Prevention and Management of Diabetes Mellitus and its Complications Science-based medicine and the management of diabetes mellitus Jak Jervell Department of Medicine Rikshospitalet Oslo, Norway Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Based on Science - What does it mean? The therapy, method or technology must have been properly tested and evaluated. To many procedures are used which have not been properly evaluated. WHO: Appropriate technology Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Science-based medicine for diabetes Insulin in IDDM Education (+ insulin) in IDDM to prevent coma, hypoglycaemia and death. Glycemic control in IDDM (DCCT) Education and home monitoring to improve glycemic control. Urine testing is as effective as blood testing for achieving glycemic control, provided education is good. Near-normalisation of blood glucose before and during pregnancy in women with type 1 and 2 diabetes. Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

IDDM Pregnancies in Norway Perinatal mortality 1967-90 Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Science-based medicine for diabetes Stop smoking! Education on foot care prevents amputation Monofilament picks “feet at risk” Laser treatment in retinopathy prevents blindness. Antihypertensive therapy in diabetic nephropathy delays progression. ACE-inhibitors in diabetic nephropathy delays progression even more. Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Prevention and Management of Diabetes Mellitus and its Complications The 10 gram monofilament in use Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Prevention and Management of Diabetes Mellitus and its Complications The 10 gram monofilament in use Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Prevention and Management of Diabetes Mellitus and its Complications Where to test with the monofilament. If the filament is felt in all 5 places on both feet, the risk of a neuropathic ulcer during the next 12 months is negligible Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Science-based medicine for diabetes Statins in diabetics with coronary heart disease. -blockers in NIDDM with previous myocardial infarction (and probably coronary heart disease in general). Glycemic control and blood pressure control are both of great importance to prevent complications and death in type 2 diabetes Methformin is probably advantageous in overweight and obese type 2 diabetes Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Glucose Control Study Summary UKPDS 1998 The intensive glucose control policy maintained a lower HbA1c by mean 0.9 % over a median follow up of 10 years from diagnosis of type 2 diabetes with reduction in risk of: 12% for any diabetes related endpoint p=0.029 25% for microvascular endpoints p=0.0099 16% for myocardial infarction p=0.052 24% for cataract extraction p=0.046 21% for retinopathy at twelve years p=0.015 33% for albuminuria at twelve years p=0.000054 Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Blood Pressure : Tight vs Less Tight Control (UKPDS 1998) Less tight control Tight control Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Therapy requirement (UKPDS 1998) Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Blood Pressure Control Study In 1148 Type 2 diabetic patients a tight blood pressure control policy which achieved blood pressure of 144 / 82 gave reduced risk for Any diabetes-related endpoint 24% p=0.0046 Diabetes-related deaths 32% p=0.019 Stroke 44% p=0.013 Microvascular disease 37% p=0.009 Heart failure 56% p=0.0043 Retinopathy progression 34% p=0.0038 Deterioration of vision 47% p=0.0036 Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Probably useful, but not fully proven Weight control and physical exercise in NIDDM. The annual review Eyes Microalbumin Lipids BP Feet Smoking Erectile dysfunction Review of past year and plan for next Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Is education scientifically validated? Yes! Of people with type 1 and type 2 diabetes About foot care, for people with feet at risk On healthy eating The approach should be to teach ”know-how” not theoretical knowledge. The purpose is to change behaviour, not to improve knowledge. Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

From compliance to empowerment. “Diabetes education has become not an element of the treatment, but the treatment itself” EP Joslin “Education is a constant process for the liberation of human beings” Paulo Freire

To Learn or to Educate The pedagogic paradox The persons with diabetes has the responsibility for learning (to educate themselves) how to live long and well with diabetes. The health care professional has the responsibility to educate the person with diabetes on how to live long and well with diabetes. This reciprocal relationship should lead to a gradual empowerment and liberation of the person with diabetes.

Not scientifically valid Human insulin is not better than purified pork or bovine insulin Expensive sulphonylureas are not better than the cheap ones. Most antihypertensives are good. ACE-inhbitors and -blockers may be advantageous Vitamins and special foods for people with diabetes are not necessary Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Life style changes or drugs physical activiyty healthy diet stop smoking Pharmacological intervention 4S CARE UKPDS HOPE Aspirin etc-etc-etc. Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Mediterranian vs AHA diet 605 persons (10% women) were put on two randomised diets 2 months after a myocardial infarction AHA diet Mediterranian: less meat, more fish, more chicken, no fat from milk, much unsaturated fats, fruits and vegetables and red wine in moderation with meals. Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Mediterranian vs AHA diet After 4 years there were 24 deaths in the AHA group and 14 in the M-group, cardiac deaths 19 vs 6, cancer deaths 4 vs. 3, new late cancers (last 2 years) 12 vs. 2. Special difference in intake of omega-3-fatty acids, vitamin C and vitamin E. Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Prevention and Management of Diabetes Mellitus and its Complications Life style changes and metabolic control. 10 diabetic aborigenes before and after 7 weeks traditional lifestyle. We were meant to be hunter gatherers Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Prevention and Management of Diabetes Mellitus and its Complications Life style changes and risk factor control. 10 diabetic aborigenes before and after 7 weeks traditional lifestyle. Weren’t we? Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

The hunter-gatherer existence Survival factors Preference for energy-dense food Ability to gorge Laziness, avoiding unnecessary physical activity The reality Food was very varied, rarely energy-dense, with much fibre. Gorging was seldom possible, but much enjoyed. High level of physical activity necessary for survival. Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Prevention and Management of Diabetes Mellitus and its Complications The importance of setting targets Vascular risk assessment IDF Europe 1999 Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

The importance of setting targets Sett targets for Glycemia Lipids Blood pressure No smoking The tools Education and empowerment Diet Physical activity Hypoglycemic drugs (oral and/or insulin) Lipid lowering drugs Antihypertensives Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

What is necessary to give good diabetes care? The best can become the enemy of the good ! . Appropriate Technology: “Methods, procedures, techniques and equipment that are scientifically valid, adapted to local needs and acceptable to those who use them and to those for whom they are used, and that can be maintained and utilized with resources the community or country can afford.” Educational program on smoking, diet and physical activity on skills and facts of diabetes HbA1c BP Monofilament Total cholesterol Home monitoring - with urine or blood glucose Microalbumin Proper eye service with laser And so on without end Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Prevention and Management of Diabetes Mellitus and its Complications What is “acceptable” ? varies between countries depending on culture, health beliefs, education etc. It may also vary form person to person, a technology like home blood glucose monitoring, or urine testing, may not be acceptable to all persons with diabetes. Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

The world changes rapidly An important part of any set of guidelines or programmes is to realise their transitory nature. Modification is always necessary, as circumstances change, new knowledge becomes available, or we find that the guidelines are not practical. Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications

Prevention and Management of Diabetes Mellitus and its Complications Thank you for your attention! Birzeit, March 11 - 13, 2000 Prevention and Management of Diabetes Mellitus and its Complications