Dr man wo tsang t dnt case sharing [compatibility mode]

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Dr man wo tsang t dnt case sharing [compatibility mode]

  1. 1. tDNT. Case sharingMan Wo Tsang, MD, MRCP(UK), FRCP(L.,E.,G)Medical Consultant, Medical and Geriatric DepartmentDivision Head EndocrinologyDirector, Diabetes Ambulatory Care CentreUnited Christian HospitalKwun Tong, Hong Kong
  2. 2. Scheme of presentation tDNT: Algorithm development Application – Background – Experience sharing – Conclusion
  3. 3. Scheme of presentation tDNT: Algorithm development Application – Background – Experience sharing – Conclusion
  4. 4. Algorithm Development &TransculturalMedical Nutrition for Prediabetes andDiabetes Management Represents a consensus of experienced practitioners, researchers, and academicians; Supported by evidence and opinion that was graded for quality according to the standards expressed in the ACE and ADA Helps identify patients with one or more risk factors, both prediabetes and diabetes Helps to address conditions that are mitigated with dietary modification include overweight or obesity, hypertension, and dyslipidemia.
  5. 5. Objectives: Increase awareness of the benefits of nutrition interventions Enhance the implementation of existing clinical practice guidelines Simplify nutritional therapy for ease of application and portability around the world
  6. 6. Nutrition Expert Group USA : Jeffrey I. Mechanick ;Albert E. Marchetti; Caroline Apovian ; Osama Hamdy ; Refaat A. Hegazi Canada: David Jenkins ; Holland: Peter H. Bisschop ; Mexico : Alexis Bolio-Galvis Brazil: Alexander Koglin Benchimol Italy: Patrizio Tatti Panama : Enrique Mendoza Spain :Miguel Leon Sanz & Asia: Wayne Huey-Herng Sheu ; Man-Wo Tsang ; India: Shashank R. Joshi : Germany 6
  7. 7. Mile stones Abstracts/Posters –Asian Congress of Nutrition (poster) –Asia-Pacific Congress of Diabetes Education (poster) –American Diabetes Association (abstract) Main transcultural manuscript –Curr Diab Rep. 2012 Feb 9. Regional manuscripts –Southeast Asia (Curr Diab Rep. 2012 Feb 5) –Asian Indian (Curr Diab Rep. 2012 Feb 22. ) 7
  8. 8. Transcultural Medical Nutrition Algorithm New for Prediabetes and Type 2 Diabetes Actions Comments Prediabetes is established by: IFG = 100-125 mg/dL, IGT = 140-199 Ethno-cultural Lifestyle Input mg/dL, and/or A1c = 5.7-6.4%. Diabetes is established by: FPG1) Geographic location and 2) Ethno-cultural classification ≥126 mg/dL; casual PG ≥200 mg/dL; 2 hr OGTT: ≥200 mg/dL; A1c: ≥6.5%. (A1c alone is not recommended to diagnose diabetes) Individual Risk Stratification Location, ethnicity, and culture individualize recommendations. Family history of high-risk dietary patterns and premature cardiovascular disease, less than Inputs will inform other areas of the algorithm. recommended physical activity, abnormal anthropometrics (BMI/WC/WHR over normal ranges for Anthropometrics include weight, BMI, waist circumference, locale), hypertension, dyslipidemia, any cardiovascular event, any liver disease, microalbuminuria and/or waist-hip ratio according to local preference/custom. over normal range, risky alcohol intake, any sleep disturbance, any chronic illness See body composition parameters in Tables 1 and 2. Low Risk Excessive daily alcohol consumption is defined as >2 drinks for High Risk men and >1 drink for women. General Recommendations Individual risk stratification directs lifestyle interventions for improved glycemic control and decreased risks for progression, Counseling, physical activity, and healthy eating consistent with current clinical practice complications and mortality. guidelines or evidence (Tables 3-5) Insufficient physical activity is <30 min/day and/or <5 days/week. +/- Low-risk patients with prediabetes or type 2 diabetes have no Overweight/Obesity adverse conditions other than an impaired glycemic profile and Physical activity consistent with guidelines (Table 3) should follow established general recommendations for lifestyle Weight loss consistent with guidelines (Table 4) interventions plus nutritional therapy per AACE/ADA guidelines. MNT consistent with guidelines (Table 4) High-risk patients have ≥1 risk factors that require specific Formula/Caloric supplementation or replacement interventions to reduce progression, complications, and consistent with options and strategies (Table 5) mortality. Conditions amenable to lifestyle change include Consider bariatric surgery (Table 6) overweight/obesity, hypertension, and dyslipidemia. +/- Hypertension Hypertension is defined as blood pressure >130/80 mm Hg. Antihypertensive diet consistent with DASH and 2.4 g Na+ = 6 g salt (≈ 1 teaspoon) sodium restriction of <1.5 g/day (Table 7) 1.5 g Na+ = 3.7 g salt (≈ 2/3 teaspoon). +/- The nutritional management of obesity and that of dyslipidemia Dyslipidemia are similar (Table 4). Lipid-modifying diet (Table 4) When hypertension and dyslipidemia complicate prediabetes and diabetes, interventions are additive and intensified. Follow-up Evaluation (1-3 months) Follow-up evaluation is scheduled according to patient needs History, physical (anthropometrics, blood pressure); chemistries (glucose, A1c, lipids, urinary and local practice. alb/creatinine, liver enzymes); urinalysis At Goals Not At Goals Mechanick JI, et al. Maintain physical activity, meal plan, Intensify physical activity, meal plan, Curr Diab Rep. 2012. and medical nutrition therapy and medical nutrition therapy Feb 9.
  9. 9. Actions Comments Diabetes /PreDiabetes Ethno-cultural Lifestyle Input Diabetes is established by: FPG ≥126 mg/dL; casual PG ≥200 mg/dL; 2 hr OGTT: ≥200 mg/dL;1) Geographic location and 2) Ethno-cultural classification A1c: ≥6.5%. (A1c alone is not recommended to diagnose diabetes.) Individual Risk Stratification Location, ethnicity, and culture individualizeFamily history of high-risk dietary patterns and premature cardiovascular disease, less recommendations. Inputs will populate otherthan recommended physical activity, abnormal anthropometrics (BMI/WC/WHR over areas of the algorithm.normal ranges for locale), hypertension, dyslipidemia, any cardiovascular event, any liverdisease, microalbuminuria over normal range, risky alcohol intake, any sleep Anthropometrics include weight, BMI, waistdisturbance, any chronic illness circumference, and/or waist-hip ratio according to local preference/custom. See body composition parameters in Tables 1 and 2. Low Risk High Risk Excessive daily alcohol consumption is defined as >2 drinks for men and >1 drink for women General Recommendations Individual risk stratification directs lifestyle interventions for improved glycemic control andProfessional counseling, physical activity, and healthy eating consistent with current decreased risk for complications and mortality.clinical practice guidelines or evidence (Tables 3-5) Insufficient physical activity is <30 min/day +/- and/or <5 days/week. Overweight/Obesity Low-risk patients with diabetes have no adverse Physical activity consistent with guidelines (Table 3) conditions other than an impaired glycemic Weight loss consistent with guidelines (Table 4) profile and should follow established general MNT consistent with guidelines (Table 4) recommendations for lifestyle interventions plus nutrition therapy per AACE/ADA guidelines. Formula/Caloric supplementation or replacement consistent High-risk patients with diabetes have ≥1 risk with options and strategies (Table 5) factors that require specific interventions to Consider bariatric surgery (Table 6) reduce complications. Conditions amenable to lifestyle change include overweight/obesity, hypertension, and dyslipidemia. +/- 9
  10. 10. Actions Comments Hypertension is defined as blood pressure Hypertension >130/80 mm Hg. Antihypertensive diet consistent with DASH and sodium restriction of <1.5 g/day (Table 7) 2.4 g Na+ = 6 g salt (≈ 1 teaspoon) 1.5 g Na+ = 3.7 g salt (≈ 2/3 teaspoon). +/- The nutrition management of obesity and that of dyslipidemia are similar (Table 4). Dyslipidemia When hypertension and dyslipidemia complicate Lipid-modifying diet (Table 4) prediabetes and diabetes, interventions are additive and intensified. Follow-up Evaluation (1-3 months)History, physical (anthropometrics, blood pressure); chemistries (glucose, A1c, lipids,urinary albumin/creatinine, liver enzymes); urinalysis Follow-up evaluation is scheduled according to At Goals Not at Goals patient needs and local practice.Maintain physical activity, meal plan, Intensify physical activity, meal plan, andand medical nutrition therapy medical nutrition therapy. Improve compliance 10
  11. 11. 1. WHO Expert Consultation. Lancet. 2004;363:157-163; 2. International Diabetes Institute. The Asia-Pacific perspective: Redefiningobesity and its treatment. 2000. http://www.diabetes.come.au/pdf/obesity.report.pdf/ Accessed November 9 2011; 3. ExaminationCommittee of Criteria for Obesity Disease in Japan; Japan Society for the Study of Obesity. Circ J. 2002;66:987-992. 11
  12. 12. Asians with T2D experience more postprandial hyperglycemia dueto frequent consumption of high glycemic index (GI) food (ie,“glutinous”)The replacement or exchange quantities of the high GI grainwith lower GI or glycemic load grain would lead to effectiveglycemic control 12
  13. 13. Relative % Contributions of Postprandialand Fasting Hyperglycemia Over Quintilesof HbA1c aSignificant difference was between tasting and post-prandial plasma glucose. bSignificantly different from all other quintiles (ANOVA). cSignificantly different from quintile 5 (ANOVA). Monnier L, et al. Diabetes Care .2003;26:881-885.. 13
  14. 14. 14
  15. 15. Relative % Contributions of PostprandialGlucose to Hyperglycemia Over Quintiles ofHbA1cWang JS, et al. Diabetes Metab Res Rev.2011;27:79-84. 15
  16. 16. In Asia, diabetes is distinguished by onset with lower BMI andyounger age as compared with CaucasiansThe lifestyle, food, and tradition vary between Western andAsian people, and current CPG may not address the differencesMany clinical trials have demonstrated that nutrition, counseling,and lifestyle modification are effective in prevention of prediabetesand T2D across ethnic and racial groupsStudies also indicated that, compared with standard enteralnutrition formula, the low-carbohydrate, high-MUFA formula hasbetter glycemic control 16
  17. 17. Glycemia –targted specialized nutrition(Pre-diabetes and Diabetes) Table 6 Overweight/ Use calorie replacements* as part of a reduced calorie meal plan. (Grade C; LOE 3) Obese Calorie goals: <250 lb= 1200 to 1500 calories >250lb = 1500 to 1800 calories Calorie replacement goals: 2 to 3 calorie replacements per day to be incorporated into an a reduced calorie meal plan, as a meal replacement, partial meal replacement or snack. Use of calorie replacement/calorie supplement should be based on clinical Controlled Diabetes judgment and individual assessment ** (Grade D; expert opinion) A1c<7% Normal Weight 1 to 2 calorie replacements per day to be incorporated into an a reduced calorie Uncontrolled Diabetes meal plan, as a meal replacement, partial meal replacement or snack. A1c>7% (Grade D; LOE4) Use nutrition supplement*** 1-3 units/day per clinical judgment based on desired rate of weight gain andUnderweight clinical tolerance. (Grade D; LOE4) *Calorie replacement are nutritional products used as a meal replacement, partial meal replacement or snack to replace calories in the diet. Calorie replacements provide approximately 100 to 300 kcal per serving. **Individuals who may have muscle mass and/or function loss and/or micronutrient deficiency may benefit from a nutrition supplement. Individuals who need support with weight maintanenece and/or a healthy meal plan could benefit from calorie replacement. *** Nutritional supplements are complete and balanced nutritional products with ≥ 200 calories per serving used in addition to a typical meal
  18. 18. Case 2 : use of paired haemoglustixSK Chan , M 56T2DM : metformin 1gm BD, Insulin , Protaphane 26 om and 30 nocteFasting hyperglycaemiaPostprandial hyperglycaemia 18
  19. 19. 19
  20. 20. 20
  21. 21. 21
  22. 22. Three day paired haemoglucostix 22
  23. 23. Case 3 WS Tsang , M47 Known hypertension/hyperlipidaemia, defaulted follow up Chronic alcoholic and smoker, nightclub manager Presented Oct 2009 Sudden numbness of left side of body bp 170/ 102 mmhg 23
  24. 24. 24
  25. 25. 25
  26. 26. Mealreplacement 26
  27. 27. HbAc% 27
  28. 28. 28
  29. 29. Mad Li , 67T2DM,On insulinProtaphane 50 om 45 pmActrapid 24 30 30Suggest BariatricSurgery: morbid obesity poor dm controlInsulin resistanceOSASSevere OA knee 29
  30. 30. BMI pre op ( Sleeve Gastrectomy) 14 12 12 10 9 no. of patients 8 6 6 Obese class1 30- 34.9 4 Obese class2 35.0- 39.9 2 Obese class3 ≥40 0 Obese class1 Obese class2 Obese class3 BMI 30-34.9 35.0-39.9 ≥40 Dr. C.W.Ho, Dr. M.W. Tsang, Dr. E. Cheung, Dr. G.Kam, Dr. C.S.Hung, Dr. G. Hui HKSEMR , Scientic meeting 2011
  31. 31. No. of co-morbidities no. of co-morbidities None, 2, 7% Five, 5, 17% One, 3, 10% Two, 3, 10% None One Two Three Four Five Four, 9, 29% Three, 8, 27%
  32. 32. Result- mean % excess weight loss % Excessive weight loss after operation 70 60 61.2±28 50 54.2±21 40 %EWL 45.9±20 26.9 ±15 % EWL 30 20 10 0 0 1 6 12 24 no. of months after operation % excess weight loss = (weight loss/ excess weight) x100% Excess weight = total preoperative weight –ideal weight (kg)
  33. 33. Result- mean fasting blood glucose 10 5 6.84±2.5 6.77± 2.5 5.59± 1.7 5.94± 2.5 5.27± 1.3 0 pre op post op 1 post op 6 post op 12 post op 24 -5 month months month months -1% -10 -13% -15 glucose ( mmol/l) % change from baseline -20 -18% -23% -25 time
  34. 34. Result- mean HbA1C 8.5 8.2±2.3 8 7.5 7 mean HbA1C (%) 6.5 6.7±1.8 6.4± 2.5 6 5.5 5 pre op pre op 6 pre op 12 months months
  35. 35. Meal replacement study
  36. 36. RESEARCH PROTOCOLEffect of a Low Glycaemic index Diabetic Specific Mealreplacement on metabolic control in Type 1 diabetes mellitussubjects PURPOSEWe aim to examine the metabolic effects and safety of usingGlucerna as low glycaemic index meal replacement strategyincorporated into an integrated intervention programme for Type 1diabetes mellitus (T1DM) patients. 36
  37. 37. STUDY DESIGNThis study is designed as an open-labeled, randomized, controlledcross-over clinical trial. All participants are T1DM patientsrecruited from Diabetes Centre of United Christian Hospital, HongKong. 37
  38. 38. Patient 1 (Control) vs Study 0=baseline, 2= 4 weeks12108 C0 C26 S0 S2420 BF PPBF LH PPLh Din PPDin Nocte 38
  39. 39. 109876 C-05 C-2 S-04 S-23210 BF PPBF LH PPLh Din PPDin Nocte 39
  40. 40. SLGOPDKTGOPC LTGOPC DM service: Insulin DM Clinic SPOPDNKTGOPC KBGOPC
  41. 41. 45.0% % with HbA1c under control (<7%)- KEC40.0% 39.6%35.0%30.0%25.0% 26.8%20.0%15.0%10.0%5.0%0.0% 2008 2009 Total No. of DM patients-KEC 2008 39,100 2009 42,200
  42. 42. Proposed New Infrastructure of DM Service Low risk Primary care Medium risk Risk assessment & Stratification PEP Community High risk New DM PPP patients Very High risk 3000/year Special group: Paed., pregnant women, etc. NC Nurse led clinic with MDT, Pharmacist & Diabetologist support Empowerment, Intensive Treatment, Existing DM Treat-to-target, protocol –based care patients IT data tracking and identify patients not reaching target
  43. 43. Enhanced Dietetic Service For DM ManagementObjective Current Workload Statistics (July 2010-June• Enhanced DM dietetic management for 2011) SOPD OP and IP Overall HA dietetic OP attendance 23797 vs. totalService need attendance 64043 (37.2 % of Diet OP attendance) Individual hospital ranged from 40-75% total OP Usual new case contact time 30 workload on DM mgmt minutes and subsequent visit 10-15 minutes Actions Uneven distribution of manpower for IP To develop protocol-driven DM case mgmt model, i.e. DM cases due to shortage of ratio of new to subsequent visits To increase contact time for each consultation manpower for timely consultation (e.g. UCH ratio of IP and OP DM caseload Deliverables was 1:3) Increase contact time per visit Increase frequency of visit for each patient Inadequate FU - frequency of OP Promote compliance to diet therapy subsequent attendance minimum 6 Performance indicators months interval and average FU Compliance to protocol attendance is 1.4 per new case ( range Attendance from 1-1.8) and may contribute to less Waiting time than satisfactory effectiveness and To enhance quality of service in joint clinics high default rate resulted Patients from joint clinics even those
  44. 44. Thank You

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