PENGENDALIAN PERKHIDMATAN PENYAKIT TIDAK BERJANGKIT NCD UNTUK PARAMEDIK
PENGENDALIAN PERKHIDMATAN PENYAKIT TIDAK BERJANGKIT (NCD) UNTUK PARAMEDIK KEMENTERIAN KESIHATAN MALAYSIA KULIAH 9 – DIABETES ANJURAN : BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA DAN BAHAGIAN KAWALAN PENYAKIT Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
PATOFISIOLOGI DIABETES Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Diabetes: The Disease • It is a common chronic disorder • There is chronic hyperglycaemia together with other metabolic abnormalities • It is due to insulin resistance and/or deficiency as well as increased hepatic glucose output • It is a risk factor for CVD • Currently there is no known cure but the disease can be controlled enabling the person to lead a healthy and productive life • The aim of management is directed at reducing complications (micro and macrovascular) Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
KLIEN BERISIKO DIABETES Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Who should be screened? : Asymptomatic (ADA Position Statement 2015) Testing should be considered in all adults who are overweight [body mass index (BMI) > 23 kg/m 2 or waist circumference (WC) > 80 cm for women & > 90 cm for men] and have additional risk factors: • Dyslipidaemia either high density lipoprotein (HDL) cholesterol < 0. 9 mmol/L or triglycerides (TG) > 2. 8 mmol/L • History of cardiovascular disease (CVD) • Hypertension (≥ 140/90 mm. Hg or on therapy for hypertension) • Impaired Glucose Tolerance (IGT) or Impaired Fasting Glucose (IFG) on previous testing • First-degree relative with diabetes • Other clinical conditions associated with insulin resistance (e. g. , severe obesity and acanthosis nigricans) • Physical inactivity • Women with polycystic ovarian syndrome (PCOS) • Women with history of gestational diabetes / baby > 4 kg should be screened for diabetes annually. Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Prevalence of Diabetes, ≥ 18 years, by age groups (2015) 45. 0 40. 0 38. 3 35. 0 27. 9 26. 5 24. 4 22. 0 20. 0 24. 4 20. 6 17. 6 14. 8 15. 0 12. 9 10. 6 9. 5 7. 2 3. 9 3. 4 6. 9 3. 4 4. 6 6. 0 5. 8 11. 8 5. 9 5. 8 12. 6 11. 2 5. 5 6. 0 5. 4 4. 8 Known Undiagnosed Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik Total diabetes IFG + 75 4 70 -7 9 65 -6 4 60 -6 9 55 -5 4 50 -5 9 45 -4 4 9 35 -3 30 -3 4 1. 4 9 0. 7 4 18 -1 9 0. 0 20 -2 5. 5 3. 6 5. 9 5. 2 3. 6 25 -2 10. 0 8. 9 7. 4 13. 6 12. 4 12. 2 11. 5 10. 5 11. 0 40 -4 Prevalence (%) 27. 0 25. 0 0. 0 37. 0 32. 9 30. 0 5. 0 39. 1 38. 0
KAEDAH SARINGAN • • • Venous or capillary blood using a glucometer A 1 C OGTT FBG RBG Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Algorithm: Screening for T 2 DM at Primary Care Level – With Symptoms WITH SYMPTOMS Venous Plasma Glucose Fasting < 7. 0 OGTT Random ≥ 7. 0 > 11. 1 Type 2 Diabetes Mellitus • All values in mmol/L Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik < 11. 1 OGTT
Algorithm: Screening for T 2 DM at Primary Care Level – Without Symptoms ASYMPTOMATIC WITH RISK Capillary Plasma Glucose < 5. 6 > 5. 6 Random Plasma Glucose (RPG) Fasting Plasma Glucose (FPG) < 7. 8 NORMAL < 6. 1 to 6. 9 Follow-up > 7. 0 7. 8 to 11. 0 OGTT > 11. 1 Second RPG Second FPG Follow-up < 7. 0 > 11. 1 DM OGTT DM FPG 2 hour PPG < 6. 1 to 6. 9 > 7. 0 < 7. 8 to 11. 0 > 11. 1 NORMAL IFG DM NORMAL IGT DM • All values in mmol/L Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
INTEPRETASI KEPUTUSAN & DIAGNOSA Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Diagnostic Values for Diagnosis of T 2 DM based on Venous Plasma Glucose Fasting Random ≥ 7. 0 mmol/L ≥ 11. 1 mmol/L • In the symptomatic individual, one abnormal glucose value is diagnostic • In the asymptomatic individual, 2 abnormal glucose values are required Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Diagnostic Values - OGTT Plasma Glucose Values (mmol/L) Category 0 -hour 2 -hour Normal ≤ 6. 1 < 7. 8 IFG 6. 1 – 6. 9 - IGT - 7. 8 – 11. 0 DM ≥ 7. 0 ≥ 11. 1 Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Diagnostic Values for Pre-Diabetes and T 2 DM based on A 1 c Normal Pre-diabetes Diabetes <5. 6% (38 mmol/mol) 5. 6 – 6. 2% (38 -44 mmol/mol) > 6. 3% (45 mmol/mol) Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
PENGAMBILAN SEJARAH • • • Sejarah Keluarga Merokok Kehamilan Obesity / BMI Tabiat makan Aktiviti fizikal Sejarah perubatan Pengambilan ubat-ubatan / supplemen Penurunan berat badan Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
PEMERIKSAAN FIZIKAL • • • BP BMI Visual acuity Pemeriksaan kaki Pemeriksaan saraf – sensation (touch, vibration) Blood glucose Pemeriksaan CVD Tanda cutaneous / kulit Keadaan fizikal Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
UJIAN ASAS Fasting blood glucose (FBG) A 1 c Renal Profile Lipid profile Liver function test Urinalysis for albumin, microalbuminuria if albuminuria is absent • ECG • Fundus photo • • • Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
JANJITEMU SUSULAN • Bergantung kepada rawatan • Bila keputusan darah di jangka boleh di semak • Keperluan mengambil ujian darah / ujian-ujian lain (ECG, fundus photography) • Janjitemu susulan dengan PSP / pegawai dietetik / diabetes educator • Terkawal – 3 bulan Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
PEMANTAUAN K 0 -MORBIDITI DAN KOMPLIKASI • • • Sekurang-kurangnya setahun sekali Fundus examination – setahun sekali ECG – setahun sekali Pemeriksaan kaki – setahun sekali Pemantauan ginjal – setahun sekali Ujian makmal – setahun sekali Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Type 2 diabetes increases CVD risk § Any CVD event § Stroke Intermittent claudication † Cardiac failure † † CHD § § ‡ ‡ MI § Angina pectoris Sudden death * N/A † Coronary mortality 1 Men with diabetes Women with diabetes † 2 3 4 5 Age-adjusted risk ratio (1 = risk for individuals without diabetes) *p < 0. 1; †p < 0. 05; ‡p < 0. 01; §p < 0. 001 6 Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik Adapted from Kannel WB et al. Am Heart J 1990; 120: 672– 6.
INTERVENSI DIABETES UMUM (PHAMACOLOGICAL & NON PHARMACOLOGICAL) Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Intervention • Diet and physical activity are the mainstay of therapy. • Weight loss remains a priority in prevention of T 2 DM • In addition, Metformin should be considered: – Those at very high risk (combined IFG & IGT, plus other risk factors) – Fail lifestyle therapy after 6 months Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Diabetes Education DOCTOR: Clinical Evaluation EDUCATOR Reinforce on the importance of continuous education Review for Medication EDUCATOR Doctor, Nurse, Assistant Medical Officer, Health Education Officer, Dietitian and others OBJECTIVE • To reassure and alleviate anxiety ·To understand the disease, its management and complication ·To promote compliance and self-care EDUCATION PLAN Assess knowledge, skill, attitude, health beliefs, psychosocial barriers, education needs CONTENTS Diabetes • Diet ·Exercise ·Medication ·Complications (acute and chronic) ·Self-care/SBGM/foot care ·Stop smoking ·Problem solving skills ·Psychosocial adaptation to diabetes Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Medical Nutrition Therapy: General recommendations 1. Nutrition counselling by a dietician is recommended 2. Dietary counselling should be individualised according to: n n Nutritional needs Severity of disease Cultural preferences and Willingness to change Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Physical Activity • Increased physical activity can improve glycaemic control, assist with weight maintenance and reduce risk of CVD. • Before beginning a program more vigorous than brisk walking: – Assess for complications (CVD, retinopathy, neuropathy and foot injury) – Patient’s age and previous physical activity level should be considered Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
General recommendations • Exercise 5 days a week, preferably most days of the week and with no more than 2 consecutive days without physical activity • Supervised exercise programs • Both aerobic and resistance exercise beneficial • Duration at least 150 min/week moderate intensity aerobic • 90 minutes / week of vigorous aerobic Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
General Recommendation • Overweight and obese individuals should gradually increase physical activity to 60 -90 minutes per day for long term weight loss • Any increase in daily energy expenditure is beneficial emple gardening, walking up stairs etc • In order to prevent hypoglycaemia, medication doses can be reduced or extra carbohydrate can be consumed before or during physical activity Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
TAKE HOME MESSAGES • Diabetes adalah penyakit kronik yang progresif dan menyebabkan komplikasi yang boleh membawa kematian dan mobiditi • Penyebab kematian kardiovaskular tertinggi • Masalah metabolic rembesan insulin menyebabkan pancreas menghasilkan jumlah insulin yang kurang (insulin deficiency), gagal (insulin failure) atau organ tisu menghadapi rintangan tindak balas insulin (insulin resistance) • Diabetes kerap kali adalah asymptomatic • Saringan untuk semua individu berumur 30 ke atas • Pengambilan sejarah dan pemeriksaan fizikal mestilah menjurus kepada fakta risiko / symptom diabetes Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
TAKE HOME MESSAGES • Pemantauan komplikasi dan ko-mobiditi sekurang -kurangnya setahun sekali atau lebih kerap jika simptomatik • Ujian pemantauan / asas hendaklah di buat sekurang-kurangnya setahun sekali / mengikut CPG DM 2015 • Intervensi non-pharmacology (diet dan aktiviti fizikal) hendaklah menjadi asas pengendalian diabetes • Pendidikan diabetes sangat penting untuk memastikan pesakit diabetes diperkasa dan boleh mengendalikan diabetes sendiri Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
Thank You Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik
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