Diabetes management and complications Dr. Louise Johnson-Loots Specialist physician and insulin pump centre Montana hospital, Pretoria

Diabetes types Type 1 – auto immune Type 2 - insulin resistant Secondary – surgery, medication (i.e. steroids) GDM ( gestational diabetes)

Type 2 Diabetes Type 1 Younger than 30 yr Thin Auto-immune disease 10-20% of Pt. Type 2 Older than 30 yr Obese – ♂ waist > 94 cm ♀ waist > 80 cm Ass diseases i.e. HT,Dyslipiedemiae 80% of Pt

What you see is what you have… Type 2 Type 1

Insulin resistance (metabolic syndrome) First step on diabetes ladder Waist circumference Male >94 cm Female >80cm Associated disease –Hypertension - gout -abnormal cholesterol

How to manage my metabolic abnormality? Know your numbers Set targets – keep to them Know your bar stool (diet, exercise ,medication) NO smoking!! Test regularly

Targets to achieve Waist - 94 cm male, 80cm female Blood pressure < 130/80mmHg LDL cholesterol< 1.8 HDL cholesterol > 1.0 HbA1c < 7% FPG < 5.5 , 2h PPG < 7.8

How to get to target? Diet Exercise 30 min brisk walking/day Correct medication – suit your life style Regular blood glucose testing – 2x/day on insulin - wake up/2h PPG if on tablets Test more if unwell

Diabetic diet sign language Fist – carbohydrate portion (tennis ball size) Palm size – protein ( thickness of thumb ball ) Two open hands – vegetables Thumb tip – fat 3 regular meals- don’t skip Enough water - weight ( 84 kg = 8 glasses)

Alcohol and diabetes Female 1 unit/day Male 2 units/day Unit - single whiskey/brandy (spirits) - 200 ml dry white/red wine Stay away from mixes, beer, sherry ,port liqueur

Important pitfalls Diabetic sweets - too much fat Flavored water = Coke in calories!! Fruit juice Not what we eat but how much of it!

Medication - Type 2 diabetes Metformin basis of type 2 management Incretin – tablets and injections (see second lecture after lunch break) Sulphonylurea – hypoglycemia TZD- pioglitazone – swelling of feet

Medication Type 1 Diabetes Insulin –to suit your lifestyle Basal/bolus Basal( long acting) Levemir, Lantus, Bolus (short acting)– novorapid,apidra,humalog Fixed mixes –novomix,humalog mix25 Insulin pumps

Progression of type 2 diabetes 20 40 60 80 100 ―10 ―8 ―6 ―4 ―2 2 4 6 Time of diagnosis ? Pancreatic function = 50% of normal -cell function (% of normal by HOMA) Type 2 diabetes mellitus (T2DM) develops because of a progressive decline in pancreatic -cell function, together with increasing insulin resistance, for which the -cells cannot compensate. The United Kingdom Prospective Diabetes Study (UKPDS) has demonstrated that by the time of diagnosis, patients may have already lost as much as 50% of their -cell function. Holman RR. Diabetes Res Clin Pract 1998;40(suppl):S215. Time (years) HOMA=homeostasis model assessment. Adapted from Holman RR. Diabetes Res Clin Pract 1998;40(suppl 1):S21―5.

The first insulin 11/1/1922 Leonard Thompson 14yr 25 days on dog insulin

Expectations today Fast Reliable Smooth Reproducible Safe

Complications Preventable Preventable! Preventable!! Know the rules of the metabolic abnormality to prevent the disease

Rules for diabetes Rule 1 – medical check 6 monthly with a specialist physician –Blood pressure, kidney ,heart,feet sensation and blood flow. Rule 2 – eye check at an eye specialist (not the person giving the glasses) Rule 3 – no bare foot walking

More rules Rule 4 – sin once every 14 days (ice cream ,chocolate ,cookies etc) Rule 5 - if female and your baby weighed >4.0kg – get screened for diabetes yearly Rule 6 – Become the captain of your own ship !

Questions ??