In March the Northern Rivers Division of General Practice hosted a diabetes seminar in Byron Bay. One of the visiting speakers, Dr David Chipps, an endocrinologist at Westmead Hospital, addressed the meeting on the implementation of the NSW Health Department Guidelines for the clinical management of diabetes in adults.
The guidelines have been drawn up from evidence gained from large centre multinational trials, which demonstrate how improved glycaemic control reduces the onset and rate of deterioration of diabetes complications.
The essential message is that good clinical management of diabetes leads to a reduced complication rate and that frequently the simple process of measuring the parameters of diabetic control and discussing them with patients induces better control.
Some of the points from Dr Chipp's talk:
- Unless we can stop our diabetic patients smoking we can expect very little benefit from complication prevention.
- Poorly controlled MODM patients on maximal oral and dietary therapy frequently gain improved control and feel healthier when insulin is started. Their oral therapy should be continued when insulin is commenced. It is usual to start with a dose of eight units of Isophane insulin at night and increase by two units every three or four days, monitoring fasting morning insulins until they are less than 8.0 mmol/l.
- Vibration sense is felt to be the most sensitive test for detection of early diabetic neuropathy. The best frequency is middle C. In addition, a nylon filament calibrated to exert 10g of force is very effective for testing for sensory neuropathy. They are cheap, especially if obtained from drug reps! Testing is done on the dorsal and plantar aspects of feet and toes.
- A diabetic has a one in two risk of a major coronary event over 5 years if their cholesterol is over 5.5. This can be reduced to a one in five risk by correcting their cholesterol with a statin.
From Professor Truswell's talk to the seminar:
1. Weight should be measured together with height and body mass index calculated on initial diagnosis and then 3 monthly.
Body Mass Index (BMI) =Height in metres / Weight in kg2. This should be less than 25.
Weight measurements should be done more frequently if on a weight reduction program.
2. If BMI is less than 25, then simple dietary advice may be all that is required after checking lipids and BP.
- Stop smoking.
- Encourage complex high fibre carbohydrates.
- Reduce saturated fat and eat moderate amounts of unsaturated fat.
- Encourage daily protein intake and increase fruit and vegetables.
- Limit salt.
- Moderate alcohol.
- Discuss use of low glycaemic index foods (hand outs available from the division) to spread out the glycaemic load.
- Maintain daily exercise program.
- Breakfast is an important meal to 'kick start' the metabolism and three equal calorific meals with three snacks in between is recommended.
- A healthy diet for diabetics is healthy for the whole family.
3. If BMI is more than 25 diabetics need to strictly reduce fat intake to less than daily requirements. Reducing weight to a BMI of less than 25 is ideal but a 10kg weight loss has a marked effect on control.
Average daily fat requirements are about 55g for men and 45g for women (fat being mainly needed to replace the phospholipid walls of the gut and skin cells shed daily).
4. Evidence shows that if fat intake is kept to below these levels then energy consumed in the form of carbohydrate and protein will not be converted to (and therefore stored as) fat. The person can lose weight by being strict with their fat intake and not need to be hungry.
5. Studies also show that weight loss will not be maintained without a regular sustainable exercise program.
6. The concern about the trans fatty acid content of margarine has been minimised, as the food industry has been able to reduce their concentrations to a minimum.
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