Powerpoint presented in the Indian Medical Association, Karunagappally Branch of Kerala on 30-08-2009

1. Life style modifications in the prevention and management of Dm2 Dr. S. Aswini Kumar. MD

2. Case Study 1: Ms. Aparna 15 year old Girl Weight: 95kg FBS: 325 PPBS: 450 Family doctor referred her after starting on OHA THE NEW YOUNG DIABETIC

3. Case Study 2: Ms. Aswathy 12 year old Girl Weight: 65kg FBS: 110 PPBS: 140 Presented with complaints of Abdominal distension PREDIABETIC

4. Can You prevent Diabetes Mellitus? YES

5. Definition A metabolic disorder of multiple aetiologycharacterized by chronic hyperglycaemia with disturbances of CHO, fat and protein metabolismresulting from defects in insulin secretion, insulin action or both” Associated with risk of developing late diabetic complications Microvascular (retinopathy, nephropathy) Macrovascular (atherosclerosis, coronary artery disease, Neuropathy (peripheral, autonomic)

6. World-wide Epidemic India: 2008:32 mill 2020: 81 mill

7. Increasing mortality from Diabetes Male 60 50 40 30 20 10 0 With Diabetes* Female Without Diabetes CHD Mortality/1,000 Male Female 0-3 4-7 8-11 12-15 16-19 20-23 Duration of Follow-up (yrs) * Diagnosed between 35 and 65 years of age Am J Med 90(2A): 56S-61S,1991

8. The ContinuUM OF CVD RISK IN DM

9. WHAT IF DIABETIC DEVELOPES CVD Coronary Events Multivessel disease Complications PC Interventions Diabetic ketosis Bypass surgery

10. Why is the prevalence of DM2 increasing? 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

11. Why should we prevent diabetes? To reduce human suffering Improve Quality of Life of individuals Reduce the number of hospitalization To reduce human suffering Reduce mortality from diabetes Prevent Sudden cardiac death

12. Levels of Prevention in Type 2 DM Primary: Includes activities aimed at preventing diabetes from occurring in susceptible individuals or populations Secondary: Early diagnosis and effective control of diabetes in order to avoid or at least delay the progress of the disease Tertiary: Includes measures taken to prevent complications and disabilities due to diabetes

13. Natural History of Diabetes Insulin secretion Years from diagnosis 0 10 5 15 -10 -5 Onset Diagnosis Insulin resistance Postprandial glucose Fasting glucose Microvascular complications Macrovascular complications Pre-diabetes Type 2 diabetes

14. Diagnostic Criteria for DM2 Fasting blood sugar > 126 mg/dl 2 hour glucose tolerance > 200 mg/dl Impaired Glucose Tolerance - “Pre-diabetes” Impaired Fasting: Level between >100 mg/dl and <126 mg/dl Impaired Post prandial glucose: During 2 hour glucose tolerance test Level between >140 and <200 mg/dl

15. What are the goals? ADA and ACE/ AACE differ from each other ADA Goals FBS - 70-130 PPBS - <180 HbA1c - <7.0 ACE/AACE Goals FBS - <110 PPBS - <140 HbA1c - ≤6.5

16. Hb A1c Excellent test to judge overall glycemic control Gives idea of average blood sugar Over a period of previous 120 days Because RBC Life Span is 121 days Ideally done every 3-4 months Normal < 6.5 Good <7.0 Fair <8.0 Poor<9.0 Bad >10 Disadvantages: Costly – Rs. 250 per test Falsely high values – Renal failure Falsely low values – RBC life span

17. Exercise Advantages Benefits glycemic control Improves insulin sensitivity Builds physical fitness Optimizes body weight Gives psychological well being Disadvantages Carry some risk also Strains the compromised CVS Injuries to musculoskeletal system Predisposes to hypoglycemia May exacerbate complications

18. Energy expenditure Calories spent /minute Lying down, sleeping, sitting 1 Standing, desk work, driving 2 Level walking, level bicycling 3 Social doubles badminton 4 Social singles badminton 5 Gardening , swimming 6 Competitive badminton 7 Jogging 8 Basketball 9 Running 1km in 10min 10

20. Walking 5 miles/hr 420/hr

21. Cycling, 8 miles/hour 325/hr

22. Mopping, vacuuming 240/hr

23. Scrubbing floors 300/hr

24. Gardening 220/hr

26. What prevents one from Walking Traffic, heavy rain or dogs on the street Choose Vellayambalam Museum or Gandhi Park 21

27. Precautions Correct foot wear Comfortable loose clothes Close inspection of feet every day Carry snacks as protection from hypoglycemia How it should be: Patient should be able to carry out a normal conversation while exercising without getting breathless 22

28. Physique Exercise Treadmill 23

29. Medical Nutrition Therapy Dietprescription Main stay of treatment Shall be individualized, realistic flexible & suitable to patients life style preferably Indian diet Patient educatedand at regular intervals compliance judged 24

31. Read against ready made charts – To get BMI

32. Healthy value 20-25

33. Above 25 – Overweight

34. Above 30 – Obese.

35. EAT HEALTHY FOOD

36. Glycemic Index of Common Food items Measure of the effects of carbohydrates onblood glucose levels

37. Diet Control Principle less food – Better insulin action No sugars sweets tubers Otherwise USUAl food 28

38. CHOOSE FROM THE FOOD PYRAMID

39. Diabetes – What not to eat Vada Sweets Pastry Sugar Mutton Beef fry Colas Chips

40. Diet and Diabetes – A days menu 06.30 am Tea without 08.30am Break fast 10.30am Snack 01.30pm Lunch 02.30pm Fruits 04.30pm Tea without 08.30pm Dinner 06.30pm Green salad

41. Benefits of 10% Weight Loss 20% fall in total mortality 30% fall in diabetes related death 40% fall in obesity related death 20% fall in Systolic BP 10% fall in Diastolic BP 50% fall Fasting Glucose 10% fall in Total Cholesterol 15% fall in LDL 8% increase in HDL 30% fall in Triglyceride

42. Avoid all fried foods 33

43. Microvascular and Macrovascular Complications of Diabetes Type 2 Diabetes It’s a Nightmare! Chronic Kidney Disease Peripheral Occlusive Vascular Disease Autonomic Neuropathy Stroke Sudden Blindness Heart Attack Peripheral Neuropathy 34 Aswini Kumar. MD

44. Tertiary Prevention Actions taken to prevent and delay the development of acute or chronic complications Acute complications: such as hypoglycemia, severe hyperglycemia Diabetic ketoacidosis and infections Chronic complications: such as atherosclerosis, retinopathy, nephropathy, neuropathy and foot problem

45. Examples of socio-cultural barriers:

46. Tackling socio-cultural barriers:

47. Take Home Messages DM2 is a major challenge to human health Type 2 diabetes can be prevented Primary prevention is suitable and affordable lifestyle interventions are effective in prevention Barriers for prevention should be addressed Diabetes can be managed with life style alone Healthy eating and regular exercise are needed