SEMINAR 5: TYPE 2 DIABETES MELLITUS GROUP 3A&B

REFLECTIVE QUESTIONS

A-PRIMARY CARE MANAGEMENT

1. How would I approach a patient for ‘routine’ follow up?

As for routine follow up for this patient:-
Perform history taking

 Specific symptoms – increased thirst, polydipsia, polyphagia, polyuria, nocturnal,

malaise, fatigue, weight loss, altered vision and frequent infection
 General symptoms review – CV symptoms (pleuritic chest pain, syncope),
neurological symptoms (loss of sensation), foot and toe problems (diabetic foot ulcer),
recurrent infections (especially urinary and skin), bladder problems (frequency,
urgency) and depressive symptoms (loss of motivation, change in appetite)
 Lifestyle issues

o Smoking status – did he started smoking recently? If present, how many

cigarettes per day? What make he started to smoke?
o Alcoholic drink status – did he started to drink alcoholic drink recently? If
present, how frequent did he drank? What would make him to start on
drinking alcoholic drink?
o Occupation – any stress-related of work?
o Dietary habits – did he follow on diet management plan of diabetes? A
minimum of 130g/day CHO should be provided to ensure adequate intake of
fibre, vitamins and minerals as well as to prevent ketosis and to provide
dietary palatability. Apart from that, sucrose intake must be counted as part of
the total carbohydrate intake. Excess sucrose intake contributes to calories and
may cause weight gain. In fact, non-nutritive sweeteners intake do not impact
glycemic level but it should not exceed acceptable daily intake (ADI) levels.
o Physical activity – use the FITT principle (involve Frequency, Intensity, Time
and Type). Mild to moderate exercise is generally safe but before beginning a
program of vigorous physical activity, people with diabetes should be assessed
for complications that may preclude vigorous exercise (CVD, retinopathy,
neuropathy and foot injury). The patient should choose an activity that he or
she is likely to maintain.

 Frequency – how frequent did you go for exercise?

 Intensity – how hard you did for the exercise?
 Time – for how long did you spent for exercise?
 Types – what types of exercise that you did?

 Review of vital signs signs and anthropometry

 Physical examination – CVS, eyes, feet, peripheral nerves
 Review on laboratory investigation regarding to his diabetes
 Adjust medications to achieve guideline-derived medical therapy
 Review on medication programme for opportunities to improve care – diabetes
education
 Review multiple team approach – dietician, nephrologist, ophthalmologist
2. What are the physical examination required for the patient?

3. What are the investigation required for this patient?

Baseline investigation

Targets for control of type 2 Diabetes Mellitus

* Modified from the NICE guideline: Type 2 diabetes: The management of type 2 diabetes,
2009. Glycaemic target should be individualised to minimise risk of hypoglycaemia. The
committee acknowledges the increased CVD death in the intensive group of the ACCORD
study. 43 (Level I) However, the committee believes it is due to the overall treatment
strategies that were employed to achieve the A1c target rather than the reduction in A1c.
**Measured at least 90 minutes after meals.
++ A1c 6.5% is advocated for patients with a shorter duration of diabetes, no evidence of
significant CVD and longer life expectancy and have minimal risk of hypoglycaemia. There
are strong benefits for reduction of nephropathy (ADVANCE) and retinopathy
(ACCORD/ACCORD Eye Study Group) at or below this level of A1c
#In individuals with overt CVD, LDL cholesterol target is <1.8 mmol/L.
§ In children and adolescents, blood pressure (BP) should be <95th percentile for age and sex

A1c targets

B-PATIENT CENTRED CARE

4. What are his ideas, concerns and expectations about his disease?
Ideas :
 Mr. Ahmad who is a diabetic patient for 15 years knows that diabetes mellitus will be
lifelong and can only be control with anti diabetic medications.
 Mr. Ahmad also has an idea that he needs advices and helps from healthcare
professionals in order for him to keep control of his Diabetes Mellitus issue.
 Mr. Ahmad also gets the idea that by consuming “Jus Peria Katak”, his illness
(Diabetes Mellitus) maybe better controlled compare to modern drugs.
Concerns :
 Mr. Ahmad is getting concern if his illness might cause him to lose job .
 He is gaining weight for the past 1 year thus think that it will affect him to work
efficiently as factory worker.
 He is also concern for his lack of capability to consume medications constantly thus
worsening the diabetes mellitus.
Expectations :
 Mr. Ahmad is expecting that he can works as optimum as he can.
 Mr. Ahmad is also expecting that his illness will be kept control as normal as he can
without develop any complications.
 Mr. Ahmad is also hoping that he can lead healthy lifestyle later on.
5. What are the implications of his disease on his life?
 Need to take medication daily
 Cannot skip meal
 Need to control daily intake of sugar
 Avoid injury especially to the foot
 Need to buy proper shoes
 Spend money on his transportation for routine follow up
 Need to take a day off from work (morning shift)
 Need to buy glucometer
  Not able to drive
6. What are the non-pharmacological management for him and why is he having
difficulty to adhere to it?
The nonpharmacological approach that we can do to this patient by medical nutrition therapy
and regular exercise
Medical Nutrition Therapy helps to prevent diabetes, managing existing diabetes and delayed
complication.
Since the patient start gain weight, he needs to start reducing calorie diet. Standard weight-
loss diets reduce daily energy by 500-1000 kcal to achieve an initial weight loss of 0.5-1.0kg
per week. He also to limit consumption of sugar-sweetened beverages (SBB) to less than 2
servings a day or about 10% of total daily caloric intake.
His meals must consist of 45-60% energy from carbohydrate,15-20% energy from protein
and 25-35% energy from fat. He needs to monitored Total Carbohydrate intake and must
consistent daily.
Advised him to avoid high sodium foods (soya sauce, ketchup, premixed cooking paste,
monosodium glutamate and process food). Since the patient has CKD, he needs to restrict his
protein intake of 0.8-1.0 g/Kg body weight/day.
He also needs to replace the high glycaemic index food to low glycaemic index food. By
replacing it, it will reduce postprandial blood glucose and reduction of A1c between 0.14%
and 0.5%.
The patient difficult to adhere with this ideal plan is the patient need to eat whatever the
cafeteria provided to him, which is difficult for him to plan what he needs to eat.
Next, regular exercise. By increasing physical activity, it can improve glycaemic control,
reduce weight and reduce risk of cardiovascular disease.
The patient needs to start from mild exercise then proceed to moderate or vigorous exercise.
The duration of exercise should be at least 150 minutes/week of moderate -intensity aerobic
physical activity and/or at least 90 minutes 90 minutes /week of vigorous aerobic

The patient difficult to do physical activity is because of his work. Since he works on shift, I
believe it is very hard for him to find free time to do some exercise.
7. Why is this patient non-compliant to his medication?
The reasons maybe due to:
1. Patient factors
 The patient still has lack of awareness and knowledge of T2DM and the complications.
 The patient has not taken seriously on his illness
 The patient has difficulty to following the treatment and schedules.

2. Healthcare Professional factors

 Limited knowledge and experience in managing T2DM
 Lack of manpower such as trained diabetes educators
 Service burden and increase patient load

3. Health services factors

 Inequality in the distribution of manpower, resources and facilities
 Limited resources and facilities

C-SPECIFIC PROBLEM SOLVING

8. How do I diagnose diabetes?
Diagnostic criteria for diabetes mellitus:

 Random plasma glucose ≥11.1 mmol/L in a patient presenting with hyperglycaemic

crisis or classic symptoms of hyperglycaemia (polyuria, polydipsia, recurrent
infection, unexplained weight loss).
OR
 FPG ≥7 mmol/L- considered when there is no caloric intake for at least 8 hours.
OR
 2-hour plasma glucose ≥11.1 mmol/L during OGTT- The test should be performed
using a glucose load containing of 75g anhydrous glucose dissolved in 200 mL of
water.
OR
 HbA1c ≥6.3%- Test should be performed in a lab using a national glycohemoglobin
standardization program (NGSP) certified method and standardized to Diabetes
Control and Complications Trial (DCCT) assay.
9. What are the treatment options of diabetes?

Pharmacological treatment options for DM: Oral anti-diabetic agents (OAD) and injectable
agents.

Oral anti-diabetic agents (OADs)

Insulin

 Required in all patients with type 1 diabetes mellitus and considered in patients with
type 2 diabetes mellitus when other antidiabetic agents fail to reach target blood
glucose level or when patient presents with severe hyperglycaemia.
 Initiation and optimization of insulin therapy should be done in newly diagnosed DM
with osmotic symptoms regardless of HbA1c or FPG and also for T2DM on maximal
OADs with HbA1c >7%.
 May be administered through insulin pump or insulin pen device, pen needle or
syringe.
 The choice of insulin regimen should be individualised, based on the patient’s
glycaemic profile, dietary pattern and lifestyle.

Types

 Prandial insulin- administered pre-meal because of its short & rapid acting to control
postprandial glucose excursion.
 Basal insulin- administered once or twice daily. It covers the basal insulin
requirements in between meals & night times.
 Premixed insulin- Covers both types of insulin into a single preparation.
10. Do I need to adjust his medications?

Yes. Considering that despite of his current treatment, his blood investigations have not yet
achieved the targets.

 Need to have doctor-patient agreement for the prescribed medication- using 5A’s
approach
i) Ask
ii) Advice
iii) Assess
iv) Assists
v) Arrange for follow up
 For example, in this case, considering that the patient having past medical history of
CKD, we might need to adjust the Metformin dose, as it may further worsening the
kidney functions and develop the long-term complications of lactic acidosis*rare.
 Considering that the he is an obese patient, we might need to change the medications
of Glicazide (SFU) as it may cause weight gain.
 Insulin therapy should be considered due to inadequate glycaemic control on optimal
dose and number of OADs.
11. What are his treatment targets?
12. What is global cardiovascular risk?

- In general, patients with pre-diabetes and T2DM have 2-3 fold increased risk of
developing cardiovascular disease. 60% of patients with diabetes will eventually die
from cardiovascular complications.
- As such, it is prudent that the cardiovascular risk profiles be determined at diagnosis
of pre-diabetes and diabetes. It is recommended to perform cardiovascular risk
assessment using either one of the following two tools:

1. Framingham Risk Score (FRS)

2. Systemic Coronary Risk Evaluation (SCORE)
-High model (validated only for men)
13. What is the recommended screening for other target
organ damage?
a. Diabetic retinopathy
- Visual acuity is assessed with a Snellen chart
- A non-mydriatic fundus camera should be used as a screening
tool for DR
- Ophthalmoscope
- Tropicamide 1% should be used for pupillary dilatation in selected
cases by trained personnel
b. Diabetic nephropathy
– Urine dipstick test to check for proteinuria – upon diagnosis &
annually
– If urine dipstick for proteinuria is negative, screening for microalbuminuria using first
morning urine sample.
– If microalbuminuria is detected, confirmation should be made with a repeat test within 3
to 6 months.
– If microalbuminuria is not detected, re-screening should be performed annually.
– Urine-Albumin Creatinine Ratio (ACR) may be performed in those with negative
microalbuminuria.
- albumin:creatinine ratio >2.5 mg/mmol in men and >3.5 mg/mmol in women
- equivalent to a 24-hour urine collection level of >20 mg/L.
– Regardless of the degree of proteinuria, renal profile to assess serum
creatinine level should be measured annually to
determine eGFR and stage the level of chronic kidney
disease.
c. Diabetic Neuropathy
- Ankle reflexes
- Sensation: touch (eg. With 10-g monofilament)
and pin prick
- Vibration sense using 128-Hz tuning fork
- Vibration perception threshold testing using biosthesiometer
d. Cardiovascular disease
–Based on symptom ie. dyspnoea, fatigue, and gastrointestinal symptoms associated with
exertion.
–In asymptomatic patient, routine screening for coronary artery disease is not recommended
but a CVD risk calculator such as Framingham Risk Score (FRS) or SCORE should be
applied.
–Lipid profile annually
- LDL cholesterol <2.6 mmol/L
- HDL cholesterol >1.0 mmol/L in males and >1.2 mmol/L in females
- TG <1.7 mmol/L

e. Sexual dysfunction
Erectile dysfunction
-Screened for any symptoms or signs of hypogonadism such as decreased libido, absence of
early morning erection, testicular or muscle atrophy. In those with clinical features of
hypogonadism, early morning serum testosterone should be performed.
-Screening can be done using the 5-item version of the International Index of Erectile
Function (IIEF) questionnaire.
D-COMPREHENIVE APPROACH
14. Should this patient be referred?
Yes to nephrologist, dietitian, and ophthalmologist.
Referral to: Indication
Nephrologist a) Estimated GFR <30 mL/min or serum creatinine >200 μmol/L
b) Heavy proteinuria (urine protein 3 g/day or urine protein: creatinine
ratio (uPCR) 0.3 g/mmol)
c) Haematuria
d) Rapidly declining renal function (loss of glomerular filtration
rate/GFR >5 mL/min/1.73 m2 in one year or >10 mL/min/1.73 m2
within five years)
e) Resistant hypertension (failure to achieve target blood pressure
despite three antihypertensive agents including a diuretic)
f) Suspected renal artery stenosis
g) Other suspected causes of CKD (primary glomerular disease, genetic
or uncertain causes of CKD)
h) Pregnant or when pregnancy is planned
 Dietitian a) Education
Cardiologist If the patient have typical symptoms of CHD
Ophthalmologist a)Severe non-proliferative DR
b)Any level of diabetic maculopathy
c)Any proliferative DR
d)Unexplained visual loss
e) If screening examination cannot be performed including ungradable
fundus photo

Urologist a) If patient with erectile dysfunction not responding to PDE-5

inhibitors.
Mental health a) Depression with the possibility of self-harm
specialist b) Debilitating anxiety (alone or with depression)
c) Indications of an eating disorder
d) Cognitive functioning that significantly impairs judgment
Oral Health Patients with diabetes should be advised to see a dentist regularly
Professional because they tend to have poorer oral hygiene and more severe gingival
and periodontal diseases. These may contribute to worsening of
glycaemic control.

E-COMMUNITY ORIENTATION
15. Do I think workplaces should have exercise facilities for the workers?

“Nature of his work, he is unable to exercise and eats at irregular times. He eats any food
that is available at his cafeteria. He also frequently drinks 3-in-1 coffee to stay awake
during night shift. He has been gaining weight over the last one year and now is 80kg (BMI
30kg/m2).”

Not necessarily. – It is not practical, cost a lot, there are a lot of other practical ways to
exercise whilst at work. There are also not much time that they can spend at the workplace
solely for exercising.

In a way, instead of exercising facilities, companies should provide enough break time for
employees to spend 30 minutes time to walk every day.
16. Do I think workplace cafeterias should serve healthy diets only?

They should provide food that follows the ministry of health guideline, and instead of
providing oily food for snacking time, they should replace them with fruits or energy bars
that are better.

¼ - Carbohydrates (Rice, buns and bread, cereal products)

¼ - Protein (Fish, meat and poultries)

½ - Vegetables and fruits of all kinds.

F-HOLISTIC APPROACH

17. Should I involve his wife in his care?

 Yes, the wife should be involved in the care of the patient.

 This is because he cannot manage his diseases and be compliance to the medications
by himself due to the nature of his work that kept him busy.
  This is evidently by the lack of exercises, bad eating habit with irregular eating times,
frequently drink coffee to stay awake during night shift and misses his medications
due to his busy work schedule.
 If his wife is involved in his care, he can keep control of his disease and prevent the
complication arise from his diseases by encouraging him to exercise together to keep
healthy such as jogging, cycling or brisk walking.
 Besides that, his wife can manage his diet by preparing healthy meals that are filled
with high fiber and low glycemic index source carbohydrates and preparing healthy
packed meals for him to eat at work, instead of him having to buy food provided by
the cafeteria which is not known to be really healthy or not.
 Lastly, his wife can help to remind him to take his medications so that he would not
forget and misses it, and also remind him to go for regular follow-up at nearby Klinik
Kesihatan so that physician can monitor his health and disease progression.

18. Should I inform his employer regarding his condition?

 Yes, his employer should be informed regarding of his condition, with the consent of
the patient.
 This is because, he is constantly busy with his work that he does not have time to take
care of his health, which causes him to be unable to exercise and not practicing
healthy diet by eating any food that available in the cafeteria at irregular times. He
also frequently needs to take 3-1 coffee just to stay awake during his night shifts
which can worsen his hypertension and chronic kidney disease.
 If we inform his employer, we can discuss about the patient’s working hours and
adjusting it to accommodate with the patient’s conditions such as reducing his night
shift and assigning him to a more manageable working hour. As such, the patient can
have more time to manage his health and spending time with his wife and family.
 Besides that, we can also advise the employer to prepare more healthy foods in the
cafeteria and also establish an exercise facilities so that the workers beside the patient
can exercise and also as a way to reduce stress at work, thus increasing productivity at
work.

19. What do you think about his Peria Katak juice?

  I would first explain that diabetes is best managed with compliance to the prescribed
medications and lifestyles changes such as exercise regularly and practicing a healthy
diet.
 And after that I would explain that only taking herbal supplements is not a
replacement to the current prescribed medications, because we do not know the
effectiveness of the supplements and the effects that it may have to the disease or the
body in short and long term and also if the patient’s finance can support buying the
supplements in the long run.
 In this case, since he has chronic kidney disease, I would advise him to not take peria
katak juice, since it would have worsened his chronic kidney disease, even peria katak
juice does exhibit some anti-diabetic effect.
 If the patient is adamant on taking it, I would ask the reason the reason for it. If he
insisted on taking it, I would advise him to consume in low quantity and make sure to
came for follow up to monitor his condition.

G-CONTEXTUAL FEATURES
20. From your observation during your attachments in primary care clinic, what are
the barriers to deliver optimal diabetes care?
Three main groups of barriers
i. Patient factors
 Lack of awareness and knowledge of T2DM and its complications.
 False beliefs and perceptions about T2DM, complications and management.
 Misplaced priorities and expectations on T2DM and its management
 Lack of self-management skills
 Has financial problem to access to a wide range of therapeutic options
 Complexity of current treatment regimes and schedules  poor medication adherence
 Complex co-morbidities

ii. Healthcare professional factors

 Lack of knowledge and experience in managing T2DM
 Lack of manpower such as trained diabetes educators
 Inability to bring together patient preferences with guideline recommendations
 Lack of use of available resources
 Service burden and increased/high patient load
 Lack of continuity and coordination of patient care by multidisciplinary team

iii. Health services factors

 Imbalance in the distribution of manpower, resources and facilities
 Budgetary and economic limitations
 Long waiting list for specialist consultation

H-ATTITUDINAL FEATURES
21. Should patient who is non-compliant to treatment be allowed to continue their
follow up at the clinic?
Yes.
1. Ask detail about reasons for patient not following treatment.
2. Ask about patient’s idea and understanding on the disease, complication and treatment
plan and identify the concerns and expectations. (ICE)
3. Advice and try to educate patient on facilitating knowledge on the treatment plan
4. Reinforce the health education, diet therapy, exercise and compliance to medications
at the follow up.
5. Discuss with the patient and try to achieve mutual agreement on treatment plan. Take
into considerations of patient’s perspective.

I-SCIENTIFIC FEATURES
22. What are appropriate resourceful to learn about diabetes?

1. NICE guideline: (type 2 diabetes in adults : management) 2015

2. Cpg: ( management of tyoe 2 diabetes mellitus 5th edition) 2015
3. Uptodate

23. How do I calculate the Framingham Cardiovascular risk?