DIABETES MANAGEMENT, BEYONDNUMBERS!

Dr. SYED SULAIMAN;M.D. (GEN.MED) PHYSICIAN & DIABETOLOGIST

GOALS IN DIABETES MANAGEMENT

FPG <100 mg%

PPPG < 140mg %

HbA1C <7%

TOTAL CHOLESTEROL < 200mg %

LDL CHOLESTEROL < 100mg%

TRIGLYCERIDE <150mg%

B.P <130/85mm of Hg

KNOW YOUR NUMBERS

100 FPG,LDL

150 PPPG,TG

200 T.C

7 HbA1C

130/85 B.P

ARE WE JUSTIFIED ??

YES

Justify yourself!

NO

Give me reason to negate!

TWO SIDES OF A COIN

Management of the disease

Management of the co morbid conditions

COMORBID CONDITIONS

Depression

Erectile Dysfunction

Skin diseases

Endocrine disorders

EFFECT OF DEPRESSION ON ALL-CAUSE MORTALITY IN PEOPLE WITH DIABETES

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

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

DEADLY DUO

Depression 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

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

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%)

LIFE TIME PREVALENCE OF DEPRESSION IN DIABETIC PATIENTS

36%

DepressionFemale > Male

18%

Normal populationFemale > Male

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

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.

ERECTILE DYSFUNCTION

“The consistent inability to achieve or sustain

an erection of sufficient rigidity to permit

sexual intercourse “

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

PREVALENCE OF E.D

20-30 50-60 70-750

10

20

30

40

50

60

70

80

90

100

CAUSES

• Genetics: A family disposition for the disease

• Diet: High in fat and processed foods

• Lack of exercise: Getting off the couch

PATHOPHYSIOLOGY OF DIABETES RELATED E.D

Neurogenic: Penile autonomic neuropathy

Vasculogenic: Diabetic microangiopathy

Endocrinologic:

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

ARTERIOGENIC CAUSE OF ED

Hypertension Smoking Diabetes Hyperlipidaemia Peripheral vascular disease Blunt perineal or pelvic trauma Pelvic irradiation

ENDOCRINE CAUSES OF ED

Hypogonadism Low testosterone Raised SHBG Raised Prolactin

Thyroid disease

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

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

EVALUATION OF E.D

Sexual

Medical

Psychosocial history

DIABETES & SKIN

SKIN MANIFESTATIONS OF DIABETES

Cutaneous 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

CUTANEOUS INFECTIONS

TAENIA PEDIS ONYCHOMYCOSIS

NEUROLOGIC LESIONS

NEUROPATHICULCER

CHARCOT FOOT

COLLAGEN DISORDERS

GRANULOMA ANNULARE

NECROBIOSISLIPOIDICA

SCLERODERMADIABETICORUM

SKIN CONDITIONS STRONGLY ASSOCIATED WITH DMACANTHOSIS NIGRICANS

BULLAE

DIABETIC DERMOPATHY

METABOLIC DISEASES

xanthomatosis Haemochromatosis

Porphyriacutaneatarda

SKIN REACTIONSTO DIABETIC THERAPYLIPODYSTROPHY

LIPOHYPERTROPHY

ACANTHOSIS NIGRICANS

BULLAE

CELLULITIS

DIABETIC DERMOPATHY

FOLLICULITIS

GRANULOMA ANNULARE

TAENIA PEDIS

PARONYCHIA

ONYCHOMYCOSIS

NEUROPATHIC ULCER

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

The good physician treats the disease; the great physician treats the patient who has the disease.

William Osler