Sunday Times 2
Crucial role of the GP in fighting diabetes
View(s):By Dr A.L.P. de S. Seneviratne
World Diabetes Day with the theme ‘Raise public awareness of diabetes’ was on Friday (November 14).
Diabetes mellitus, once considered a disease of the developed world, has become a worldwide pandemic, with two-thirds of the global diabetic population living in developing countries.
Local studies show a definite upward trend of diabetes. Rising to endemic proportions, around one in four Sri Lankans over the age of 30 years has diabetes. It is estimated that 4.2 million people in Sri Lanka are suffering from this disease.
An alarming feature is the changing profile of diabetes. Now the onset of Type 2 diabetes—earlier regarded as a disease of middle and old age—has fallen to 30 years.
Dr A.L.P. de S. Seneviratne
The Primary Care Diabetes Group Sri Lanka (PCDGSL) consists of General Practitioners (GPs) with an interest in diabetic care. GPs provide continuing and comprehensive care to patients and their families, and diabetes needs a strong doctor-patient relationship and good communication.
GPs should identify the need for referral to a team member, with such a team comprising the GP, dietician, endocrinologist, ophthalmologist, cardiologist, neurologist, vascular surgeon, obstetrician and podiatrist.
Managing patients with diabetes
Epidemiological evidence has reported a higher incidence of Type 2 diabetes in low birth weight children. With maternal nutrition playing a major role, studies suggest a relationship between stress and insulin resistance. As such, maternal stress is an aetiological factor which may predispose the newborn to develop diabetes in the future.
Preventing Type 2 diabetes starts with understanding your risk—in addition to lifestyle factors, such as what you eat and drink, your daily movements and well-being, age, family history and ethnicity play a role.
However, with personalised support and guidance, you could take steps that may help you to reduce your risk.
Your GP should screen all patients over 30 years with a Fasting Blood Sugar (FBS) test. If there is a degree of suspicion of a person having diabetes, he/she should request a 2h Post-Prandial Blood Sugar Test, while an HbA1C test will support the diagnosis. If these are normal, they could be repeated in three years.
In those with cardio-metabolic risk (CMR), screening should be at an early age and, if normal, repeated annually.
Once a clear diagnosis of diabetes is made, it should be conveyed to the patient along with information on the disorder, symptoms and risk of complications. Giving individual targets of treatment and lifestyle modification is important.
The patient should also be advised on symptoms of hypoglycaemia and treatment. If he/she is on insulin, it is important to advise on self-monitoring of blood glucose levels using a glucometer.
Diabetes can be diagnosed with a fasting blood sugar of over 126 mg/dL in a patient with symptoms.
The patient should be advised to avoid sugar and foods containing sugar, highly refined carbohydrates, fats and high calorie content.
An exercise plan should include brisk walking (1 km distance in 10 minutes) or jogging for at least 30 minutes for five days a week. Other types of beneficial exercises include cycling, gardening and swimming.
Drug treatment
These could be selected according to the type of diabetes, age of the patient, cost of drugs, BMI (body mass index), meal pattern, postprandial hyperglycaemia and evidence of other complications.
Metformin is recommended as a first-line therapy in obese and non-obese patients. It promotes modest weight reduction, reduces lipid levels and reduces HbA1c by 1.5%. It is not prescribed in hypoxic states and in situations with other organ failure.
Other drugs
The other drugs prescribed may include sulphonylureas, -glucosidase inhibitors, glinides, GLP 1 (glucagon-like peptide-1), DPP-4 (dipeptidyl peptidase-4) inhibitors, and Sodium Glucose Transport 2 (SGLT2) inhibitors.
Insulins
Insulin is used in the treatment of Type 1 diabetes, diabetes complications in pregnancy and in some patients with Type 2 diabetes. The disadvantages of insulin are fear of injections, risk of hypoglycaemia and difficulties in storage.
The types of insulin are short-acting, rapid-acting regular-human, intermediate-acting and long-acting.
As diabetes is a metabolic disease affecting most of the body’s organs, leading to complications, a blood pressure of 140/90 or lower should be maintained. The lipid levels too should be maintained at lower than a non-diabetic. The level depends on the co-morbidities.
Renal assessment
Patients should be tested for urinary microalbumin, serum creatinine and estimated glomerular filtration rate (eGFR). If serum creatinine is >1.5 mg/dL with eGFR <30, metformin should be avoided.
Foot care & eye referral
This forms a vital role in patient care. The GP should follow a checklist and provide advice accordingly, identify the risk of a patient for foot amputation and reinforce foot care advice at every visit.
Patients should also be referred to an eye surgeon for assessment.
To facilitate good diabetic care, the GP could run a diabetic clinic with a well-maintained follow-up medical record. Poor glycaemic control in spite of treatment, Type 1 diabetes, diabetes in pregnancy, evidence of kidney disease, diabetic ketoacidosis, cellulitis, peripheral vascular disease and a non-healing diabetic foot ulcer would be indications for referral to other specialists.
(The writer is a consultant family physician and president of the Primary Care Diabetes Group Sri Lanka.)