Each year World Diabetes Day is commemorated globally to raise awareness. The theme for 2021-2023 is “Access to Diabetes Care”. In this regard, we spoke to Primary Care Diabetic Group Sri Lanka President and Consultant Family Physician Dr. A.L.P. de S. Seneviratne on how to effectively manage Diabetes Mellitus.
Primary Care Diabetes Group Sri Lanka (PCDGSL) is an organisation consisting of general practitioners with a special interest in diabetic care. They play an active role in mitigating the rapid increase in the number of patients with diabetes by facilitating continuing and comprehensive care to the patients and their families. Diabetes is a chronic illness, needing an excellent doctor-patient relationship with ongoing care and support to manage their condition and to avoid complications. Therefore, the family physician plays a pivotal role in service provision to the community, and is best suited to identify when a referral to an endocrinologist is needed.
World Diabetes Day was launched in 1991 by the International Diabetes Federation (IDF) and the World Health Organisation (WHO). The day marks the birthday of Frederick Banting, who, along with Charles Best and John Rickard Macleod, first conceived the idea leading to the discovery of insulin, saving millions of lives. Yet millions of people across the world don’t have adequate access to diabetes care, and it has now risen to endemic proportions in our island nation. The latest figures from Sri Lanka have shown that 10.7% of the population of 25-79 years are suffering from diabetes, with an estimated global prevalence of 9.3% (463 million people) in 2019, and this will rise to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045. Although the numbers are predicted to increase in every country, the greatest increase is seen in developing nations.
Diabetes is changing, and is now affecting the younger population, whereas earlier it was predominantly seen in the middle aged and the elderly. “There is accumulating and disturbing evidence that the age of onset has now fallen to the 20 to 30 year age group in our country. Worse still, children are now caught up in the diabetic epidemic too,” cautioned Dr. Seneviratne.
What are the key steps in managing patients with diabetes?
Prevention is always better than cure. According to epidemiological data, there is a higher incidence of type 2 diabetes in low birth weight children. Therefore, maternal nutrition plays a major role. Studies suggest a relationship between stress and insulin resistance. Maternal stress is a known etiological factor that may predispose the newborn to develop this condition in the future. Maternal infections during the antenatal period also contribute strongly. Thus, the family doctor should take all steps to avoid low birth weight (LBW) babies, improve maternal nutrition, and avoid maternal stress and infections during the antenatal period, stated Dr. Seneviratne.
Screening for diabetes
If you are 40 years or older your family physician will suggest you get screened with a Fasting Blood Sugar (FBS) test. If there is a degree of suspicion,they will request a two-hour postprandial blood sugar test (PPBS). If the patient can afford a Hemoglobin A1C (HbA1C) test, it is very useful for early diagnosis. If these tests are normal, it could be repeated in three years. In those with Cardio-metabolic risk (CMR), screening should be done < 35 years of age, and if normal, repeated annually.
Who are those with CMR?
- Patients at risk of developing type 2 diabetes and/or cardiovascular disease (MI/stroke)
- Patients with a cluster of modifiable risk factors such as the classical risk factors for diabetes, high blood pressure, ischemic heart disease, dyslipidemia, obesity, or smoking
- Other-endothelial dysfunction, vascular inflammation, coagulatory disorders e.g. High CRP
Once a clear diagnosis of diabetes is made this will be conveyed to the patient.
Caption: Risk factors associated with Diabetes Mellitus
Diagnostic criteria of Diabetes Mellitus-venous plasma glucose
Caption: The American Diabetes Association diagnostic criteria for pre-diabetes and diabetes
If someone is diagnosed with diabetes, what information should they seek from their family doctor?
Patients with diabetes should know:
- The nature of the disorder
- Symptoms of diabetes
- Risk of complications and especially the importance of foot care
- Individual targets of treatment
- Lifestyle requirement and meal planning
- Regular exercises
- Oral hypoglycemics and side effects
- Features of hypoglycaemia and treatment
- Self-monitoring of blood glucose
- Special attention in pregnancy
Managing high blood sugar
- Lifestyle modification
The patient should be advised on the dietary requirements such as – “AVOID”
- Sugars and foods containing sugar
- Sugar, jaggery, and honey
- Sweet snacks
- Sweets, chocolates, and sweet biscuits
- Buns and cakes
- Sugar in tea and coffee
- Cordials and cool beverages
- All those with highly refined carbohydrates, fats, and high-calorie content
- Ideal foods
Caption: Diabetic plate
In the diabetes plate method, the plate is divided into the three main food groups; non-starchy vegetables, carbohydrate foods, and protein foods, and provides colorful representations of commonly consumed foods from each of those groups. Some of the locally available food items that can be included in your diabetic plate are:
- Rice – parboiled red rice/nivudu rice/basmati
- High fibre vegetables
E.g. kohila, cucumber, watakolu, snake gourd (avoid oil and coconut during preparation)
- Pulses – green gram, cowpea, chickpeas, dhal, bean seeds, ulundi, winged bean (dambala)
- You can also include a variety of seasonal fruits
- Physical activity
Physical activity is important to control blood sugar due to various reasons. Your exercise plan should consist of;
- Brisk walking/jogging
- Minimum of five days a week
- At least 30 minutes at a session
- Ideally, the pulse rate should reach 100/min
- Avoid chatting during your walk
- Walk at a uniform speed
- Usually should cover 1 km distance in 10 mins
Other types of beneficial exercises include cycling, gardening, swimming, farming, digging drains and pits, and climbing stairs and mountains.
- Drug therapy
Oral hypoglycemic drugs
These could be selected according to the type of diabetes, individual age, cost of treatment, Body Mass Index (BMI) of the patient, meal pattern, postprandial hyperglycemia, and evidence of other complications. Depending on this, your doctor will choose the most appropriate treatment option.
Insulins
Indications for insulin therapy:
- Type 1 diabetes
- Most women with diabetes who become pregnant or are breastfeeding
- Transiently in type 2 diabetes in special situations
- In type 2 diabetes, inadequately controlled on glucose-lowering medicines (secondary failure)
Barriers of insulin therapy
- Patients perception that is the last resort
- Fear of injection and pain
- Fear of symptoms of hypoglycaemia
- Difficulties in storage
There are several regimes of insulin therapy to suit the patient’s needs.
The GP should start encouraging self-monitoring blood glucose (SMBG) among their patients. This will give better patient care, responsibility, patient satisfaction, and even be cost-effective, stated Dr. Seneviratne.
Diabetes is a metabolic disease affecting most of the body organs leading to complications.
There is increasing evidence that diabetes is a major risk factor for severe Covid-19 illness. It is a disease that affects multiple organ systems.
Blood pressure control and addressing dyslipidemia
A blood pressure of 140/90 or lower should be always maintained with an appropriate treatment regimen. The lipid levels should also be maintained lower than a normal person. The target levels will be as follows. If using Statins, liver enzymes should also be checked.
- Total Cholesterol < 160 mg to get the maximum benefit
- LDL < 100 mg
- Triglycerides < 150 mg
- HDL > 45-50 mg
Renal assessment
Renal assessment should include urinary microalbumin, urine full report, serum creatinine with eGFR and urine full report.
Foot care
This is a very important and neglected area. The family doctor should follow a checklist, advise accordingly, identify the risk patient for foot amputation and reinforce foot care advice in every visit. Dr. Seneviratne advises all general practitioners to have a 10 g monofilament in their clinic. This will give the earliest evidence of loss of protective sensation.
Diabetic foot examination should be comprehensive and should include
- Sensory Functions
- Touch (cotton wool)
- Pain (prick)
- Vibration (128 Mhz tunings folk) foot pulses
- 10 g monofilament
- Vascular Status
- Skin temperature
- Pallor on elevation
- Deformities
- Prominent metatarsal heads
- Claw toes
- Callosities
- Charcot joints
- Infections
- Ulcers
- Tinea
- Paronychia
- Cellulitis
- Obesity
- Impaired sight
Patients at risk for foot amputation are those with:
- Peripheral Vasculopathy
- Sensory neuropathy
- Infection of the feet
- Foot deformities
- History of foot ulcers
- Obesity
- Impaired sight
Eye referral
Patients with diabetes should be referred to an eye surgeon for ophthalmic assessment.
To facilitate good diabetic care, the GPs could run a diabetic clinic with a well-maintained diabetic follow-up medical record. “This is one of our objectives, in our members of PCDGSL,” stated Dr. Seneviratne.
What are the indications for referral to a specialist?
- Poor glycaemic control despite treatment
- Type 1 Diabetes Mellitus
- Diabetes in pregnancy
- Evidence of chronic kidney disease
- Complication of diabetes e.g. ketoacidosis
- Diabetic cellulitis
- Peripheral vascular disease needing vascular surgery
- A non-healing diabetic foot ulcer
Finally, Dr. Seneviratne stated that, in keeping with the theme for this year, everybody should have equitable access to diabetic care, and that the family physician is a key player in preventing this chronic non-communicable disease which is becoming an epidemic.
Primary Care Diabetic Group Sri Lanka President and Consultant Family Physician Dr. A.L.P. de S. Seneviratne (MB.BS,DFM,FCGP,MD,MRCGP[INT.])
