1. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

2. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

3. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

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

5. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

6. Prevention and Management of Diabetes Mellitus and its Complications
The 10 gram monofilament in use
Birzeit, March , 2000
Prevention and Management of Diabetes Mellitus and its Complications

7. Prevention and Management of Diabetes Mellitus and its Complications
The 10 gram monofilament in use
Birzeit, March , 2000
Prevention and Management of Diabetes Mellitus and its Complications

8. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

9. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

10. 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=
Birzeit, March , 2000
Prevention and Management of Diabetes Mellitus and its Complications

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

12. Therapy requirement (UKPDS 1998)
Birzeit, March , 2000
Prevention and Management of Diabetes Mellitus and its Complications

13. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

14. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

15. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

16. 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

17. 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.

18. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

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

20. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

21. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

22. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

23. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

24. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

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

26. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

27. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

28. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

29. 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 , 2000
Prevention and Management of Diabetes Mellitus and its Complications

30. Prevention and Management of Diabetes Mellitus and its Complications
Thank you for your attention!
Birzeit, March , 2000
Prevention and Management of Diabetes Mellitus and its Complications