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MODULE FOR STUDENTS Diabetes Mellitus

Modul Modul Modul Modul Modul Modul Modul Modul Modul 1 2 3 4 5 6 7 8 9 Definition, presentation, diagnosis, classification Aetiopathology Manage ent ! "ifestyle odification Manage ent ! Drug therapy Acute co plications Micro#ascular co plication Macro#ascular co plication $re#ention %hildren and Pregnancy

FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY MALANG 2012

MODULE 1

: DIABETES MELLITUS Definiti n! "#e$ent%ti n! Di%&n $i$ %n' C(%$$ifi)%ti n


Dia&etes ellitus 'DM(, a chronic, de&ilitating disease, is associated )ith a range of se#ere co plication* De ographic and epide iological e#idences suggest that the incidence of dia&etes is increasing )orld)ide* +he anage ent of dia&etes ellitus and the anage ent of its co plications are a,or challenges for the future* +o pro#ide the opportunity of e ori-ing the different cutoff #alues for raised &llod glucose at different in#estigation setting* +he acti#ities )ill de#elop your s.ill to la&el indi#iduals suffering fro dia&etes* /t )ill also fa iliari-e you )ith clinical differentiation of different classes of dia&etes, particularly typ 1 DM #s type 2 DM* After co pletion of this odule, you should &e a&le to ! 1* define dia&etes ellitus* 2* discuss a&out the a etiological factors and types of dia&etes ellitus* 3* a.e distinction &et)een type 1 DM and type 2 DM &y o&ser#ing clinical presentations* 4* super#ise the procedures for 01++* 5* interpret &lood glucose #alues at fasting, at rando or during 01++ for diagnosis of dia&etes, /1+ anf /21* Acti#e learning )ith odule tas., group discussion, and e3pert lecture*

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ACTIVITY 1/1 4nderstanding .01e#&(0)e2i% and )3tt ff *%(3e$ for dia&etes ellitus for fasting &lood glucose and &lood glucose le#el 2 hours after a standard oral glucose drin. fro la&oratory reports* Ai2 : +his acti#ity )ill help you practice understanding ho) la&oratory #alues of &lood glucose in fasting and 2 hours after oral glucose drin. are interpreted to la&el a person as a dia&etic*
N / 1 2 3 4 5 N%2e V"G %t 0 2in V"G %t 120 2in Mr* A 77 152 Mr* 6 92 288 Mr* % 192 414 Mrs* D 79 117 Mr* 7 335 423 8*6 ! 9$1 : 9enous plas a glucose ' g;d"( and the assay is done &y Auto<analy-er &y using glucose<o3ida-e ethod

/n the left hand colu n, )rite )hether the person is dia&etic or not= in the right hand colu n, )rite the reasons for the 4 reports 'fro sl*no 2<5( using the style sho)n for report of sl*no*1* Mr* A is not suffering fro Mr* 6 Mr* % Mrs* D Mr* 7 8*6* ! >our tutor )ill pro#ide feed&ac. on this acti#ity* A)ti*it0 1/2 : T01i)%( 1#e$ent%ti n f 'i%,ete$ 2e((it3$ in % )%$e/ Ai2 : +his acti#ity )ill help you to understand the typical presentation of a dia&etic &y a case study* Mr* ?, a 17<year &oy, 1st year student of @A@ class, )as &rought at hospital )ith the co plaints of e3cessi#e urination and increased thirst and appetite )ith ild )eight loss and general )ea.ness for last 15 days* 0n the pre#ious day his fasting &lood glucose )as 335 g;d" and 423 g;d" 2 hours after a 75 gra of glucose drin.* At presentation, his pulse )as 155 &p and 6$ 125;75 of Ag, 6M/ 18*5 .g; B, glycosuria and .etonuria )ere detected &y urine e3a ination* a* Crite do)n 3 presenting features of dia&etes ellitus of Mr* ?* 1( 2( 3( Ce ha#e learned that type 1 DM, )here there is total lac. of insulin fro disease, al)ays has a typical presentation* the &eginning of dia&etes 6oth the #alues are &elo) the cutoff le#el for a dia&etic*

&* Chat do you feel a&out the follo)ing state ent DA dia&etic not &elonging to type 1 DM has the potentiality to ha#e a typical presentation also*E 1i#e your opinion*

A)ti*it0 1/4 : Di%&n $ti) t ($ 3$e' f # 'i%,ete$ 2e((it3$/ Ai2 : +his acti#ity )ill a.e you understand )hich of the diagnostic tests are to &e used for deter ining dia&etes in a person /n the left hand colu n, there is a state ent regarding a particular tool= in the right hand colu n, )rite do)n the appropriate figure 's( if you agree )ith the state ent*

6lood glucose of a f%$tin& sa ple can Do you agree )ith the state ent F indicate ascertain that one is non<dia&etic* /f GyesH )rite do)n the *%(3e %, *e )hich a person is 'i%,eti)* g;dl 6lood glucose of a #%n' 2 $%21(e can Do you agree )ith the state ent F indicate that a person is li.ely to &e a /f GyesH )rite do)n the range* dia&etic if the #alue is either a&o#e or to g;dl &elo) a certain range* 6lood glucose of an OGTT can certainly Do you agree )ith the state ent F tell us )hether a person is dia&etic, non< /f GyesH )rite do)n of the range )ithin )hich &lood dia&etic or e#en pre<dia&etic '/1+(* glucose at 125th inute the le#el ust &e &elo) 115 g;dl(* to g;dl Fee',%)5 ! /f your are at li&erty to $3&&e$t % te$t f # 'i%,ete$ for a gentle an +. i$ n t $021t 2%ti) f 'i%,ete$, )hich test you )ill as. for F Chy F N%2e f t.e te$t Re%$ n

A)ti*it0 1/6 : C(%$$ifi)%ti n f 'i%,ete$ ,0 )%$e $t3'0 Ai2 : +his acti#ity )ill help you understand the clinical classification &ased on presentations of dia&etes &y case study* Mr* I, a 48 years old gentle an )as referred to endocrine outpatient clinic &y his 1$ )ith a clinical diagnosis of %ushingHs @yndro e* 7ndocrinologist confir ed the case as a %ushingHs syndro e due a cortisol secreting tu ors in his right adrenal gland* During the diagnostic )or. up n 01++ docu ented that he )as a dia&etic too, &ecause &lood glucose le#els in &oth the ti e poits )ere clearly a&o#e the e3pected le#el i*e* 192 g;d" at 5 inute and 414 g;d" at 125th inute* 0n Juestioning he ad itted that had typical features of dia&etes* Give your comment about the type of diabetes from which Mr. K was suffering.

A)ti*it0 1/7 : Se(e)tin& in*e$ti&%ti n f # 'i%&n $i$ f 'i%,ete$ 2e((it3$ C%$e : >our ne3t<door neigh&our Mrs* I, )anted to .no) )hether she )as suffering fro dia&etes or not F @he )as fro a dia&etic fa ily, &ut she did not ha#e any co plaints suggesti#e of dia&etes ellitus* Chat )ould you as. her to doF

1* A &lood sugar 2 to 3 hours after her lunch &ecause lunch )as her a,or eal* 2* 6lood glucose in the ne3t orning &efore her &rea.fast* 3* An 01++ after ta.ing proper preparations* In the left hand column, give a written instruction to Mrs. K for the best; in the right hand column, write the reasons for which you have selected this test.

A)ti*it0 1/8 : Un'e#$t%n'in& 3$e 2e((it3$/

f f%$tin& ,(

' &(3) $e in 'i%&n $i$

f 'i%,ete$

Mar. T 'rue( or F 'alse( for the follo)ing state ents regarding a f%$tin& ,( ' &(3) $e 9FBG: ! 1* 261 can la&el a person as 'i%,eti) if its #alue is 128 2&;'L* 2* 261 can la&el a person as IGT if its #alue is in ,et+een 100 < 128 2&;'L/ 3* 261 can la&el a person as IFG if its #alue is = 100 2&;'L < > 128 2&;'L and the person should undergo an 01++* 4* 261 cannot la&el a person as non<dia&etic* A)ti*it0 1/? : Re$1 n' t t.e f (( +in& t.#ee $. #t @3e$ti n$/ A3e$ti n % 8a e 3 clinical feature of dia&etes i( ii( ellitus that are called Gtypical featureH of dia&etes iii( ellitus*

A3e$ti n , Crite do)n the #alues of fasting &lood glucose in /21;/1+ and dia&etic state* 2or /21 ! 2or /1+ ! 2or DM !

MODULE 2
O*e#*ie+

: DIABETES MELLITUS -

Aeti 1%t. ( &0

Dia&etes ellitus 'DM( pri arily affects the car&ohydrate eta&olis = &ut it also affects protein and fat eta&olis * +he distur&ed eta&olis is due to defects in insulin secretion or insulin action or &oth* +o pro#ide you )ith the opportunity of understanding ho) &lood glucose le#el is aintained after ta.ing food and in &et)een eals, and ho) &ioche ical a&nor alities set in &y the a&nor alities 'pathology( of secretion and action of insulin in dia&etes ellitus along )ith factor's( responsi&le for doing so* After co pletion of this odule, you should &e a&le to ! 1* descri&e the relationship &et)een &lood glucose and insulin in healthy people* 2* discuss insulin actions* 3* discuss conseJuences of insulin lac. and insulin resistance in dia&etes* 4* identify the factors ' odifia&le K non L odifia&le( associated in a dia&etic person* 5* descri&e pathogenesis of dia&etes ellitus* Acti#e learning )ith odule tas., group discussion, and e3pert lecture*

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ACTIVITY 2/1 +o understand 3ti(iB%ti n f ,( ' &(3) $e &y cells and its relation )ith insulin secretion in non<dia&etic person* Ai2 : +his acti#ity )ill pro#ide you the opportunity to recall physiology of insulin and glucose eta&olis *

A/ Chat is the i portances of glucose in hu an &odyF


MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM B/ 8a e 4 types of cells that do not reJuire insulin for entry of glucose a* MMMMMMMMMMMMMMMMMM &* MMMMMMMMMMMMMMMMMMMMM c* MMMMMMMMMMMMMMMMMM d* MMMMMMMMMMMMMMMMMMMMM

C/ Mention three 1#in)i1%( t%#&et ti$$3e$ f # in$3(in %)ti n and se#eral effects of insulin action in these tissues* a* MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM &* MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM c* MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

D/ @u

ari-e the 1.0$i ( &i)%( effe)t$ f in$3(in in! eta&olis of car&ohydrate

a* +he

&* +he

eta&olis

of protein

c* +he

eta&olis

of lipid

7* M%#5 T'rue( or F'alse( n t.e $t%te2ent$ 1* /n &et)een eals and throughout night )hen there is no glucose supply to &lood fro the gut the follo)ing changes occur! N /nsulin secretion goes up* N Aepatic glucose output 'A10( goes up* N 1lucose upta.e is ostly &y insulin independents cells 2* 2ollo)ing ingestion of eal, )hen there is e3cess glucose supply to &lood fro our &ody echanis is ad,usted to ensure euglyce ia as! N /nsulin secretions goes up* N Aepatic glucose output 'A10( goes up* N 1lucose upta.e is ostly &y insulin independents cells the gut,

F/ Fi((-31 t.e &%1$ f t.e f (( +in& $t%te2ent$ : 1* /nsulin sti ulatesMMMMMMMMMMMMMMMMMMMMM synthesis in the li#er and s.eletal uscle and increases MMMMMMMMMMMMMMMMMMMM stoc. of li#er and uscle* 2* /nsulin increases MMMMMMMMMMMMMMMMMMM acti#ity in fat and s.eletal uscle there&y increases entry of glucose into fat cells and s.eletal uscle*

ACTIVITY 2/2 +o understand that there are so e f%)t #$! )hich contri&ute to the de#elop ent of, type 2 DM &y increasing in$3(in #e$i$t%n)e and their association )ith de#elop ent of other disorders in the sa e indi#iduals* Ai2 ! +his acti#ity )ill help you to understand that type 2DM has ultiple a etiological ris. factors, therefore during treat ent plan you )ill see different approaches in su&seJuent chapters* /n the left hand colu n of the follo)ing ta&le )rite 4 factors that contri&ute to the de#elop ent of insulin resistance and in the right hand colu n )rite 4 conditions that are contri&uted &y insulin resistance* Left .%n' ) (32n '2actors contri&ute to de#elop ent of insulin resistance( 1 2 4 6 ACTIVITY 2/4 +o understand that 1%t.+%0 of de#elop ent of type 1 DM is different fro that of type 2DM* Ai2 ! +his acti#ity )ill help you to understand )hy there are differences in anage ent of dia&etes* Manage ent )ill &e discussed in su&seJuent chapters* 2ollo)ing etipathological factors lead to the path)ay for de#elop ent of either type 1 or type 2 DM, ar. tic. in the appropriate colu n* F%)t #$ 1* 1enetic suscepti&ility is lin.ed )ith certain types of A/"A 2* 1enetic suscepti&ility can &e identified si ply &y a positi#e fa ily history of DM* 3* Autoi une nature of the disease can &e identified &y so e ar.ers in the seru * 4* /nsulin lac. is a&solute fro #ery &eginning of hyperglyce ia* 5* /nsulin lac. and insulin resistance ay #ary in a patient )ith ti e* 6* 7n#iron ental factors li.e o&esity, physical inacti#ity ha#e definite role in production of this type of DM* T01e 1DM T01e 2DM Ri&.t .%n' ) (32n '%onditions that are contri&uted &y insulin resistance(

A)ti*it0 2/6 : I'entif0 #i$5 f%)t #$ f t01e 2 DM Ai2 ! +o acJuire s.ill of identify ris. factors of type 2 DM during case study* Mr* 8 Ali, a 56<year<old anager of a pri#ate &an. did 01++ &y the ad#ice of his personal physician to )ho he co plained of general )ea.ness for fe) onths* 01++ docu ented dia&etes ellitus* Mr* Ali is father of 3 children L 2 daughters and a &oy* Ais )ife had dia&etes during her 3rd pregnancy 'gestational dia&etes ellitus(, )hich &eca e nor al after deli#ery* 8o)<a<days Mr* Ali has to spend ore ti e in the &an. for longer due to so e audit pro&le * 6y nature Mr* Ali does not go for e3ercise or sports and en,oys eating* 2or the last couple of years he is gaining )eight* Ais father, father in la), 1 &rother and 1 sister are .no)n dia&etic* +he factors that ight ha#e contri&uted to causation of dia&etes for Mr* Ali are gi#en in the left hand colu n of the ta&le &ello)* 2ill<up other colu ns* FACTORS Age ! 56 years @e3 ! Male Married 2ather is dia&etic 2ather<in<la) is dia&etic 6rother and sister are dia&etic Cife is dia&etic Ae has stress in )or.ing place Ceight gain @edentary life style YES NO IF YES : IS IT MODIFIABLEC

A)ti*it0 2/7 : In$3(in %)ti n Ai2 : +o test your e ory on relationship &et)een glucose and insulin in healthy person and on insulin action <cells sho) follo)ing insulin secretion pattern ! a( +here is a continuo lo)<le#el secretion of insulin 'appro3i ately MMMMunit per hour( &et)een eals and throughout night* /t is called MMMMMMMMMMMMMMMMMMMMMMMMM insulin* @o a&out MMMMMMMM units of insulin is secreted as &asal secretion* &( 2ollo)ing eals there is sharp rise, )hich is called MMMMMMMMMMMMMM or MMMMMMMMMM 'MMMMMMMMMMMMMMMM( 'also called 1st phase( insulin release* +he rate and a ount secretion is influenced &y MMMMMMMMMMMMMMMMM and MMMMMMMMMMMMMMMMMM of eals* A)ti*it0 2/8 : Eti ( &0 f t01e 2 DM M%#5 T9#3e: f F9%($e: f # t.e f (( +in& $t%te2ent n % eti ( &0 f t01e 2DM/ A/ B/ C/ D/ E/ +he &asis of eta&olic i pair ent i*e* hyperglyce ia is a defecti#e insulin response* A fe) patients ay e3hi&it a se#ere i pair ent of insulin release and nor al sensiti#ity* Another s all group of patients de onstrates e3aggerated insulin release* /nheritance of the disease is ulti<factorial* %o plete concordance in ono-ygotic t)in for type 2 DM has pro#en the )ea. genetic &asis of the disease

MODULE 4

: DIABETES MELLITUS M%n%&e2ent : Life$t0(e 2 'ifi)%ti n


Manage ent of dia&etes ellitus, till date, is ai ed at supporting people to li#e )ith dia&etes )ith or no ris. of co plication's( and there is a ple e#idence that such an ai is achie#a&le &y achie#ing so e specific targets of &lood glucose, lipids, and &ody )eight etc* +o understand the role of diet and physical acti#ity in achie#ing the targets of dia&etes anage ent* After co pletion of this odule, you should &e a&le to ! 1* discuss the issue regarding ad,ust ent of oneHs daily life &y planning of eal, daily acti#ities including e3ercise )ith specific targets that )ill ena&le li#ing healthy in spite of dia&etes* 2* discuss the &asic principles of car&ohydrate counting in dia&etes 3* discuss the &enefit of physical acti#ity in dia&etes Acti#e learning )ith odule tas., group discussion, and e3pert lecture*

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A)ti*it0 4/1 4nderstanding reco endation of '%i(0 )%( #ie int%5e for a dia&etic* Ai2: +his acti#ity )ill help you to understand the ideal distri&ution of daily calorie inta.e fro car&ohydrate, protein and fat for a dia&etic* 2ill up the &lan.s! A reco endation of daily calorie inta.e for a dia&etic person is as follo)s! %ar&ohydrate MMMMMMMMMMMO of total calories 2at MMMMMMMMMMMM O of total calories= saturated fat should &e P7O of total calories $rotein MMMMMMMMMM O of total calories* A)ti*it0 4/2 +o understand the 1#in)i1%( $ 3#)e$ of protein, fats and car&ohydrate in our diet* Ai2: +his acti#ity )ill help you to understand the sources of proten, fat and car&ohydrate in our diet* 1i#e tic.
F

ar. in the appropriate colu n*


' "# tein "#e' 2in%nt(0 F%t C%#, .0'#%te

Cheat 7gg, il., eat 2ish Qice @oft drin.s, ,a $otatoes $oultry Aoney

A)ti*it0 4/4 4nderstanding principles of 'iet%#0 %'-3$t2ent in the daily life of a dia&etic* Ai2: +his acti#ity )ill pro#ide you the opportunity to recall so e principles of dietary ad,ust ents for a dia&etic* A/ 8a e 4 car&ohydrate sources, )hich sharply raise the &lood sugar in a dia&etic patient* a* MMMMMMMMMMMMMMMMMMM &* MMMMMMMMMMMMMMMMMMM c* MMMMMMMMMMMMMMMMMMM d* MMMMMMMMMMMMMMMMMMM

B/ @elect the appropriate priorities


St#%te&0 T01e 1DM T01e 2DM O,e$e %onsistency of day<to<day inta.e Meal spacing 2at Modication A @ucrose li itation M 73ercise A 73ercise snac. A " %aloric restriction 6lood glucose onitoring A 8*6 ! A L Aigh priority, M L Moderate priority, " L "o) priority T01e 2DM N n-O,e$e A M

A)ti*it0 4/6 : BMI %n' )%( #ie #e@3i#e2ent Ai2: +o acJuire s.ill of calculating 6M/ and reco ending calorie reJuire ent during case study* Mr* >, for er sports an has ,oined in a ultinational co pany as a &usiness e3ecuti#e for the last 2 years* Ae is no) 28 years, 165 c tall )eighing 78 .g* Ae does not get ti e for any e3erci3e* Ais eating ha&it is irregular due to office schedule* During annual edical chec.<up he )as diagnosed to &e dia&etic* Ae is fro a dia&etic fa ily* a( Chat is his 6M/F MMMMMMMMMMMMMMMMMMMMM &( /s he o#er )eightF MMMMMMMMMMMMMMMMMMMMM if G>esH )hat )ould &e caloric reco endation i( /so<caloric or ii( Aypo<caloric A)ti*it0 4/7 4nderstanding principles of ,%$i) )%#, .0'#%te ) 3ntin& in the daily life of a dia&etic* Ai2: +his acti#ity )ill pro#ide you the opportunity to recall so e principles of &asic car&ohydrate counting for a dia&etic* A* Chat is the definition of car&ohydrate counting F
Many people with diabetes use carbohydrate ("carb") counting to estimate the amount of carbohydrate in the foods they eat. One "carb" contains 15 grams of carbohydrate. Carbohydrates are mainly responsible for the rise in blood sugar that occurs after eating, so people with diabetes can use carbohydrate counting to match the amount of insulin they ta e with the amount of carbohydrate eaten in a meal or snac . !his techni"ue can help people achie#e better control of blood sugar le#els as they manage their diabetes.

6* Cho can use car&ohydrate counting F %ar&ohydrate counting can &e used &y anyone )ith dia&etes, not ,ust people ta.ing insulin* %* Chy should people )ith dia&etes use car&ohydrate counting F +his ethod is useful for people )ho are using ore intensi#e ethods of ad,usting insulin to control dia&etes* +he a ount of eal and snac. car&ohydrate is ad,usted &ased on the pre< eal &lood glucose reading* Depending on the reading, ore or less car&ohydrate ay &e eaten* "i.e)ise, insulin ay &e ad,usted &ased on )hat the person )ants to eat* 2or e3a ple, if you )ant to eat a uch larger eal than usual, car& counting can help you deter ine ho) uch e3tra insulin to ta.e*

A)ti*it0 4/8 : EDe#)i$e f # t01e 2 DM Mar. + 'rue( or 2'alse( for the follo)ing state ents on e3ercise for type 2 DM* a( / pro#es cardio#ascular ; cardio L respiratory function &( /ncreases &lood supply to uscles and their a&ility to use o3ygen c( "o)ers hearts rate and &lood pressure at any le#el of e3ercise d( /ncreases "D" cholesterol e( Decreases &lood triglycerides f( Qeduces &ody fat and i pro#es )eight control g( / pro#es glucose tolerance and reduces insulin resistance

MODULE 6

DIABETES MELLITUS E MANAGEMENT : D#3& t.e#%10

O*e#*ie+

Diet and e3ercise are the first line of treat ent for all people )ith +ype 2 dia&etes, including the young* Ao)e#er, due to the natural history of +ype 2 dia&etes, 55L75O are unli.ely to achie#e nor oglyce ia through these easures alone* +he icro#ascular co plications of dia&etes are associated )ith the duration of dia&etes and poor control* +herefore, it is no) )ell accepted that oral agents should &e co enced earlier )hen they are ost effecti#e, rather than later in the treat ent of people )ith +ype 2 dia&etes* +o understand of the different oral agents and insulin used to treat dia&etes and )hy particular agents are chosen in preference to others* After co pletion of this odule, you should &e a&le to ! 1* descri&e the echanis of action and a3i u dose of oral anti< dia&etes '0AD( agents in treat ent of +2DM* 2* identify appropriate ti e to co ence drug treat ent and type of drug to &e used in different clinical situations* 3* identify pri ary K secondary failures 4* e3plain different insulin regi ens and understand the principles of insulin dose ad,ust ent* 5* identify appropriate regi en of insulin to &e used in different clinical situations* Acti#e learning )ith odule tas., group discussion, and e3pert lecture*

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A)ti*it0 6/1 Qecalling the e ory on a3i u dose, duration of action and freJuency;day of co only used secretagogues in type 2 DM )hen appropriate lifestyle ad,ust ent fails to achie#e the glyce ic targets* Ai2 ! +his acti#ity )ill ser#e you to practice in using a3i u dose of secretagogue to achie#e treat ent targets and there&y ena&le you to pic. up 0AD failure cases in ti e* 2ill<up the gaps of the follo)ing ta&le !

D#3&$ 1li&encla ide 1licla-ide 1li epiride 1liJuidone Qepaglinide 8ateglinide

M%D/ ' $e ; '%0 g g g g g g

F#e@3en)0;'%0

D3#%ti n f %)ti n 9.#$:

A)ti*it0 6/2 4nderstanding achie#e ent of glyce ic targets in a dia&etic patient on oral antidia&etic agent's( &y studying la&oratory reports* Ai ! this acti#ity )ill ser#e you to practice in identifying cases )ith 0AD failure and to decide change in anage ent protocol in type 2 DM in ti e* T%#&et$ f &(0)e2i) ) nt# ( 9ADA! 2011: A1C < 7.0% Preprandial capillary plasma glucose 70130 mg/dl (3.97.2 mmol/l Pea! pos"prandial capillary plasma glucose # < 1$0 mg/dl (< 10.0 mmol/l
*Postprandial glucose measurements should be made 12 h after the beginning of the meal, generally peak

N 1* 2*

N%2e Mr* MA Mr* A

Life$t0(e %$ % 'i%,eti) @atisfactory @atisfactory

Me'i)%ti n 1li&encla ide '5 g( 1*5 L 5 L 5 1li&encla ide '5 g( 2L5L1 Metfor in '555 g( 5L1L1 Metfor in '855 g( 1L1L1 1li epiride '4 g( 2L5L5 Metfor in '555 g( 5L1L1

' &(3) $e F%$tin& < " $t1#%n'i%( 145 K 245 g;d" 185 K 335 g;d"

B(

F,A1) 9G: 8*5 9*5

3* 4*

Mr* I Mrs* "

@atisfactory @atisfactory

158 K 355 162 K 342

g;d" g;d"

6*8 8*9

+he a&o#e sheet contains reports of 5 different indi#iduals< read the carefully and perfor the follo)ing acti#ity* /n the left hand colu n, )rite )hether the person has de#eloped 0AA failure or not= in the right hand colu n, )rite the reasons for the 3 reports using the style sho)n for report of sl* 8o 1* Mr* MA has not de#eloped 0AA failure +he secretagogue he is ta.ing can &e further increased to see )hether he can achie#e the targets or not*

Mr* A Mr* I Mrs* " 8*6 ! >ou tutor )ill pro#ide feed&ac. on this acti#ity* A)ti*it0 6/4 +o understand ho) to ad,ust dose's( of insulin according to &lood glucose profile* Ai2 ! +his acti#ity )ill ser#e you to practice in ad,usting dose of insulin N / 1* N%2e! %&e Mr* A, 52 yo Life$t0(e %$ 'i%,eti) @atisfactory Me'i)%ti n ' &(3) $e 92&;'L: 261 185= A" 315 B(

Mi3 insulin '35!75( 24L5L16 iu 2* Mr* I, 48 yo @atisfactory @hort acting insulin 12<5<15 iu 261 198= A62 225 /nter ediate act* insulin A" 324= AD 198 25L5L14 iu 3* Mr* I, 57 yo @atisfactory "ong acting insulin 5L5L14 iu 261 99= A62 145= Qapid acting insulin 2L4L4 A" 324= AD 144 261 ! 2asting &loid glucose= A62 ! After &rea.fast= A" ! After lunch= AD ! After dinner +he a&o#e sheet contains reports of 3 different indi#iduals<read the carefully and perfor the follo)ing acti#ity* /n the left hand colu n, )rite )hether the person has achie#ed the target or not= in the right hand colu n )rite the change you )ant to a.e for the 3 reports 'fro case no 2<3( using the style sho)n for case no* 1* %ase 8o* 1 6oth the glucose #alues are a&o#e the targets* / li.e to increase the dose of the present preparation of insulin in orning and at night* 6ecause inter ediate acting insulin )ill &e a&le to &ring the glucose #alues to targets*

8o* 2

8o* 3

8*6 ! >our tutor )ill pro#ide feed&ac. on this acti#ity* A)ti*it0 6/6 : D#3&$ 3$e f # t01e 2 DM Mar. +'rue( or 2'alse( for the follo)ing state ents on drugs use for type 2 DM*

1* /nsulin secretagogues are preferred as first line treat ent in young, iddle<aged non< o&ese patients* 2* /nsulin action enhancers such as &iguanides li.e etfor in or the thia-olidinediones such as Qosiglita-one or $ioglita-one are preferred as initial therapy in patients )ith e#idence of insulin resistance* 3* %o &inations of insulin releasing and insulin action enhancing drugs ay &e used )hen single agent does not )or. alone* 4* 2or ost 0ADs to ha#e any significant effect, the presence of sufficient aounts of insulin or the a&ility of the R<cells to secrete endogenous insulin is ust* 5* 0ADs ay &e replaced &y or used in co &ination )ith insulin after carefully considering all aspects of the disease and features of therapy* 2ill up the
C%te& #0 In$3(in! ( n&-%)tin& In$3(in! #%1i'-%)tin& Metf #2in S3(f n0(3#e% G(ini' THD IG(3) $i'%$e In.i,it #$ D""-6 in.i,it # GL"-1 %& ni$t 5*5 L 1*5 $$1 1/ pro&le s, no outco e studies 5*5 L 1*5 2asting 8o 8o 8eutral %9 pro&le s, fracture

issing points of follo)ing ta&le**


A1C 9G: D# 1 1*5<2*5 F%$tin& vs ""G 2asting $$1 8o 8eutral Aypo glyce ia F01 G(0)e2i% >es Wei&.t C.%n&e 1ain I$$3e$ Aypoglyce ia Aypoglyce ia

$$1 ! post prandial glucose A)ti*it0 6/7 : In'i)%ti n f 'iffe#ent #e&i2en$ f in$3(in/ 2ill<up the gaps of the follo)ing ta&le ! In$3(in #e&i2en$ 0ne in,ection a day +)o in,ections a day Multiple in,ections a day A11# 1#i%te ; effe)ti*e in

Re%' t.e )%$e ,e( + %n' %n$+e# t.e @3e$ti n$ An 18<year<old college student )as referred to the endocrine clinic at her student health ser#ice &ecause a routine urinalysis re#ealed glycosuria and rando plas a glucose easured su&seJuently )as 255 g;d"* +he history disclosed that this )as the studentHs first ti e a)ay fro ho e and that she had had a nu &er of sy pto s she attri&uted to an3iety associated )ith the o#e to college* +hese sy pto s included )eight loss '5 .g(, polydipsia, nocturia, fatigue, and three episodes of #aginal yeast infections in the past 3 onths* 6efore co ing to college, she had e3perienced a series of upper respiratory tract infections* +he fa ily history )as negati#e for dia&etes and she )as not ta.ing edications* +he physical e3a ination )as )ithin nor al li its* Aer )eight )as 55 .g, )hich is in the 25th percentile for her height* +he la&oratory results )ere as follo)s! fasting plas a glucose 285 g;d" 'nor al P115(, urine glucose and .etones strongly positi#e* 0n the &asis of these another findings, a diagnosis of type 1 dia&etes )as ade* A3e$ti n$: a* Chat are the pri ary therapeutic strategies a#aila&le in this caseF Descri&e your reason*

&* Chat ethods of your reason*

onitoring and ad,usting therapy are a#aila&le to the patientF Descri&e

MODULE 7 : DIABETES MELLITUS E A)3te C 21(i)%ti n$


O*e#*ie+ Acute co plications are caused either &y hypoglyce ia or hyperglyce ia and are a co on cause of hospitali-ation* Aypoglyce ia can cause loss of consciousness and sei-ures* Ayperglyce ia can result in dia&etic .etoacidosis or hyperglyce ic hyperos olar non.etotic syndro e* @hort< ter co plications are often pre#enta&le= therefore, people )ith dia&etes need to .no) the causes, signs and sy pto s, treat ent and pre#ention strategies to ini i-e the ris. of de#eloping these co plications* +o identify DIA and A08I in persons .no)n to ha#e dia&etes or e#en at the ti e of detection of their dia&etes* >ou )ill &e a&le de#elop your s.ill of identifying and anaging hypoglyce ia in dia&etic patients* After co pletion of this odule, you should &e a&le to ! 1* identify a case of DIA along )ith its cause and;or precipitating factor's(= there&y to initiate its treat ent and hospitali-ation* 2* /dentify a case of A08I along )ith its cause and;or precipitating factor's(= there&y to initiate its treat ent and hospitali-ation* 3* Diagnose and treat cases of hypoglyce ia and teach the patient ho) to pre#ent hypoglyce ia* Acti#e learning )ith odule tas., group discussion, and e3pert lecture*

G %(

O,-e)ti*e$

Te%).in& $t#%te&ie$

A)ti*it0 7/1 +o understand )hy a person ay de#elop hyperglyce ic crisis li.e DIA or A08I* Ai ! +his acti#ity )ill gi#e opportunity to practice )ho to suspect for DIA or A08I and there&y arrange pro pt transfer to hospitals* +he left hand colu n contains so e clinical states of indi#iduals= in the right hand colu n, )rite )hether he or she ay de#elop DIA or A08I* Mr* I, a 17 yo &oy )as suffering fro type 1 DM* Ae )as on split< i3ed regi en insulin, )as playing cric.et )ith his class ates* 6ut )as found dehydrated and &reathing rapidly at 1135 a * Mr* ", a 71 yo an )as &rought to you &y his grandson for dro)siness* +he grandson clai ed that his grandpa )as not suffering fro DM* Mrs* ", 35 yo lafy, 2nd gra#ida )as &rought to you for fe#er, respiratory distress and i paired le#el of consciousness* @he )as fro a dia&etic fa ily and prior to this conception her 01++ )as nor al*

Mrs* @, a 51 yo poor )ido) )as on pre i3ed insulin 24 L 5 L 18 iu, ca e to you )ith an a&scess in the thigh* @he is running fe#er for last 3 days and she is not ta.ing insulin &ecause she is una&le to eat anything for 3 days* 8*6 ! >our tutor )ill pro#ide feed&ac. on this acti#ity* A)ti*it0 7/2 : Di%&n $ti) )#ite#i% f DJA %n' FONJ Ai ! +o recall the e ory on diagnostic criteria of DIA and A08I Fi(( 31 t.e ,(%n5$ Di%&n $ti) )#ite#i% 6lood glucose ' g;dl( @eru os olality ' 0s ( Arterial &lood pA 6icar&onate ' 7J;"( 4rine;plas a .eton DJA FONJ

A)ti*it0 7/4 : C%3$%tin f DJA %n'; # FONJ Ai ! +o understand )hy a person ay de#elop hyperglyce ic crisis li.e DIA and;or A08I* M%#5 T9#3e: # F9%($e: f # t.e f (( +in& $t%te2ent$ n )%3$%ti n f DJA %n'; # FONJ 1* 4ndiagnosed dia&etes 2* 0 ission of insulin dose 3* /n,udicious reduction of insulin dose 4* /nter<current illness, especially acute infection* A)ti*it0 7/6 : F01 &(0)e2i% in 'i%,eti) 1%tient$ Ai ! +o understand )hy a person ay de#elop hypoglyce ia* 1* 73plain ho) hypoglyce ic state can &e pathologic to hu an &odyS

2* Mar. T9#3e: or F9%($e: for the follo)ing state ents on causation of hypoglyce ia in dia&etic patients* a( Doing ore e3ercise than usual &( Delay or o ission of a snac. or eal c( Ad inistration of too uch insulin d( 73cess inta.e of insulin secretagagoues e( 0#er indulgence in alcohol f( @e#ere i pair ent of renal function* 3* Mar. A9'#ene#&i): or N9e3# &(0) 1eni): for the follo)ing state ents on hypoglyce ia in dia&etic patients* %onfusion 8er#ousness, irrita&ility, hunger %on#ulsion $alpitation, tachycardia

+re or 9isual distur&ances "oss of e ory 6eha#ioural a&nor ality A)ti*it0 7/7 : "#e$ent%ti n %n' #i$5 f%)t #$ f FONJ in t01e 2 DM Ai ! +o understand presentation and ris. factors of A08I in type 2 DM &y case study* Mr* ?, a 61 yo retired officer is a .no)n case of type 2 DM for last 15 years* Ae is on secretagogue and etfor in* Ais last follo)<up in outpatient clinic 3 onths ago docu ented satisfactory glyce ic status '261 113 g;dl, A" 145 g;dl, A&A1% 6*8O(* 2ifteen days ago he lost his )ife in a tragic car accident* +heir only issue is studying in 4@A )ho could not anage to co e ho e* 73cept a teen<aged ain ser#ant there is none to loo. after Mr* ? at ho e* /n the eanti e, he &eca e irregular in diet and drugs, and progressi#ely &eca e )ea.* 0ne orning he )as found unconscious and fe&rile in his &edroo )here he is li#ing alone* 0n e3a ination his pulse )as 112; in, 6$ 145;85 Ag, dehydrated, not icteric, no s ell in outh 'alcohol or poison( and instant &lood glucose )as 478 g;dl* Acetone )as not detected in urine* 8o focal neurological deficit could &e detected* 1* Chat is the possi&le cause of his unconsciousness F

2*

Do you need to hospitali-e Mr* ?F ChyF

3* Ma.e a list of factors that you thin.

ight ha#e contri&uted to this acute co plication*

MODULE 8

: DIABETES MELLITUS E Mi)# -*%$)3(%# C 21(i)%ti n$


Dia&etes ellitus is a chronic, de&ilitating disease, )hich is associated )ith a range of se#ere co plications including renal disease, cardio#ascular and &lindness* 7arly detection and eticulous anage ent to pre#ent co plications is the a,or challenge of dia&etic case* +o understand the retinopathy, nephropathy, and neuropathy in dia&etes ellitus* After co pletion of this odule, you should &e a&le to ! 1* enu erate the icro#ascular co plications of dia&etes ellitus and discuss their pathogenesis* 2* discuss on #arious types of dia&etic retinopathies* 3* perfor clinical e3a inations to detect and anage nephropathy* 4* perfor clinical e3a inations to detect and anage peripheral and autono ic neuropathy due to dia&etes* Acti#e learning )ith odule tas., group discussion, and e3pert lecture*

O*e#*ie+

G %(

O,-e)ti*e$

Te%).in& $t#%te&ie$

A)ti*it0 8/1 +o .no) the factors responsi&le for de#eloping chronic co plications of dia&etes ellitus* Ai2 ! +his acti#ity )ill help you to e ori-e the factors responsi&le for de#eloping co plications in a dia&etic person* Mar. T9#3e: and F9%($e: for the follo)ing state ents regarding co plications in a dia&etic* 1* %hance of co plications increases )ith the duration of dia&etes* 2* Dia&etic control has no i pact on reducing rate of co plications in type 2 DM* 3* 1enetic suscepti&ility to certain co plications ay &e present* 4* Aypertension is a co on ris. factor for de#eloping retinopathy, nephropathy, coronary and cere&ro#ascular diseases* 5* @ o.ing, hypertension, hyperlipide ia, o&esity and lac. of e3ercise are ris. factors for coronary heart disease and cere&ro<#ascular diasease* A)ti*it0 8/2 Ai2 ! +o understand pathology in#ol#ed in de#eloping chronic co plications in dia&etes ellitus* Ans)er the Juestion &elo) ! A* 73plain ho) chronic hyperglyce ic can cause icro#ascular co plication F

6* Mar. T9#3e: or F9%($e: for the follo)ing state ents on icro#ascular co plications in dia&etes ellitus* 1* A&A1% is strongly related to chronic co plications of dia&etes* 2* Duration of dia&etes is a deter inant of chronic co plications* 3* +ype 2 DM patients often ha#e a long undiagnosed period after the onset of the disease* @o a significant nu &er of a cases present )ith chronic co plications, li.e retinopathy, neuropathy or foot ulcer at the ti e of detection of dia&etes* 4* @o e degree of retinopathy is e#ident after 15 to 25 years in nearly all type 1 dia&etics and in ore than 65O of type 2 dia&etes* A)ti*it0 8/4 Ai2 ! +o understand the hall ar.s of icro<angiopathy in retina* ar. of icroangiopathy in eye

Mar. T9#3e: or F9%($e: if the follo)ing are regarded as a hall of a dia&etic* 1* 8e) #essel for ation 2* Microaneurys 3* Aae orrhage 4* 73udate

A)ti*it0 8/6 Ai2 ! +o understand dia&etic nephropathy and its anage ent* 2ill up the gaps* 1* Dia&etic nephropathy is defined &y MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM 2* Dietary protein restriction is done in dia&etic nephropathy, &ecause diet lo) in protein reduces MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

A)ti*it0 8/8 Ai2 ! +o understand dia&etic neuropathy 1* Chat is the definition of Dia&etic 8europathy F

2* 1i#e so e e3a ples of dia&etic neuropathy*

MODULE ?

: DIABETES MELLITUS E M%)# -*%$)3(%# C 21(i)%ti n$


Dia&etes ellitus is a diasease associated )ith se#eral acro<#ascular co plications including coronary artery disease, cere&ro#ascular disease and peripheral #ascular disease etc* Aypertension and dyslipide ia are the t)o pro inent odifia&le factors in the de#elop ent of these for s of co plication in a dia&etic person* +o understand )hy and ho) to screen for hypertension and dyslipide ia in dia&etic person for pre#ention of acro<#ascular co plications* /t )ill also help you to learn ho) to screen for Ghigh ris. footH and pro#ide appropriate care of foot in dia&etics* After co pletion of this odule, you should &e a&le to ! 1* .no) the factors responsi&le for de#eloping chronic co plications* 2* understand pathology in#ol#ed in de#eloping chronic co plications* Acti#e learning )ith odule tas., group discussion, and e3pert lecture*

O*e#*ie+

G %(

O,-e)ti*e$

Te%).in& $t#%te&ie$

A)ti*it0 ?/1 Ai2 ! +o recall a list of

acro#ascular co plications in dia&etes ost co ost co

ellitus*

2ill up the gaps )ith appropriate )ord's(* 1* MMMMMMMMMMMMMMMMMMMMMMMdisease is the type 2 dia&etes* 2* MMMMMMMMMMMMMMMMMMMMMM is the second

on cause of death in persons )ith on #ascular pro&le in dia&etes*

3* $eripheral #ascular disease '$9D( affecting the MMMMMMMMMMMMMMM arteries supplying &lood to the li &s particularly the lo)er li &s is also co on in dia&etes and adds considera&ly to the or&idity related to foot pro&le s leading to MMMMMMMMMMMMMMM a putations* A)ti*it0 ?/2 Ai2 ! +o understand the pathological changes in ellitus* Mar. T9#3e: or F9%($e: for the follo)ing state ents*

acro#asculature syste

in dia&etes

1* Atherosclerosis is se#eral folds ore freJuent in persons )ith dia&etes* 2* /n dia&etic people athero atous lesions are usually less se#ere and locali-ed* 3* Aigh &lood glucose le#el a ages the endothelial cells lining the &lood #essels a.ing the thic., harder, and less elastic* +his a.es it difficult for the &lood to flo) through* 4* $eople )ith dia&etes ha#e higher le#els of fat in the &lood* +he fats or lipids in the &lood #essels ay clot and restrict the flo) of &lod* 5* Aigh &lood glucose affects the Q6%s and a.es the less plia&le, and increase the factors that fa#our &lood clotting* A)ti*it0 ?/4 Ai2 ! +o understand the changes in ellitus* icro#asculature syste in hypertension K dia&etes

Mar. T9#3e: or F9%($e( for the follo)ing state ents* 1* /n larger arteries the internal elastic la ina is thic.ened, s ooth uscle is hypertrophied and fi&rous tissue is deposited &ut in s aller arteries hyaline arteriosclerosis occurs in the )all, the lu en narro)s and aneurys ay de#elop* 2* Cidespread athero a ay de#elop leading to coronary or cere&ro#ascular disease particularly if other ris. factors li.e s o.ing, hyperlipide ia are present* 3* @tro.e is a co on co plication of hypertension and ay &e due to cere&ral hae orrhage or infarction* 4* Aypertension enhances the already e3isting retinal da age due to dia&etes* /t accelerates the progression as )ell as increases the se#erity of e3isting dia&etic retinopathy* 5* Aypertension ay cause proteinuria and progressi#e renal failure &y da aging renal #asculature* 6* Dia&etics are already at ris. of .idney disease and added hypertension increases the ris. of .idney disease se#eral folds* 7* +reat ent is ai ed to achie#e 6$ P 135;95 Ag and if proteinuria or chronic .idney disease is present then, 6$ should &e P 135;85 Ag* 8* 2or ild hypertension, first line anage ent is al)ays non<phar acological one* 9* Antihypertensi#e regi ens should include A%7 inhi&itors or Ang//Q &loc.ers in order to pro#ide a3i u cardio< and renoprotection in these patients* 15* $hysicians ust a.e e#ery effort to decrease the &lood pressure to as close as possi&le to the target &t the least intrusi#e eans possi&le* +his )ill ini i-e drug< related side effects, i pro#e patient adherence, and reduce cardio#ascular and renal e#ents* A)ti*it0 ?/6 Ai2 ! +o e ori-e features of dyslipide ia in dia&etes Mar. T9#3e: or F9%($e( for the follo)ing state ents* Iey features of dyslipide ia of dia&etes ellitus include ! 1* Aypertriglyceride ia 2* A rise in lo) density lipoprotein cholesterol '"D"( 3* A reduction in high density lipoprotein cholesterol 'AD"(* A)ti*it0 ?/7 Ai2 ! +o understand high ris. foot* ellitus*

Mar. T9#3e: or F9%($e: for the follo)ing state ents* A foot is le#eled as DAigh Qis.E is one or 1* "oss of protecti#e sensation 2* A&sent pedal pulses 3* @e#ere foot defor ity 4* Aistory of foot ulcer 5* $re#ious a putation ore of the follo)ing factors is;are present !

A)ti*it0 ?/8 Ai2 ! +o understand )hy dia&etics are prone to high ris. foot* 2ill<up the gaps )ith appropriate )ord's(* +here are se#eral reasons )hy foot of a dia&etic person is #ulnera&le to lesions, these include! 1* "oss of sensation !MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM 2* $oor circulation !MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM 3* Aigher li.ehood of de#eloping MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM A)ti*it0 ?/? Ai2 ! +o test your e ory on grading of foot lesion*

CagnerHs classification of dia&etic foot lesions G#%'e 1rade 5 1rade 1 1rade 2 1rade 3 1rade 4 1rade 5 De$)#i1ti n f (e$i n$ 8o ulcer K high ris. foot Deep ulcer &ut no &ony in#ol#e ent A&scess )ith &ony in#ol#e ent

MODULE K
O*e#*ie+

: DIABETES MELLITUS E "#e*enti n


Dia&etes ellitus, a chronic de&ilitating disease )hich is associated )ith a range of se#ere co plications* $re#ention of the diasease and or it co plications is a challenge for dia&etic health care deli#ery pro#iders* +o understand )hat are the different types of pre#ention strategies of dia&etes* /t )ill also help you to learn ealy detection and achie#e ent of targets of treat ent are i portant in secondary and tertiary pre#entions of dia&etes respecti#ely* After co pletion of this odule, you should &e a&le to ! 1* enu erate the types of pre#ention applica&le for dia&etes ellitus* 2* discuss on pri ary, secondary, and tertiary pre#entions of dia&etes ellitus* 3* identify indi#iduals )ith Ghigh ris.H of de#eloping dia&etes and help the to do appropriate lifestyle ad,ust ent topre#ent or delay de#elop ent of dia&etes Acti#e learning )ith odule tas., group discussion, and e3pert lecture*

G %(

O,-e)ti*e$

Te%).in& $t#%te&ie$

A)ti*it0 K/1: "#e*enti n f 'i%,ete$ 2e((it3$ Ai2 ! +o recall three different types of pre#ention of dia&etes

ellitus*

2ill<up the gaps )ith appropriate )ord's(* a( MMMMMMMMMMMMMMMMMMpre#ention refers to a#oiding the onset of the dia&etes* &( MMMMMMMMMMMMMMMMMMpre#ention initiation of treat ent* c( MMMMMMMMMMMMMMMMMMpre#ention co plications* eans early detection of dia&etes and prop pt ai s to delay and;or pre#ent progression of

Mar. T9#3e: or F9%($e: for the follo)ing state ents on ris. factor for de#eloping dia&etes ellitus* 1* 2* 3* 4* 5* Age T 45 years* $ositi#e fa ily history of DM Aa&itual physical acti#ity 6M/ a&o#e nor al Caist Aip Qatio a&o#e nor al

6* $re#iously identified as /21;/1+;1DM

A)ti*it0 K/2 : "#i2%#0 1#e*enti n f 'i%,ete$ 2e((it3$ Ai2 ! +o understand the pri ary pre#ention of dia&etes ellitus* Mar. T9#3e( or F9%($e: for the follo)ing state ents* 1* $opulation approach of pri ary pre#ention includes ! a( %reation of ass a)areness &( Qeinforce ent of GlifestyleH changes &y ensuring regular physical acti#ity and practice of edical nutrition therapy to odify the ris. factors* 2* Aigh ris. group strategies of pri ary pre#ention is in fact clinical approach )here physicians perfor follo)ing acti#ities ! a( Detect the presence of esta&lished ris. factors in an indi#idual &( %are of ris. factors for dia&etes through pu&lic health and clinical approaches* 3* @trategies for high<ris. group for pri ary pre#ention include ! a( /ndi#iduals at ris. of de#eloping dia&etes need to &eco e a)are of the &enefit of odest )eight loss and participating in regular physical acti#ity* &( >ounger indi#iduals )ith a 6M/ U 25 plus additional ris. factors need to underho screening to detect /21 or /1+* A)ti*it0 K/4 : Se) n'%#0 1#e*enti n f 'i%,ete$ 2e((it3$ Ai2 ! +o understand the secondary pre#ention of dia&etes ellitus* Mar. T9#3e: or F9%($e: for the follo)ing state ents* 1* 7arly detection of dia&etes to initiate its treat ent there&y to halt or delay the co plications is the ai of secondary pre#ention* 2* Achie#e ent of glyce ic targets is not an ele ent of secondary pre#ention* 3* Dia&etes a)areness in the co unity and a ong 1$s to enhance the chances of routine screening of population at ris. is i portant* +hose a&o#e 45 years, positi#e fa ily history of dia&etes, o#er)eight '6M/ U 25(, high C$Q, and other associated ris. factors ust &e routinely screened* 4* @tudies docu ented that appro3i ately 55O of type 2 DM patient already ha#e co plications at detection of their dia&etes* A)ti*it0 K/6 Ai2 ! +o recall the targets of &ood glucose, A&A1%, lipids, &lood pressure and 6M/ for prevention for dia&etes ellitus* 2ill<up the gaps )ith appropriate )ord's(* A* 6lood glucose 2asting;preprandial PMMMMMMMMMM g;d" $ost<prandial PMMMMMMMMMMM g;d" 6* 6lood lipids "D" cholesterol P MMMMMMMMMM g;d" AD" cholesterol T MMMMMMMMMM g;d" +1 P MMMMMMMMMM g;d" %* A&A1% P MMMMMMMO

D* 6M/ V MMMMMMMMM .g; 2 7* 6lood pressure ! @ystolic P MMMMMMMMM

Ag= diastolic P MMMMMMMMM

Ag

A)ti*it0 K/7 : Te#ti%#0 1#e*enti n f 'i%,ete$ 2e((it3$ Ai2 ! +o understand the tertiary pre#ention of dia&etes ellitus* Mar. T9#3e: or F9%($e: for the follo)ing state ents* 1* /n tertiary pre#ention atte pts are directed to contain da age &y aggressi#e therapy to arrest or delay progression of co plications* 2* 7cono ic analysis fro the different pre#ention progra es is not cost effecti#e* 3* %o prehensi#e care of dia&etes )ith patientHs education and a)areness a&out co plications can &ring a&out a re ar.a&le reduction in &lindness, end stage renal disease '7@QD( and a putation*

MODULE L

: DIABETES MELLITUS E C.i('#en %n' "#e&n%n)0


Dia&etes ellitus in childhood and adolescence is ost often type 1 DM &ut type 2 or secondary dia&etes ay also occur* Dia&etes care in children reJuires intensi#e indi#iduali-ed education of the children and the fa ily e &ers* $regnancy in )o en )ith dia&etes is a high ris. one* %are ust &e gi#en )ith an ai to a.e pregnancy as safe as in non<dia&etic state for &oth the e3pectant other and the &a&y* +o understand the pregnancy* anage ent principles of dia&etes in children and during

O*e#*ie+

G %(

O,-e)ti*e$

After co pletion of this odule, you should &e a&le to ! 1* enu erate the &asic principles of anage ent of dia&etes ellitus in children* 2* enu erate the &asic principles of anage ent of dia&etes ellitus during pregnancy* Acti#e learning )ith odule tas., group discussion, and e3pert lecture*

Te%).in& $t#%te&ie$ A)ti*it0 10/1 Ai2 ! +o recall the

e ory on the targets of

anage ent of dia&etes in %hildren*

2ill<up the gaps )ith appropriate )ord's(*


V%(3e$ ,0 %&e 90e%#$:
T '(e#$ %n' 1#e$). (e#$ 90-8:

Bef #e 2e%($
155 < 185

"(%$2% ,( ' &(3) $e & %( #%n&e 92&;'L: Be'ti2e; *e# ni&.t A1C R%ti n%(e
<9ulnera&ility to hypoglyce ia </nsulin sensiti#ity <4npredicta&ility in dietary inta.e and physical acti#ity <A lo)er goal ',8*5O( is reasona&le if it can &e achie#ed )ithout e3cessi#e hypoglyce ia 155 < 185

S). ( %&e 98-12: A' (e$)ent$ %n' 0 3n& %'3(t$ 914-1L:

P 7*5 O

'%are of %hildren and Adolescents Cith +ype 1 Dia&etes, Dia&etes %are, 9olu e 28, 8u &er 1, Wanuary 2555(

A)ti*it0 10/2 Ai2 : +o understand the &asic principles of

anage ent of dia&etes in children*

Mar. T9#3e: or F9%($e( for the follo)ing state ents* A* +o pro#ide dia&etic education to children and their parents* 6* +o train the a&out ho e onitoring of &lood glucose and insulin in,ection techniJues* %* +o onitor physical gro)th and de#elop ent* A)ti*it0 10/4 Ai2 : +o recall the e ory on t ris. factor for de#eloping 1DM

Mar. T9#3e: or F9%($e: for the follo)ing state ents on ris. factor for de#eloping 1DM* 1* 2* 3* 4* 5* 6* 7* Age T 24 years* $ositi#e fa ily history of DM* Aa&itual physical inacti#ity* 6M/ a&o#e nor al* Caist Aip Qatio a&o#e nor al* $re#iosly identified as /21;/1+;DM Aistory of a&ortion, still &irth, infertility* e ory on the pro&le s and the targets of anage ent of dia&etes in

A)ti*it0 10/6 Ai2 : +o recall the pregnancy*

2ill<up the gaps )ith appropriate )ord's(* Targets of glycemic control in pregnancy 2asting P MMMMMMMMMMMM g;d" $ost prandial P MMMMMMMMMMM g;d" A&A1% P MMMMMMMMMO Mar. T9#3e: or F9%($e: for the follo)ing state ents* Pregnancy in diabetic women have the following problems : 1* 2* 3* 4* 5* 6* 7* $regnancy loss ! a&ortion;intrauterine death %ongenital alfor ations of &a&y Difficulties of dia&etes control $ro&le s in neonates li.e hypoglyce ia, repiratory distress, hypocalce ia, etc Dia&etes ellitus of the neonate Maternal pro&le s li.e pre<ecla psia, ecla psia, etc* /nsulin is the phar acologic therapy that has ost consistently &een sho)n to reduce fetal or&idities )hen added to M8+ 'Medical 8utrition +herapy(*

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