LIFE STYLE MODIFICATIONS IN THE PREVENTION AND MANAGEMENT OF DM2

Dr. S. Aswini Kumar. MD

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

CASE STUDY 2: MS. ASWATHY

12 year old Girl Weight: 65kg FBS: 110 PPBS: 140 Presented with complaints of Abdominal

distension

PREDIABETIC

CAN YOU PREVENT DIABETES MELLITUS?

YES

DEFINITION

A metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of CHO, fat and protein metabolism resulting 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)

WORLD-WIDE EPIDEMIC

India:2008:32 mill2020: 81 mill

INCREASING MORTALITY FROM DIABETES

60

50

40

30

20

10

0

0-3 4-7 8-11 12-15 16-19 20-23

Duration of Follow-up (yrs)

CH

D M

ort

ali

ty/1

,00

0

With Diabetes*

Without Diabetes

Male

Male

Female

Female

Am J Med 90(2A): 56S-61S,1991

* Diagnosed between 35 and 65 years of age

THE CONTINUUM OF CVD RISK IN DM

WHAT IF DIABETIC DEVELOPES CVD

Coronary Events Multivessel disease Complications

PC InterventionsDiabetic ketosis Bypass surgery

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

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

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

NATURAL HISTORY OF DIABETES

Insulin secretion

Type 2 diabetes

Years from diagnosis

0 5-10 -5 10 15

Pre-diabetes

Onset

Diagnosis

Insulin resistance

Postprandial glucose

Macrovascular complications

Fasting glucose

Microvascular complications

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

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

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

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

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

CALORIES SPENT IN VARIOUS ACTIVITIES

• Walking, 3.0 miles/hr 275/hr• Walking 5 miles/hr 420/hr• Cycling, 8 miles/hour 325/hr• Mopping, vacuuming 240/hr• Scrubbing floors 300/hr• Gardening 220/hr• Vigorous dancing 500/hr

20

EXERCISE

REGULAR EXERCISEDAILY AT LEAST 5 DAYS/WK

ISOTONIC EXERCISE - YESISOMETRIC - NO

21

WHAT PREVENTS ONE FROM WALKING

TRAFFIC, HEAVY RAIN OR DOGS ON THE STREET

CHOOSE VELLAYAMBALAM MUSEUM OR GANDHI

PARK

22

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

23

PHYSIQUE EXERCISE TREADMILL

24

MEDICAL NUTRITION THERAPY

Diet prescription Main stay of treatment Shall be individualized,

realisticflexible & suitable to patients life stylepreferably Indian diet

Patient educated and at regular intervals compliance judged

25

WEIGHT MANAGEMENT

.

Under weight

Normal weightS

Over weights

Increase food intake to optimize

weight

Continue same amount of food

intake

Gradually decrease the

amount of food

Record height - Record weight - Calculate BMI

Read against ready made charts – To get BMI

Healthy value 20-25

Above 25 – Overweight

Above 30 – Obese

EAT HEALTHY FOOD

GLYCEMIC INDEX OF COMMON FOOD ITEMS

The average is calculated from data collected in 10 human subjects

Cauliflower < 15 Parboiled rice 47 White bread 70

Cucumber < 15 Green peas 48 Watermelon 72

Green beans < 15 Banana 53 Honey 73

Peanuts < 15 White rice 56 French fries 76

Tomatoes 15 Ice cream 61 Total cereal 76

Fat-free milk 32 Oatmeal 65 Vanilla wafers 77

Apple 36 Table sugar 65 Cornflakes 84

Grapes 43 Pineapple 66 Baked potato 85

Orange 43 Wheat bread 69 Dates 103

Measure of the effects of carbohydrates on blood glucose levels

28

DIET CONTROL

PRINCIPLE LESS FOOD – BETTER INSULIN ACTION

NO SUGARS SWEETS TUBERS

OTHERWISE USUAL FOOD

CHOOSE FROM THE FOOD PYRAMID

DIABETES – WHAT NOT TO EAT

Sugar Sweets Pastry Vada

Mutton Beef fry Chips Colas

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

06.30pm Green salad

08.30pm Dinner

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 Total Cholesterol

15% fall in LDL

8% increase in HDL

30% fall in Triglyceride

50% fall Fasting Glucose

10% fall in Diastolic BP

33

AVOID ALL FRIED FOODS

MICROVASCULAR AND MACROVASCULAR COMPLICATIONS OF DIABETES

Heart Attack

SuddenBlindness

StrokeAutonomic

Neuropathy

Chronic

Kidney Disease

Type 2 Diabetes

Peripheral Neuropathy

It’s a Nightmare!

Aswini Kumar. MD

Peripheral Occlusive Vascular Disease

34

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

EXAMPLES OF SOCIO-CULTURAL BARRIERS:

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

TACKLING SOCIO-CULTURAL BARRIERS:

Dietary counselling

Patient education

Physical activity

Medication compliance

Aggressive follow-up

Sudden death assessment

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

Thank You for the Patient Listening