Real Life Approaches to Optimal Diabetes Care for the Busy Practitioner

Transcription

1 KTPH Diabetes and Metabolism Symposium 2015 Real Life Approaches to Optimal Diabetes Care for the Busy Practitioner 11 April 2015, Saturday Poll Question 1: MOH Clinical Practice Guidelines(CPG) guides me in my practice A) All the time B) Most of the times C) Sometimes D) Rarely E) Not at all. One Farrer Hotel (Grand Ballroom) hrs Plenary Case Scenario Mr Sim, 58yo Chinese man, factory worker, no PMH, non-smoker comes to your GP clinic- recent Health Screening results. Father & uncle had diabetes in their late 40s. No significant FH IHD. Report: Height: 168cm, Wt 75kg, BMI 26.6 BP 150/92 FPG 9.6, TC 5.35mmol/l, LDL 4.90mmol/L, TG 1.7mmol/l, HDL 1.00mmol/l, GFR and creatinine normal. UFEME trace proteinuria. Poll Question 2: Does Mr Sim have diabetes? (for this question assume pt is asymptomatic) If not what will you do? A) Yes B) Not sure C) repeat FPG & HBA1C next day D) do venous blood glucose & HBA1C same day E) arrange for OGTT At the GP clinic: BP today 140/90, RBG 16.0 (Patient not fasted) 1

2 What is diabetes: Prevalence of Retinopathy vs. Fasting Plasma Glucose? ( % ) Pima Indians NHANES III Egyptians Glucometers performance J Diabetes Sci Technol Jan; 4(1): GP decides on Option D: to do casual venous sample same day- Results next day: Venous glucose 18.5mmol/L! HBA1C 9.8% Poll Question 3-Immediate Management: What factors will I consider important in my immediate management of this patient? (Choose max of 3) A) The patient s clinical status assessment of hydration, osmotic symptoms & check urine ketones B) Blood glucose and HBA1C C) Patient s choice & health belief, profile & lifestyle D) Clinical Practice Guidelines(CPG) E) DM Complications 2

3 Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient- Centered Approach Poll Question 4: Mr Sim admits to having symptoms of polyuria and polydipsia in the last few weeks, and LOW 5kg over that period. How will you treat this patient? A) Start on Lifestyle Modification(LM) only B) Start on LM and Metformin only C) Start on LM and Dual Oral anti-glycemic Agents D) Start on LM and insulin E) Not too comfortable treating- refer other healthcare provider. Diabetes Care 2015;38: DM Workup: Take a Full history & physical examination. Including FH & occupational hx, lifestyle etc. Exploring psycho-social & financial support, establishing trust and rapport, showing empathy. Screen for micro and macrovascular complications Management will include exercise, weight control, BP, lipids, renal function monitoring & social and financial support Poll Question 5: DIET HISTORY Poll: Do you take a diet history for your diabetic pts? A) Always B) Often C) Sometimes D) Never E) What s a diet history? Diet History Will identify: Adequacy of your patient s usual food/nutrient intake Frequency of eating: regular meals and snacks? Eating out? Excess energy from added sugars/drinks, cooking & spreading fat Portion sizes? Who cooks? Diet History Simple & Easy What do you need to record? Meal timing Commonly eaten foods in a week for meals/snacks Food portion size Checklist for sugar, fat or salt 3

4 Example of a Diet History 46 years old Male, Ht: 1.77m, Wt: 70kg, BMI 22 Meals Time Foods BF (Outside) Lunch (Outside) 7.15am pm Fried rice 1 bowl OR curry puff 3-4 pcs OR biscuits 6 pcs, Teh O OR coffee 3 in 1 (low fat) Weekend: Nasi lemak OR fried noodles OR thosai 2 pcs Inject Mixtard 6.30am Rice 1 bowl + 1 side dish (curry fish or vegetables), plain water Dietary advice: Okay, so its not difficult, and it does not have to take up too much time either Can you give us some strategies to deal with the info we collected? AT 3pm Cream crackers 4 pieces + coffee 3 in 1 Dinner (Outside) 7pm Fried noodles OR Rice 1 bowl + vege + meat 1 palm size Inject Mixtard 8.30pm Sugar checklist: Denies soft drinks, chocolate, ice cream, syrup For Healthcare Professionals Use Only Portion control Strategies Questions you can ask Interventions How often do you eat,and what size is your usual portion? My Healthy Plate to estimate portion sizes CHO allowance 1. Portion Control 2. Identify foods containing CHO Can you point out foods in your diet that have CHO? 6 food groups of CHO 3. Choose nutrient-dense, high-fibre foods What kind of bread do you usually eat? How much vegetables do you normally eat in a typical day? Simple vs. Complex CHO Avoid SSBs 5. Replace foods higher in saturated or trans fat with foods higher in unsaturated fat 6. Select leaner protein sources & meat alternatives 7. Do not skip meals What types of beverages do you usually drink? What kind of cooking oil do you use? How are your dishes prepared? What do you normally choose when eating out? Do you remove the skin from your chicken? How many meals and snacks do you eat in a day? Simple vs. Complex CHO Drinks with no CHO Healthier fats & oils Healthier cooking methods Tips when dining out Trim off visible fat Consider tofu as a meat option No more than 3-4 hours interval between meals Adapted from ADA Nutrition Therapy Recommendations for the Management of Adults with Diabetes, 2013 CHO Allowance Most WOMEN need Most MEN need 2. Identify Foods Containing CHO Main Meal 45-60g CHO 60-75g CHO Snack (if needed) Examples: Younger woman 15g CHO Older woman 15-30g CHO ¾ bowl rice (45g CHO) Younger man 1 fist-sized fruit (15g CHO) ½ bowl rice (30g CHO) Older man 1 fist-sized fruit (15g CHO) 1 bowl rice (60g CHO) 1 fist-sized fruit (15g CHO) ¾ bowl rice (45g CHO) 1 fist-sized fruit (15g CHO) 4

5 3. Choose Nutrient-Dense, High-Fibre Foods Fruit Vegetables High fibre breakfast cereals Brown rice 4. Avoid SSBs Carbohydrates (CHO) Simple/ Refined CHO Complex CHO High-fibre White bread Wholegrains Grain breads Oats Wholemeal bread Drinks with No Carbohydrates or Calories 5. Replace foods higher in saturated or trans fat with foods higher in unsaturated fat Healthier Cooking Methods Boiling Pressure Cooking Stir- frying Grilling Poaching Type 2 diabetes in the young We are seeing more and more younger patients with M, some as young as in their teens! What if this man was 40 years younger ie 18yo, should we be concerned, and how should our approach be different? Sautéing Braising & Stewing Microwaving Broiling Steaming 5

6 Obesity Trends Singapore Health Survey Diabetes Facts & Figures Singapore National Health Survey Age Specific Prevalence (%) Age Specific Prevalence (%) Age Group Age Group Obesity rates consistent with worldwide trends Rising diabetes numbers parallel obesity rates Ministry of Health (Singapore) Ministry of Health (Singapore) Diabetes in Youth Diagnostic Considerations Youth-Onset Type 2 Diabetes Clinical Heterogeneity Differentials Monogenic Diabetes Clinical Comparisons Caucasian Non-Caucasian Age at Diagnosis Youth/Adolescents >10 yr Adolescents Obesity Uncommon Frequently Uncommon Gender M = F F > M M = F Relatives 5% % 100% MODY Autoimmunity Frequently Uncommon Uncommon Ketoacidosis Frequently Uncommon Uncommon Mean age of diagnosis Gender Female > > Male Presentation Asymptomatic 50% 33% Ketoacidosis 4% 15-25% Obese 90% 90% Acanthosis nigricans 50% 90% Family history of 83% % Adapted from Reinehr T. Int J Obes (Lond) 2005 Reinehr T. Int J Obes (Lond) 2005 Poll Question 6 Youth-onset type 2 diabetes is associated with: A. Poorer glycaemic control compared to adult-onset type 2 diabetes B. Higher prevalence of albuminuria in contrast to age-matched patients with type 1 diabetes C. Accelerated cardiovascular disease D. All of the above E. None of the above 6

7 JADE Joint Asia Diabetes Evaluation Programme JADE Joint Asia Diabetes Evaluation Programme Conclusions Youth-onset patients had poorer glycaemic control, longer disease duration and higher rates of complications such as retinopathy and end-stage renal disease compared to adultonset Less likely to achieve targets and less likely to be on medications for hypertension and dyslipidaemia JADE Programme 2014 JADE Programme 2014 TODAY Treatment Options for in Adolescents & Youth TODAY A Stark Glimpse of Tomorrow? Markers of Cardiovascular Disease 55.9% patients remained at LDL goal of less than 3.4 mmol/l Increases in serum TG, apolipoprotein B, inflammatory markers together with low HDL were commonly observed Adverse atherogenic lipid profiles suggest possibility of premature cardiovascular disease in youth-onset Youth-onset at age 10 = 19 less life years TODAY Study Group 2012 TODAY Study Group 2012 Earlier Diabetes-Related Complications Canadian Cohort Study of Youth-Onset Earlier Diabetes-Related Complications Canadian Cohort Study of Youth-Onset Retinopathy-free survival Nephropathy-free survival Neuropathy-free survival Major complication-free survival Dart AB et al Dart AB et al

8 Youth-Onset Type 2 Diabetes Suggested Approach Young Type 2 Diabetes Clinic Meeting Unmet Needs Consider Differentials Referral Criteria Symptoms, Severity & Ketosis If present, consider early use of insulin Metformin should be the mainstay of pharmacotherapy Lifestyle Interventions Type 2 diabetes Age Fortnightly clinic Consider early referral for patients with poor glycaemic control despite pharmacotherapy Weight loss, dietary modifications, exercise Address metabolic complications & management challenges Evidence for early intervention Little catch up! Diabetes Care 2014;37: Acknowledgment: Dr Anthony Chao Prediabetics shd remain in that state for longer period of time with reduced cxs. Figure 1 The DCCT EDIC study demonstrates that a predisposition to develop diabetic complications is maintained long after switching from a poor glycemic control to a tight glycemic control regimen. Take home messages from the plenary: 1) Initial management of the newly diagnosed pt; diagnostic considerations and thresholds, and importance of setting the right target goals early & treat accordingly 2) Importance of taking a diet history for effective DM management. 3) Awareness of increasing incidence of M in the young. Recognize the challenges in management and importance of early aggressive glycemic control. 8