 28
  • 29. 29
  • 30. 30 Overweight and obesity Physical inactivity High-fat and low-fiber diet Ethnicity Family history Age Low birth weight Urbanisation
  • 31. 31  Non Modifiable  Genetic factors  Age  Ethnicity  Modifiable  Obesity and physical inactivity  Metabolic factors: IGT, IFG and GDM
  • 32. Host factors  Age  Sex  Genetic factors: HLA DR3 and DR4  Defective immune response  Central Obesity Environmental factors  Sedentary life style  High saturated fat intake  Malnutrition- failure of β cells  Excessive alcohol  Viral infections (Mumps, Rubella)  Chemical agents- Alloxan, streptozotocin, cyanide  Environmental stress 32
  • 33. Dietary factors  Characteristics of fat intake  Dairy  Glycemic load  “Western diet”  Fast food intake  Soda intake  Alcohol intake 33
  • 34. Indian J Med Res 125, March 2007, pp 217-230 34
  • 36. Short term effects of diabetes 36  Ketoacidosis  Recurrent or persistent infections (including tuberculosis)  Both hyperglycaemia and hypoglycaemia may cause coma
  • 37. Long term effects of diabetes 1. Microvascular 2. Macrovascular 37
  • 40.
  • 41.  Aging of the population  Urbanization especially in the developing countries  More sedentary lifestyle  Food consumption patterns  More foods with high fat content  More refined carbohydrates 41
  • 42.  To reduce human suffering  Improve Quality of Life  Reduce the number of hospitalization  Reduce mortality from diabetes  Prevent sudden cardiac death 42
  • 43. The human and economic costs of diabetes could be significantly reduced by investing in prevention, particularly early detection, in order to avoid the onset of diabetic complications At least 50% of all people with diabetes are unaware of their condition 43 IDF Diabetes Atlas, 2015
  • 44.  Primary  Includes activities aimed at preventing diabetes from occurring in susceptible populations  Secondary  Early diagnosis and effective control of diabetes in order to delay the progress of the disease  Tertiary  Prevent complications and disabilities due to diabetes 44
  • 45.  “There is an urgent need to take the prevention of cardiovascular disease more seriously. The only sensible strategy is the population approach to primary prevention” - Beaglehole, the Lancet 2001; 358: 661-3 Why primary prevention? 45 M. V. Hospital for Diabetes & Diabetes Research Centre
  • 46.  Behavioral interventions: including changing diet and increasing physical activity  Pharmacological interventions: utilizing pharmaceutical agents to improve glucose tolerance and insulin sensitivity Strategies 46
  • 47.  Population strategy  Primordial prevention (prevention of emergence of risk factors)  Maintain body weight through adoption of healthy nutritional habits and physical exercise  High risk strategy  Sedentary life style, obesity  Avoid alcohol  Smoking  High blood pressure  Elevated cholesterol and triglyceride levels Approaches 47
  • 48.  All of those components are risk factors for CVD and can be targeted in life style interventions to prevent Type 2 diabetes Metabolic syndrome prevention 48
  • 49.  Diet and physical activity reduce the incidence of Type 2 diabetes.  Diet and exercise for 5 years in men with IGT reduced the incidence of Type 2 diabetes by 50% - Eriksson et al, Diabetologia 1991; 34: 891-8  Reductions in the incidence of diabetes in subjects with IGT who were randomized to diet, exercise, or combined diet-exercise treatment groups - Pan et al, Diabetes Care, 1997; 20: 537-44 Behavioral interventions 49
  • 50.  The evidence for the ability of pharmacological interventions to prevent Type 2 diabetes awaits confirmation  Metformin Pharmacological interventions 50
  • 51. Evidence from studies 51 Control Diet Exercise D&E Pan et al, Diabetes Care, 1997; 20: 537-44
  • 52. Evidence from studies 52 Study Year Interventions Outcome DaQing (China) 1997 Diet, physical activity or both (control group: general) Reduction in diabetes incidence 31% in diet group, 46% in physical activity and 42% in diet and physical activity compared to control group Finnish Diabetes Prevention Study 2001 Diet and physical activity (control group: general advice) Reduction by 58% of the risk of diabetes compared to control group Diabetes Prevention Program (USA) 2002 Diet, physical activity, metformin and placebo 58% reduction in incidence of diabetes with lifestyle intervention, 31% with metformin STOP-NIDDM 2002 Acarbose or placebo 32% patients randomised to acarbose and 42% randomised to placebo developed diabetes
  • 53.  The purpose of secondary prevention activities such as screening is to identify asymptomatic people with diabetes Why secondary prevention? 53
  • 54.  Population screening  Selective screening  Opportunistic screening Approaches 54
  • 55.  Urine examination  Test for glucose, 2 hours after a meal  Lack of sensitivity  Not appropriate for case finding  Blood sugar testing  “Standard oral glucose test”  2hr value after 75 g oral glucose  Measure fasting, random, post prandial Strategies 55
  • 56. Indian Diabetes Risk Score 56 Interpretation: Total score < 30 - low risk 30-50 - medium risk > 60 - high risk Factors Score Age <35 0 35-49 20 >50 30 Abdominal obesity (WC) <80 cm (F), <90 (M) 0 80-89 cm (F), 90-99 (M) 10 >90 cm (M), >100 (M) 20 Physical activity Vigorous labour 0 Mild to moderate 20 No exercise 30 Family history None 0 One parent 10 Both parents 20 J Assoc Physicians India 2005; 53 : 759-63.
  • 57.  Includes actions taken to prevent and delay the development of acute or chronic complications Why tertiary prevention? 57
  • 58.  Strict metabolic control, education and effective treatment  Screening for complications in their early stages when intervention is more effective Approaches 58
  • 59.  Screening for diabetic retinopathy is cost-effective where subsequent treatment, such as laser treatment, is available and affordable  Where there is no access to laser treatment, good metabolic control aimed at delaying the progress of diabetic eye disease is likely to be cost-effective Screening for eye problems 59
  • 60. A number of interventions have been found to be effective in preventing foot problems  Education  Pressure-relieving interventions  Multidisciplinary clinics Managing foot problems 60
  • 61.  Renal failure in diabetes can be detected very early by screening for ‘microalbuminuria’  However, effective treatment must be available in order to follow on from the detection of this early sign of renal failure Screening for renal problems 61
  • 62.  The same basic improvements in diet and physical activity that prevent type 2 diabetes are likely to prevent CVD complications  Also, a wide range of drugs has now been proven to be effective in reducing the risk of CVD in people with diabetes, and in treating diabetes-associated CVD once it is present Macrovascular complications 62
  • 63. Evidence from studies 63 Strategy Complication Reduction Lipid control  Coronary heart disease mortality  Major coronary heart disease event  Any atherosclerotic event  Cerebrovascular disease event ↓ 36%¹ ↓ 55%¹ ↓ 37%¹ ↓ 62%¹ Blood Pressure Control  Cardiovascular disease  Heart failure  Stroke  Diabetes-related deaths ↓ 51%² ↓ 56%³ ↓ 44%³ ↓ 32%³ Blood Glucose Control  Heart Attack ↓ 37%³ 1 The 4S Study, 2 Hypertension Optimal Treatment (HOT) Randomised Trial, 3 UKPDS
  • 64.  Standardized data collection on disease magnitude, risk factors and mortality statistics.  Clear action plan with specific targets, and well defined evaluation.  Initiating community-based interventions for primary prevention.  Advocacy for influencing policies.  Advocacy for the rights of people with diabetes for quality care at all levels.  Establishing acceptable standards for health care for people with diabetes.  Establishing an effective referral system and defining the role of each level of health care.  Educating the population about this important global epidemic  Provision of appropriate training for health care providers  Coordination of prevention efforts 64
  • 65.  Type 2 diabetes prevention must be integrated in a major program addressing the prevention of other lifestyle related disorders like CVD and some cancers  Primary prevention is of the essence especially in resource-constrained countries  Diabetes prevention is an inter-sectoral effort requiring cooperation and coordination  Diabetes prevention should be addressed within the context of health system reform ensuring the availability of acceptable health care standards  Culturally appropriate and economically feasible interventions should be adopted 65
  • 66.  Type 2 diabetes is a major challenge to human health  Type 2 diabetes can be prevented  Primary prevention is a suitable and affordable choice  There is strong evidence that lifestyle interventions are effective in diabetes prevention  Barriers for prevention should be addressed 66
  • 67. 67
  • 68. Clinical services  Glycemic control  BP control  Lipid management  Annual eye examinations  Foot care  Kidney disease testing  Flu immunization  Preconception care  Diabetes education  Case Management  Targeted Screening Promotion of behaviors  Education and awareness for: • Physical activity • Reduced Tobacco • Healthy diet • Regular doctor visits • Self monitoring • Self mgt education 68 Population targeted policies • Health care access legislation • Drug and supply reimbursement policies • Population registry and feedback systems
  • 69.  Taxation  Food and Menu labeling  Engage Private Industry  Crop subsidy policies  Incentives/promotion for community availability and affordability of foods  Incentives/promotion for community support for physical activity  Regulation of foods in public areas  School food and physical education policies 69
  • 70. It is the corner stone of DM management It covers:  Self care  Changing behavior to prevent and control of complications  Encourage interaction with health care providers Education of diabetic patients 70
  • 71.  Nature of disease, types  Clinical presentation, diagnosis, complications  Types of treatment, side effects  Exercise, self monitoring , avoidance and recognition of hypoglycemia, and hyperglycemia  Foot care  Pregnancy and OC  Avoidance of smoking  CV RFs  Need for follow up  Self management skills and attitudes Contents of Educational Program 71
  • 72.  Patients should be educated to practice self-care  This allows the patient to assume responsibility and control of his/her own diabetes management  Self-care should include:  Blood glucose monitoring  Body weight monitoring  Foot-care  Personal hygiene  Healthy lifestyle/diet or physical activity  Identify targets for control  Stopping smoking Diabetic Self-Care 72
  • 73.  Individual counseling  Group teaching  Educational materials: posters, pamphlets, books  Special educational programs are needed for special groups as children and pregnant women Types of education methods 73
  • 74.  Basic understanding of DM and its managements  Training in educational methods  Training of dietetics and nurses Education of Health Professionals 74
  • 75.  Prevention or modification of dietary habits and other life-style characteristics that link with DM Education of the community 75
  • 76.  Economic problems: unavailability of needed resources  Socio-cultural problems  Lack of data, knowledge and skills 76
  • 77. Obesity is not considered negatively Fad Food Culture has caught up Changing diet is very difficult No value given to physical exercise No time for physical exercise at work Fatalism 77
  • 79.  India’s response to the growing burden of non-communicable diseases National programme for prevention and control of diabetes, cardiovascular disease and stroke 79 c.
  • 81. Plan of action 81 Guidelines Trainings Detection camps in Sub centres & Main Centres Detection / Screening Camps at institutions Regular, fixed day weekly NCD clinic at PHC Preparation of Patient Treatment Cards BCC Activities
  • 82. Key interventions 82 Key Area Activities Health Promotion  Public awareness through multi-media  Counseling for healthy lifestyle (Balanced diet, regular exercise, avoid alcohol and tobacco) Early Diagnosis  Screening of persons above 30 years and all pregnant women for diabetes and hypertension at all levels; facilities up to Sub-centre level Case Management  Facilities for diagnosis and treatment (NCD Clinic) at CHC level & above  CCU at District Hospital and above  Treatment of cancer at District Hospital & above Capacity Building  Infrastructure Development & Equipment  Training of human resources at all levels Management & Monitoring  NCD Cell at National, State & District level  Surveillance, monitoring & evaluation  Regular review meetings
  • 83. Activities at different health care facilities 83 Tertiary centres Comprehensive care, research, training, telemedicine District Hospital Diagnosis & management of difficult cases, CCU, dialysis, training CHC Early detection & appropriate treatment, health promotion
  • 84.
  • 85. a) Screening for undiagnosed cases b) Foot care c) Lipid lowering agents d) Metformin 85
  • 86. a) FPG >126 b) PPPG >100 & <140 c) PPPG >140 & <200 d) FPG <110 86
  • 87. a) USA b) China c) Russia d) Canada 87
  • 88. a) 8.8% b) 6.5% c) 12.0% d) 3.0% 88
  • 89. a) 70 million b) 50 million c) 100 million d) 40 million 89
  • 90. a) Retinopathy b) Stroke c) Coronary heart disease d) Peripheral vascular disease 90
  • 91. a) Primordial b) Primary c) Secondary d) Tertiary 91
  • 92. a) Separate centre will be set up for stroke, DM b) Will be implemented in 10 districts in 5 states c) CHC has facilities for diagnosis and treatment of CVD, diabetes d) Sub-centre will provide facilities for diagnosis and treatment 92
  • 93. This presentation is available on Email your queries to sarizwan1986@outlook.com