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3. DIABETES MELLITUS Part 3: MANAGEMENT M2 -Endocrine Sequence A. KumagaiWinter 2009

4. Diabetes Mellitus: Chronic Complications Too much sugar is bad for you. -- My mother

5. Diabetes Mellitus: Treatment THE GLUCOSE HYPOTHESIS Normalization of blood glucoselevels in individuals with diabetes will prevent or delay chronic complications.

6. THE DIABETES CONTROL AND COMPLICATIONS TRIAL (DCCT), 1993 1400 INDIVIDUALS WITH IDDM CONVENTIONAL INSULIN INTENSIVE INSULIN THERAPY THERAPY CONTROL OF Sxs. NORMALIZE BLOOD SUGAR Does long-term normalization of blood glucose levels in type 1 diabetes reduce the risk of development or progression of microvascular complications?A. Kumagai

7. The Benefits of Tight Control : The DCCT DCCT RESULTS: The Good News 100 100 90 90 80 80 70 70 60 60 50 50 40 40 Rate/100 pt-yrs. Rate/100 pt-yrs. 30 30 RETINOPATHY CONVENTIONAL NEPHROPATHY NEUROPATHY INTENSIVE Intensive metabolic control dramatically reduced the risk of developing or worsening microvascular complications in type 1 diabetes. A more recent trial, the United Kingdom Prospective Diabetes Study(UKPDS), demonstrated very similar results in individuals with type 2 diabetes. DCCT, 1993!

8. Message from the DCCT and UKPDS:Metabolic control matters.

9. Management of Diabetes Mellitus: Goals of Therapy MANAGEMENT MUST BE INDIVIDUALIZED! Normal fasting blood glucose levels. Prevention of postprandial hyperglycemia. Reduction of hypoglycemic episodes to a bare minimum. Psychosocial: Helping the patient to live a productive, enjoyable life with diabetes and NOT ruled by diabetes

10. Management of Diabetes Mellitus: Components of Therapy Diet Exercise Insulin or Oral Management Agents of Diabetes Reduction of Other Risk Factors

11. The Diabetes Care Team Primary Care Diabetes and Educator Subspecialist Physicians Patient Psychologist, Specialized Social Worker, Nutritionist PsychiatristA. Kumagai

12. Diabetes Care From the Patient s Perspective To deliver effective diabetes care, perspective is EVERYTHING Goals and ambitions Lifestyle and personal preferences Concerns and fears Since over 95% of diabetes care is SELF CARE, one must understand where the patient is coming from to deliver meaningful advice and care.

13. Diabetes Care is Self CarePhysician The concept of patient compliance is neither appropriate nor effective in Patient diabetes care. The doctor-knows-best approach is replaced byPhysician Patient shared responsibilities and alliances between the physician and the patient in diabetes care. A. Kumagai

14. The Role of the Diabetes Care Provider Knowledge speaks but wisdom listens. -- Jimi Hendrix

15. Management of Diabetes Mellitus INSULIN THERAPY

16. Treatment of Diabetes: Pre-Insulin Era1870 Siege of Paris: Apollinaire Bouchardat notices that famine actually improves control in his diabetic patients. Mangez le moins possible. ( Eat the least possible. )1914-17 New York: Under-nutrition Therapy Frederick Allen imposes severe caloric restriction (