Anexos

provide 50-60% of the total daily intake as carbohydrate from a variety of sources. The daily

consumption of a diet high in complex carbohydrate and ideally containing approximately 3g dietary fiber per 1000kJ is recommended.⁹¹

2.17.1.4 Fat: The recommended fat intake is 20% of the total energy intake. The ratio of

polyunsaturated to saturated (P:S) of 2:1 is advisable. It is highly encouraged that fat intake should come from vegetables.

2.17.1.5 Minerals and Vitamins: A diabetic under good metabolic control and adequate dietary intake needs no supplement. However, if a deficiency is demonstrated or when a person follows a very low energy diet in uncontrolled diabetics, supplement is

needed.⁹¹

2.17.1.6 Fiber: A total dietary fiber intake of 30- 40g per day or 15-20g for every 1000 calories is recommended. Soluble fibres such as pectin and guar found in legumes, fruits and vegetables have been associated with reduction in serum cholesterol and improved blood

sugar control.⁹¹

2.17.1.7 Alcohol: If alcohol must be taken, it must always be ingested with a meal. Alcohol consumption should be limited to 5% of total energy intake or 1 to 2 glasses per day, whichever is less. It is contraindicated in conditions such as hypertriglyceridemia, obesity, neuropathy and poor glycaemic control.⁹¹

2.17.1.8 Sodium: People with diabetes are frequently hypertensive. Modest restriction of sodium intake can be beneficial to most diabetics. On the other hand, severe sodium restriction may be harmful in poorly controlled diabetes when there is postural hypertension and fluid imbalance. Daily intake of sodium is restricted to 1000mg/1000 kcal and not to exceed 3000mg/day.⁹¹

2.17.1.9 Sweeteners: The use of sweetners is acceptable. However, their use must be in moderation to avoid any potential risk.⁹¹

2.17.1.10 High Carbohydrate/High Fibre/Low Fat Diet

Current concept places emphasis on the glycaemic response of various carbohydrate foods rather than the traditional belief about simple versus complex carbohydrate in the treatment of diabetes mellitus.⁹¹ There is now considerable evidence that different carbohydrate containing foods even though they contain similar amounts of carbohydrates by chemical analysis cause widely different blood glucose response after ingestion.⁹¹

Recent studies have shown that high carbohydrate/high fiber diets are effective in lowering blood glucose and are beneficial for the management of diabetes, especially in those with T2DM. The same foods that have low glycaemic index also help to reduce blood cholesterol and triglyceride levels.

Such foods should make up the major portion of the carbohydrate in the diet for diabetics.⁹¹ The glycaemic index of food is the blood glucose of a food when compared to the level found after the ingestion of an equivalent amount of glucose. It is expressed in percentage.⁹²

2.17.1.11 Body Weight: Loss of body weight will often result in near normal glycaemic, blood pressure and lipid profiles. Often an ideal body weight may not achievable and setting this as a goal discourages patients to attempt any dietary change. Studies have suggested that a weight loss of 5 to 20% will improve glycaemic control.^{91, 92} Therefore it is important to encourage any degree of weight loss. A medium term goal for overweight patients should be

5–10% body weight loss.⁹²

2.17.2 Being Physically Active

Physical activity is necessary for diabetes self-care because it helps to keep blood glucose levels closer to normal. Everyday activities such as gardening may help subjects get better control of diabetes.

Increasing physical activity improves metabolic control in people with diabetes.⁹² Low level aerobic exercise for example brisk walking for half an hour per day have the following benefits: Improved glucose tolerance as insulin sensitivity increases, increased energy expenditure resulting in weight loss, increased feeling of well-being, increased work capacity and improved blood pressure and lipid profiles.⁹²

Aerobic activity for a minimum of 30 minutes 3 or 4 times per week establishes and maintains fitness and aerobic capacity. Greater than 150 minutes per week of moderate intensity physical activity is recommended.⁹²

When prescribing a physical activity program, a careful history should be taken and special attention needs to be paid to exertion-induced symptoms such as chest or abdominal discomfort or syncope.

The importance of appropriate foot care and comfortable, well-fitting footwear during physical activity needs to be stressed, especially if there is neuropathy, vascular disease, abnormal foot structure or previous foot ulcer.⁹²

Progressive resistance exercise (exercise with free weights or weight machines) improves insulin sensitivity in older men with T2DM to the same or even a greater extent than aerobic exercise.

Clinical trials have provided strong evidence for the HbA1c lowering value of resistance training in older adults with T2DM.⁹² In the absence of contraindications, patients with T2DM should be

encouraged to do at least two weekly sessions of resistance exercise, with each session consisting of at least one set of five or more different resistance exercises involving the large muscle groups.^{21, 92}

2.17.3 Monitoring of Blood Glucose

Self-monitoring of glycaemic control is a cornerstone of diabetes care that can ensure patient

participation in achieving and maintaining specific glycaemic targets. The most important objective of monitoring is the assessment of overall glycaemic control and initiation of appropriate steps in a timely manner to achieve optimum control. Self-monitoring provides information about current glycaemic status, allowing for assessment of therapy and guiding adjustments in diet, exercise and medication in order to achieve optimal control.⁸⁰

Self-blood glucose monitoring (SBGM) is recommended for diabetes on agents that can cause hypoglycaemia.⁹³ At the outset, close supervision is recommended.⁹³ A suggested initial schedule of testing is 3 to 4 blood glucose tests daily (early morning, plus other tests before and after meals).

However, this needs to be individualized. Frequency of selfmonitoring can be determined according to the individual's self-management goals. In the elderly patients, testing on 1 or 2 days per week, varying the time, may be adequate if

diabetes control is good.^92-93

Monitoring in T2DM need not be as intensive as with T1DM except when the normal pattern is broken such as travelling, during festive season, intercurrent illness, changes to medication and diet.⁹³ The ideal would be to have 2 blood glucose estimations done, one before meal and another after meal. Targets for self-monitored blood glucose levels are 4–7 mmol/l fasting and pre-prandial, and 6–

11 mmol/L 2 hours post prandial, depending on the individual.⁹² SMBG results can be helpful to guide treatment decisions and/or patient self-management for patients’ non-insulin therapies. When

prescribing SMBG, there is need to ensure that patients receive ongoing instruction.²¹ SMBG accuracy is instrument and user dependent, so it is important to evaluate each patient’s monitoring technique, both initially and at regular intervals thereafter.⁹³ Patients should be taught how to use SMBG data to adjust food intake, exercise, or pharmacological therapy to achieve specific goals. The frequency of SMBG should be re-evaluated at each routine visit.⁹³

2.17.4 Compliant with Medication

There are several types of medications that are often recommended for people with diabetes mellitus. Hypoglycaemic and antihypertensive agents; Aspirin, and others are prescribed together to help achieve optimal control and reduce the risk of complications.⁹²

Each medication come with specific instructions for use and has different mechanism of action.

Hence, it may take a while to determine which drug work best for a patient. It is important to educate subjects on how to recognize the effect of each drug on their body and encourage them to intimate their health care provider in cases of side effect whenever it is noticed.

The ability to recognize each drug with names, dosages and instruction for each medication; and the reason for each recommended drug is important to compliance. This calls for the availability of treatment partners for each patient as needed and also bring to fore the importance of an open line of communication between the patient and his/her family and the health care team. Fitting the medication routine into each patient’s daily schedule is also paramount to compliance. Each patient is also encouraged to bring all medications and labels along to the clinic on appointment days. This gives room for compliance assessment by selfreporting or pill-count.²¹

A friend or family member can serve as treatment partner and accompany the patient on appointment days to help take notes on important issue to aid proper medication compliant and serve as reminder for drug and other self-care activities.⁹²

2.17.5 Diabetic Foot Care - (Risk Reduction Behaviour)

Foot ulceration, sepsis, and amputation are universally known and feared by almost every person on hearing that they have diabetes. Yet at the same time, these are potentially the most preventable of all diabetic complications by the simplest techniques of education and care.⁹⁴ Most precipitating causes of foot ulceration and infection are mostly preventable with adequate foot care.⁹⁵ Friction in ill-fitting or new shoes, untreated callus, Self treated callus, foot injuries for example, unnoticed trauma in shoes or when walking barefoot, burns from hot radiators; corn plaster and paronychia are recognized as risk factors to foot ulcers.⁹⁴ The clinical features of Neuropathic foot are warm with intact pulses, diminished sensation; callus, ulceration usually on tips, sepsis, local necrosis, oedema and Charcot joints while that of ischaemic foot is painless, not warm with usually diminished sensation, ulceration usually on margin of toes and heels. It also include critical ischaemia when the foot is painful, pulseless

and cold.21, 95

2.17.5.1Identification of the Foot at-risk

Careful inspection and examination of the foot is an integral part of the regular medical review that all patients with diabetes should receive.⁹⁵ The clinician should never rely on symptoms alone to identify high-risk patients; 50% of patients with insensitive feet have no previous history of neuropathic symptoms, and claudication may not be prominent in those with ischaemic feet.⁹⁵ Patients at greatest risk of ulceration are those with: evidence of neuropathy, evidence of ischaemia, foot deformity (e.g. claw toes, Charcot changes), callous at pressure areas, previous history of foot ulcers, impairment of sight and patients with restricted vision, neuropathy, poor social circumstances as in the elderly, particularly those

living alone.²²

Signs of neuropathy include dry skin, callus formation, distended dorsal foot veins (autonomic dysfunction) and small-muscle wasting (somatic neuropathy).⁹⁵ Evidence of sensory loss should be established using a pin, a 128 Hz tuning fork and, if available, monofilaments to assess the pressure perception threshold. (Monofilaments are nylon fibres of various diameters that exert a fixed pressure when applied to the surface of the skin). Inability to perceive the pressure from a 10 g monofilament has been shown to be a sensitive but simple means of identifying an ‘at-risk’ foot.⁹⁵ Skin temperature and peripheral pulses should also be assessed.²²

2.17.5.2Prevention of Foot Problems

Patients without risk factors who have healthy feet should receive general advice on foot hygiene, nail care and purchase of footwear. Their risk status should be reviewed annually.⁹⁴ Patients with any risk factor should be reviewed more frequently, and should be educated about preventive foot care.⁹⁴ High-risk patients should be advised to: wash and inspect their feet daily, use creams or lotions to prevent dry skin/callus formation, always have their feet measured when purchasing shoes and avoid walking barefoot and thermal injury. They should seek medical attention for any injury/discomfort.

However trivial it may seem they should avoid the temptation to attempt self-treatment of corns, callouses and other disorders.⁹⁵ These simple steps have been shown to significantly reduce the incidence of foot ulceration.

2.17.5.3Grading of Diabetes Foot

Table 1: University of Texas Classification of Diabetic Foot

Stage Grade

0 1 2 3

A Pre-ulcerativeor post- ulcerative lesion

Completely epithelized

Superficial wound,

not involving tendon,

capsule or bone

Wound penetrating to tendon or capsule

Wound penetrating bone or joint

to

B With tendon With

infection

With infection

With infection

C With ischaemia With

ischaemia

With ischaemia

With ischaemia

D With infection and ischaemia

With infection and ischaemia

With

infection and ischaemia

With infection ischaemia

and

2.17.5.4Diabetes Foot Care Education

To avoid serious foot problems that could result in losing a toe, foot, or leg, the following guidelines should be given to patient during diabetes foot care education.^{94 – 96}

2.17.5.4.1 Daily foot inspection

Patients should check their feet for cuts, blisters, redness, swelling, or nail problems. If there is difficulty bending over to see the feet, a mirror can be used. In the alternative, a family member or caregiver can be of help. A magnifying hand mirror should be used to look at the sole of the feet.

Patients should be advised to seek the attention of the doctor when any abnormality is noticed.⁹⁵ 2.17.5.4.2 Daily foot washing

Patients should keep their feet clean by washing them daily with lukewarm water. Then wipe it clean with dry towel. Talcum powder or cornstarch could be used to keep the skin between the toes dry to prevent infection.⁹⁴

2.17.5.4.3 Keep the foot moist

The use of a moisturizer daily should be encouraged to keep dry skin from itching or cracking.

However, moisturizing between the toes should be avoided as this could encourage a fungal infection.⁹⁴

2.17.5.4.4 Nail care

The toenails should be trimmed with nail clippers after washing. This should be done straight across and the corners smoothened with nail file. This would prevent the nails from growing into the skin.

Cut into the corners of the toenail. Razor blades or corn plasters should not be used to remove corn and callus as these could damage the skin and cause infection.⁹⁴

2.17.5.4.5 Foot-ware

Patients should be encouraged not to walk barefoot when indoors or outside. Clean, lightly padded socks with no seams that fit well should be worn. Tight elastic bands that could reduce circulation to the foot should be avoided. They should also be instructed to wear shoes that fit well and protect the feet. The inside of the shoe should be checked before putting them on to ensure that the lining is smooth and that there are no objects in the shoes.⁹⁴

2.17.5.4.6 Foot protection

Patients should be instructed to keep their feet away from heaters and open fires. Hot water bottles or heating pads should not be placed on their feet. They should be told not to cross their legs for long periods of time as this could obstruct blood flow.⁹⁴

2.17.6 Psychosocial Assessment and Care

It is reasonable to include assessment of the patient’s psychological and social situation as an ongoing part of the medical management of diabetes.⁸⁶ Psychosocial screening and follow-up may include, but is not limited to attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional), and psychiatric history. It is important to establish that emotional well-being is part of diabetes care and self-management Psychological and social problems can impair the individual’s or family’s ability to carry out diabetes care tasks and therefore compromise health status.⁷⁶ There are opportunities for the clinician to assess psychosocial status in a timely and efficient manner so that referral for appropriate services can be accomplished.