DIABETES mANAgemENT , BEYONDNUMBERS!
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DIABETES MANAGEMENT, BEYONDNUMBERS!
Dr. SYED SULAIMAN;M.D. (GEN.MED) PHYSICIAN & DIABETOLOGIST
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GOALS IN DIABETES MANAGEMENTFPG <100 mg%
PPPG < 140mg %
HbA1C <7%
TOTAL CHOLESTEROL < 200mg %
LDL CHOLESTEROL < 100mg%
TRIGLYCERIDE <150mg%
B.P <130/85mm of Hg
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KNOW YOUR NUMBERS
100 FPG,LDL
150 PPPG,TG
200 T.C
7 HbA1C
130/85 B.P
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ARE WE JUSTIFIED ??
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YES
Justify yourself!
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NO
Give me reason to negate!
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TWO SIDES OF A COIN Management of the disease
Management of the co morbid conditions
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COMORBID CONDITIONS Depression
Erectile Dysfunction
Skin diseases
Endocrine disorders
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EFFECT OF DEPRESSION ON ALL-CAUSE MORTALITY IN PEOPLE WITH DIABETES
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CRITERIA FOR DIAGNOSING DEPRESSION
At least five symptoms present nearly every day for 2 weeks, including:
• Depressed mood • Diminished interest in daily activities • Significant weight loss/gain or decreased appetite • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of worthlessness/guilt • Diminished ability to concentrate/make decisions • Recurrent thoughts of death or suicide
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DEPRESSIVE SYMPTOMS – OFTEN MEASURED USING SELF-REPORT INSTRUMENTS
Feeling sad/depressed mood Inability to sleep Early waking Lack of interest/enjoyment Tiredness/lack of energy Loss of appetite Feelings of guilt/worthlessness Recurrent thoughts about death/suicide
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DEADLY DUODepression and Diabetes share many common
threads: Chronic history Multifactorial pathogenesis Poorly understood etiology Multifaceted clinical picture Frequent exacerbations Need for patients active participation in
management Ability to be controlled but difficulty in getting cured
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EFFECTS OF DEPRESSION ON DIABETES
Poor adherence to treatment Poor glycemic control Frequent complications Sexual dysfunction Poor Quality of life Less interest in exercise Lack of physical fitness
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PREVALENCE OF DEPRESSION IN DIABETES
Life time prevalence of major depression in diabetes is 28.5%
DEPRESSION IS TWICE COMMON IN DIABETICS
More frequent in women (28%) than in men(18%)
More in uncontrolled group(30%)than in controlled group(21%)
More in clinical(32%) than in community samples(20%)
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LIFE TIME PREVALENCE OF DEPRESSION IN DIABETIC PATIENTS
36%
DepressionFemale > Male
18%
Normal populationFemale > Male
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DM AND DEPRESSIONTHE MYTH & THE REALITY
MYTH
Depression is obvious and easily recognized and expressed by the
patient
REALITY
Depression disorders are overlapping, hardly expressed by
the patient and constitute a major problem in symptom
exaggeration
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SUMMARY While depression is significantly more common in people with diabetes
compared to those without diabetes, it can be treated effectively.
Depression increases the risk of developing diabetes, Impacts on blood glucose control, and increases the risk of developing diabetes complications.
It is associated with increased body weight or obesity, and poorer diabetes self-management.
It is important to recognize that although diabetes and depression are separate conditions they often co-exist and any treatment offered must reflect this in order to maximize the benefits to the person with diabetes.
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ERECTILE DYSFUNCTION
“The consistent inability to achieve or sustain
an erection of sufficient rigidity to permit
sexual intercourse “
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DIABETES & ERECTILE DYSFUNCTION
Many men with diabetes also have erectile dysfunction:
ED can be an early sign of diabetes. A diabetic man is two to five times more likely to develop
ED than a man who is not a diabetic. Men with diabetes tend to develop ED 10-15 years earlier than men without diabetes. More than 50% of men develop diabetic ED within 10 years of getting
diabetes.¹ 50%-60% percent of diabetic men over age 50 have some problem with
ED.¹ 50%-75% of men with diabetes will experience some degree of
ED during their lives. 9% of men with diabetes age 20-29 experience ED. 95% of men with
diabetes experience ED by age 70.¹
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PREVALENCE OF E.D
20-30 50-60 70-750
102030405060708090
100
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CAUSES
• Genetics: A family disposition for the disease
• Diet: High in fat and processed foods
• Lack of exercise: Getting off the couch
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PATHOPHYSIOLOGY OF DIABETES RELATED E.D
Neurogenic: Penile autonomic neuropathy
Vasculogenic: Diabetic microangiopathy
Endocrinologic:
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NEUROGENIC CAUSES OF ED Lesions of medial preoptic nucleus, paraventicular nucleus,
hippocampus Spinal trauma Myelodisplasia (spina bifida) Pelvic surgery/radiotherapy Multiple sclerosis Intervertebral disc lesion Peripheral neuropathies
Alcohol Diabetes HIV
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ARTERIOGENIC CAUSE OF ED Hypertension Smoking Diabetes Hyperlipidaemia Peripheral vascular disease Blunt perineal or pelvic trauma Pelvic irradiation
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ENDOCRINE CAUSES OF ED Hypogonadism
Low testosterone Raised SHBG Raised Prolactin
Thyroid disease
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DRUGS ASSOCIATED WITH ED Antihypertensives
Thiazides B blockers Centrally acting drugs
Antidepressants Tricyclics MAO inhibitors SSRI
Anticholinergics Atropine
Antipsychotics Phenothiazines
Anxiolytics Benzodiazepines
Psychotropic drugs Alcohol Opiates Amphetamines Cocaine
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ED AND CORONARY ARTERY DISEASE Generalised atherosclerosis Penile arteries smaller than coronary
arteries ED pre-dates coronary artery disease Man with ED and no cardiac symptoms
is a cardiac patient until proven otherwise
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EVALUATION OF E.D Sexual
Medical
Psychosocial history
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DIABETES & SKIN
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SKIN MANIFESTATIONS OF DIABETESCutaneous Infections:1.Candidiasis2.Dermatophytosis3.Phycomycosis4.Erythrasma5.Malignant external otitis
Nuerologic lesions:1.Charcot Joint2.Compensatory hyperhydrosis3.Neuropathic ulcer
Disorders of Collagen:1.Necrobiosis lipoidica2.Granuloma annulare3.Scleroderma diabeticorum4.Waxy skin5.Sclerodermalike change of the hand
Metabolic diseases:1.Porphyria cutanea tarda2.Yellow skin3.Xanthomatosis4.Hemochromatosis5.Glucagonoma syndrome6.Generalized Pruritus
Skin conditions with strong but unexplained association with Diabetes:1.Acquired icthyosis2.Diabetic dermopathy3.Diabetic bullae4.Rubeosis5.Vitiligo6.Acanthosis nigricans7.Finger ” pebbles”8.Perforating disorders
Cutaneous reactions to diabetes therapy:Insulin induced disorders1.Insulin allergy2.Insulin Lypodystrophy3.Insulin - induced lipohypertrophyHypoglycemic agents1.Hypersensitivityreactions2.Disulfiram reactions
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CUTANEOUS INFECTIONS
TAENIA PEDIS ONYCHOMYCOSIS
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NEUROLOGIC LESIONS
NEUROPATHICULCER
CHARCOT FOOT
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COLLAGEN DISORDERS
GRANULOMA ANNULARE
NECROBIOSISLIPOIDICASCLERODERMA
DIABETICORUM
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SKIN CONDITIONS STRONGLY ASSOCIATED WITH DMACANTHOSIS NIGRICANS
BULLAE
DIABETIC DERMOPATHY
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METABOLIC DISEASESxanthomatosis Haemochromatosis
Porphyriacutaneatarda
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SKIN REACTIONSTO DIABETIC THERAPYLIPODYSTROPHY
LIPOHYPERTROPHY
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ACANTHOSIS NIGRICANS
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BULLAE
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CELLULITIS
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DIABETIC DERMOPATHY
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FOLLICULITIS
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GRANULOMA ANNULARE
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TAENIA PEDIS
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PARONYCHIA
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ONYCHOMYCOSIS
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NEUROPATHIC ULCER
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ENDOCRINE DISORDERS
Type 1 DM ,Hypothyroidism & Graves disease– autoimmune association
Girls > Boys Subclinical hypothyroidism (SCH):TSH, normal FT4 & FT3. Frequently seen in adults with Type 1 & Type
2 DM
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The good physician treats the disease; the great physician treats the patient who has the disease.
William Osler
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