1. A Critical Appraisal
Andre Sookdar - Class of 2013

2. Objective
 To critically appraise the Caribbean
Health Research Council’s (CHRC)
Guidelines on the Primary Care
Management of Diabetes in the
Caribbean

3. Introduction
 Diabetes mellitus (DM) is one of the leading
health problems in the Caribbean, contributing
significantly to morbidity and mortality and
adversely affecting both the quality and length
of life.
 The disease also places a heavy economic
burden on already limited health care resources
in the Caribbean. Costs are related directly to
treatment of the disease and its
complications, and indirectly to loss of earning
power in those affected.

4. Aim
 To produce a unified, evidence-based
approach to the management of
diabetes in the Caribbean.

5. Objectives
 To prevent or delay the onset of DM and co-
morbid conditions of obesity, hypertension
and dyslipidaemia
 To promote earlier diagnosis of DM
 To improve the quality of care of persons
with DM
 To prevent and treat acute and long-term
complications of DM
 To promote education and empowerment of
the patient, family and community, and
health care worker

6. Guidelines
 Definition – DM is defined by the World
Health Organization as a metabolic disorder
characterized by chronic hyperglycaemia
with disturbances of carbohydrate, fat and
protein metabolism resulting from defects in
insulin secretion, insulin action, or both.
 Classification – Type 1, Type 2, Gestational
Diabetes

7. Guidelines - Screening
 Fasting Plasma Glucose (FPG) is the
Recommended Screening Test
 Testing the Urine Glucose is not
recommended for screening.
 Blood Glucose Meters can be used for
initial screening but not for diagnosis.

8. Guidelines - Diagnosis
American Diabetes Association Criteria was used
in 2006 and in 2010
 Fasting Plasma Glucose ≥126 mg/dL (≥7.0
mmol/L) (No caloric intake for at least 8 hours)
 2 hour post-load glucose ≥200 mg/dL (≥11.1
mmol/L) during an OGTT
 In a patient with classic symptoms, a random
plasma glucose ≥200 mg/dl (11.1 mmol/1)
 New diagnostic criteria include HbA1c (≥6.5%)
(lab certified by a glycohemoglobin standardization program and
standardized to the Diabetes Control and Complications Trial (DCCT)
reference assay)

9. Guidelines
Increased Risk for Future Diabetes:
 Impaired Fasting Glucose
Fasting plasma glucose 100-125 mg/dl
 Impaired Glucose Tolerance
2h plasma glucose 140-199 mg/dl
 Elevated HbA1c*
HbA1c 5.7-6.4%

10. Guidelines - Effective Delivery of
Care
Effective Delivery of Care
 Personnel – Multidisciplinary team
 Facilities
 Equipment and Supplies
 Information system – Data
collection, storage, analysis

11. Effective Delivery of Care
Consultation
 History
 Examination
 Lab tests
 Referrals
 Follow-up
 Annual reviews

12. Metabolic Control
International Diabetes Federation
Blood glucose
Preprandial 90-130 mg/dL
Postprandial 180 mg/dL
HbA1c <6.5%
Total cholesterol <200 mg/dL
HDL cholesterol >40 mg/dL
LDL cholesterol <70 mg/dL
Fasting triglycerides <150 mg/dl
Blood Pressure ≤130/80 mmHg
Body Mass Index 18.5-25 kg/m2
Waist Circumference - General:
Women <80 cm (<32”)
Men <94 cm (<37”)
East Indians/Chinese:
Women <80 cm (<32”)
Men <90 cm (<35”)

13. Glycaemic Control
American Diabetes Association 2010
Step 1 – Lifestyle & Metformin
Step 2 – Add Sulfonylurea; if HbA1c >
8.5% or symptomatic of hyperglycaemia,
add Basal Insulin (Lantus, NPH)
Step 3 – Lifestyle & Metformin & Intensive
Insulin
*Other classes may be considered in Step
2

14. Glycaemic Control
Self Monitoring of Blood Glucose
Hypoglycaemia – symptoms, self
treatment

15. Complications
 Nephropathy – screening (albuminuria)
 Retinopathy – Ophthalmologist review
 Neuropathy
 Foot Care
 Cardiovascular Disease

16. Gestational DM
 Traditional 100g OGTT
 Rescreening at 24-28 weeks for at-risk
patients

17. Education Goals
 Treatment options
 Nutritional management
 Physical activity
 Monitoring
 Medication use and compliance
 Preventing Chronic complications

18. Appraisal
Is the guideline dealing with a POEM or DOE?
Patient Oriented
Who produced the guideline? What is their
reason for producing the guideline?
CHRC - AIM
Who is on the guideline panel and how were
they selected?
Endocrinologists, Primary Care doctors,
Nutritionists, Epidemiologist

19. Appraisal
Was any conflict of interest of panel
members addressed and appropriately
managed?
No duality of interest was identified
(stated)
Was the literature search transparent,
rigorous and comprehensive, including
all relevant data?

20. Appraisal
Were all impacts of the intervention considered,
including QOL and cost-effectiveness?
Primary prevention and cost effectiveness were
stated as key
Has the feasibility of implementation in a
practice similar to yours been tested or
considered?
Would you consider implementing the guideline
in your practice?

21. Conclusion
CHRC Guidelines for DM in Primary Care
are simple, cost effective and focuses
on primary prevention where ever
possible

22. The End
Feedback?
Questions?

23. References
 http://www.chrc-
caribbean.org/Guidelines.php
 http://www.chrc-
caribbean.org/files/Pocket%20/Diabetes
%20Guidelines%20-
%20Pocket%20Edition.pdf