1

The Technical Working Group

The Technical Working Group is a multidisciplinary group composed of representatives from the 4 implementing partners of the CVD Program and other relevant stakeholders. The Technical Working Group met in 6 workshops in 2010 to finalize the 4-party Memorandum of Understanding, draft the city proclamation declaring the citys observation of the World Heart Day, develop the CVD Program including its systems (health care delivery, referral system and monitoring system), review all the CVD program tools (information, education and implementation tools) and develop the basic training for the primary health care providers. The meetings of the Technical Working Group was facilitated and supported by Handicap Internationals CVD Project team. Technical Working Group Members: Dr. Anabelle Yumang - NCD Coordinator Department of Health CHD Davao Region Dr. Josephine Villafuerte- City Health Officer Davao City Dr. Julinda Acosta CVD Program Medical Coordinator, District Health Officer City Health Office Ms. Chona Dazon RN-CVD Program Nurse Coordinator City Health Office Dr. Maribel Camelotes- District Health Officer Calinan District City Health Office Ms. Ma. Teresa Ng RND- Nutrition Officer City Health Office Ms. Leah Flor Suelan RN - Public Health Nurse Talomo North City Health Office Ms. Trinidad Yambao RN - Public Health Nurse City Health Office Ms. Nelia Sarona -Public Health Midwife-Talomo North District City Health Office Ms. Alice Jaen- Public Health Midwife-Barangay Lapu-Lapu City Health Office Ms. Vilma Ong - Public Health MidwifeCity Health Office Ms. Florencia Cayon -PEO IV-City Planning and Development Office Dr. Suzette Q. Alegarbes HeadMindanao Diabetes Center Southern Philippines Medical Center Dr. Ryan Lonzaga Chief Resident -Surgery Department Southern Philippines Medical Center Dr. Raymund Darius Liberato -Chief Resident -Internal Medicine- Southern Philippines Medical Center Ms. Ma. Elena Zapanta RN-Diabetes Nurse Educator-Mindanao Diabetes Center Southern Philippines Medical Center Ms. Vivien Bayacag RND-Nutritionist DietitianMindanao Diabetes Center Southern Philippines Medical Center Ms. Nonnah Vee Macasaet RNWound Care Nurse Wound and Ostomy Care Unit Southern Philippines Medical Center Ms. Imelda Mallorca Psychologist - Wellness Center - Southern Philippines Medical Center Ms. Chona Serra PTRP-Program Coordinator Physical Rehabilitation - Davao Jubilee Foundation Dr. Ivy Boyose NolascoHandicap International Mr. Richard Erick Caballero RNHandicap International Handicap International CVD Project Team Ms. Ivy Boyose-NolascoProject Manager Ms. Mary Ann S. CabigonAdmin and Finance Mr. Richard Erick CaballeroHealth Capacity Building Officer Mr. Erolle Linus MirandaCommunication Officer Mr. Rudy CaloniaOrganizational Development Officer Ms. Aprilyn BalaquitPeer Support Officer Ms. Evisa Jean CaroTraining Assistant Ms. Eva Diana BaldozaLogistics Assistant Mr. Anthony BarcelonGeneral Services

Table of Contents
CONTENT Page

I II III

History of the CVD Program Training Design Introduction Integrated NCD Prevention and Control Program

5 6 9 10 14 17 18 19 20 21 24 25 26 27 28 29 30 31 32 33 36 36 38 39 40 44 46

IV

Module 1: CVD Overview: Risk Factors, Signs & Symptoms, Pathophysiology Diabetes mellitus Diabetes and Cardiovascular Disease Risk Factors of Diabetes and Cardiovascular Disease Pathophysiology Signs and Symptoms of Diabetes and Cardiovascular Disease Complication of Diabetes

Module 2: Screening, Diagnosis and Monitoring Definition of Terms Screening of Diabetes and CVD Risks Risk factors for Screening Algorithm for Diabetes Screening and Diagnosis for Adults Diabetes Risk Assessment Cardiovascular Event Risk Assessment Diagnosis of Diabetes and Hypertension Biochemical Tests for Screening and Diagnosis of Diabetes Screening and Diagnosis of Hypertension Monitoring of CVD Risks The 7 Monitoring Parameters

VI

Module 3: Management: Pharmacologic Treatment, Medical Nutrition Therapy and Lifestyle Interventions Pharmacologic Management of Diabetes Medical Management of Diabetes in Health Centers DOH Algorithm ADA/EASD Algorithm AACE/ACE Diabetes Algorithm Oral Anti-Diabetic Agents Insulin

Table of Contents

CONTENT Pharmacologic Management of Hypertension Oral Antihypertensive Drugs Pharmacologic Management of Dyslipidemia Oral Lipid Controlling Agents Medical Nutrition Therapy Setting Dietary Management Goals WHO Protocol for Counselling on Diet and Physical Activity Basic Nutrition Education Using the Plate Method Using the Food Diary Meal Planning Using the Plate Method Calculating Individualized Dietary Prescription Weight Management Physical Activity and Exercise The Activity Pyramid Tobacco CessationWHO: 5A Steps Protocol The Smokers Body VII Module 4: Foot, Wound and Stump Care Foot Care Foot Complications due to Diabetes Pathways to the Development of Foot Ulcers The 5 Cornerstones of Foot Management Basic Foot Care Practice Appropriate Footwear Identifying the Foot At-risk for Amputations Conducting Foot Care Sessions in Health Centers Foot Risk Assessment Wound Care Introduction to Wounds Definition and Classification of Wounds Steps in Wound Management Wound Assessment Wound Care Wound Monitoring Stump Care Importance of Stump Care Proper Residual Limb Positioning Residual Limb Wrapping

Page 48 49 51 52 53 54 55 56 57 58 60 64 69 72 74 78 79 81 82 83 84 86 87 88 89 90 92 92 96 98 100 101 102

Table of Contents

CONTENT Criteria for Artificial Leg Fitting Monitoring of Prosthesis and Stump VIII Module 5: Psychosocial and Behavioral Approaches Professional Attitudes and Behaviors 5 C Intervention Behavioral and Psychosocial Interventions in Diabetes: A Conceptual Review by Mark Peyrot PHD and Richard Rubin PHD IX Module 6: Self-Management Education Introduction The Health Educator The E.A.S.E Approach Using Patient Education Materials The Diabetes Diary Medical Nutrition Therapy Kit X Module 7: Setting up Services for CVD Risk Management in Primary Health Centers Introduction to Team Management CVD Program Tools and Equipment Functions of the Health Care Team Making Health Services Physically Accessible Information Dissemination Flow of Services for New Patients Generating the Patient Record Recording in the Patient Registry Flow of Services for Old Patients Referral Indications for Referral The Referral Form Reporting Barangay Health Station Monthly Statistics XI Module 8: Community Health Workers Training Training Design Training Documentation

Page 105 105 108 108 109 110

118 119 120 121 122 133

134 134 135 136 138 139 140 144 147 148 149 151 152 156 159

Setting up Health Services for CVD Risk Management in Primary Health Centers 137

History of the CVD Program

Upon completion of all legal requirements and securing the commitment of partner implementers, the CVD Program is set for full implementation in Davao City in 2011. This partnership to implement a city-wide program in the next 3 years is formalized through a 4-party Memorandum of Understanding (MOU) between Handicap International, the City Government of Davao with the City Health Office as its implementing arm, Southern Philippines Medical Center (formerly Davao Medical Center) and the Department of Health-Center for Health Development Davao Region.

the course of the program implementation. In the next three years 3 major trainings will be implemented in a progressive manner to increase the chances for program sustainability namely: 2011 - Basic Training, 2012- Advanced Training and 2013-Training of Trainors.

The creation of the CVD Program is facilitated by Handicap International through its Cardiovascular Disease (CVD) Project in the city of Davao. The CVD Project aims to empower relevant stakeholders through capacity building to implement integrated cardiovascular risk management (diabetes and hypertension as entry-points) and to coordinate their actions in order to increase access to health services. The project is implemented with a local A technical working group mainly consisting of inclusive development approach focusing on the representatives of the 4 partners is formed to capacity building of service providers (City Health spearhead the implementation of the CVD Office, and local rehabilitation service providers), program. The group met 5 times in 2010 to: plan for local diabetes support groups and policy makers the development of the program including how the (local government units). This is a 4-year project program will be implemented through systems of which follows the 3-year pilot Diabetes Project health service provider trainings, health care implemented from 2006 to2009. It aims to build on delivery and referral. A system of program the lessons learned from pilot testing in 10 pioneer monitoring is also planned. Handicap International barangays and replicate best health service serves as the coordinating body for the duration of delivery practices in the rest of the 182 barangays. the MOU and provides both financial and technical Tools for patient education and health service support. The CHO and SPMC will serve as the delivery developed during the first phase are implementing agencies while the DOH will provide improved on for use in the CVD Program. An technical guidance for the alignment of the important project strategy is the development of a program with current Philippine health programs. functional referral system among the health and HIs functions will be slowly turned over to the 3 other rehabilitation service providers for a coordinated partners (mainly with the City Health Office) during effort to increase access to health care.

Training Design
Objectives
General: Primary Health Care Professionals are able to implement integrated CVD risk management (focusing on diabetes and hypertension) and to coordinate their actions to provide quality health care services. Specific: At the end of the four-day training, the following are achieved:

1. Health Care Professionals are able to manage patients with diabetes and hypertension in a
multidisciplinary manner.

2. Health Care Professionals are able to implement the CVD Program and all its sub-activities in the 3.
community level. Health Care Professionals are able to train community health workers to implement the CVD Program.

Methodology
Methods take into consideration the adult learning process so lectures are minimal. Participants will be divided into groups of 4 for most of the activities. Case studies are the main method where 2 patients will be consistently discussed throughout the training. Facilitators will refer to these cases during their sessions. These patients will be introduced via a short film. More information about the 2 main characters will be provided as the training progresses and will be the bases for discussions. Sessions are also activity-based and will use group discussions, role playing and return demonstrations to maximize participation eg. actual aerobic exercise during the physical activity part. Training tools will also be maximized to make the training as visual as possible.

Training Programme
Program DAY 1 Registration Opening Ceremonies Preliminaries Attendees fill up attendance sheet and training kits will be distributed Opening Prayer National Anthem Getting to know you activity 8:00 9:00 9:009:15 9:1510:15 E.J. Caro E.D. Baldoza A. Balaquit C. Dazon R.E. Caballero R.E. Caballero I. Nolasco R.E. Caballero Dr. J. Acosta Dr. A. Yumang C. Dazon E.J. Caro Activity / Topic Time Facilitator

Levelling of Expectations and Presentation of the training objectives General Orientation to the Training Program Pretest Introduction Examination Overview of the CVD Program

10:1510:30 10:3010:45

10:45 11:30 11:30 12:15

Training Design
Training Program
Program DAY 1 Lunch Attendance Check Module 1 CVD Overview: Risk Factors, Signs and Symptoms and Pathophysiology Screening, Diagnosis and Monitoring Reading assignments maybe given in preparation for the sessions on the succeeding day END OF DAY 1 1:002:30 12:15 1:00 E.J. Caro Dr. S. Alegarbes Dr. A. Echavia Dr. J. Acosta Dr. I. Nolasco R.E. Caballero C. Dazon RE Caballero Activity / Topic Time Facilitator

Module 2 Daily Evaluation

2:30 5:30 5:30 6:00

DAY 2 Breakfast Review of Day 1 Knowledge Check 7:00 8:00 8:00 8:30 C. Dazon RE Caballero E.J. Caro Dr. S. Alegarbes Dr. A. Echavia E. Zapanta V. Bayacag M.T. Ng

Module 3

CVD Management: Pharmacologic Treatment, MNT and Lifestyle Interventions Introduction to Diabetes and Hypertension Management Calculating the TER / Diet Prescription Physical Activity and Prescription Case Study and Group Work Discussion of Case Studies Calculation of Own TER Physical Activity

Lunch Attendance Check Module 3 cont. Module 4

8:308:40 8:409:10 9:109:30 9:3010:00 10:0011:00 11:0011:30 11:3012:00 12:00 1:00

V. Javier E.J. Caro

Daily Evaluation

Tobacco Cessation Counselling Protocol CVD Management: Foot, Wound and Stump Care Basic Foot Care Basic Wound Care Stump Care Day-end evaluation and reading assignments END OF DAY 2

1:002:00 2:00 3:30 3:304:30 4:305:30 5:305:45

E. Zapanta Dr. I. Nolasco N. Macasaet C. Serra C. Dazon RE Caballero EJ Caro

Training Design
Training Program
DAY 3 Breakfast Review of Day 2 Knowledge Check 7:00 8:00 8:00 8:30 C. Dazon R.E. Caballero E.J. Caro I. Mallorca E. Zapanta R.E. Caballero Dr. I Nolasco E. Zapanta V. Javier E. Caro Setting Up Services for CVD Risk Management in Primary Health Centers Day-end evaluation and reading assignments 1:00 5:00 5:00 5:30 I. Nolasco R.E. Caballero C. Dazon R.E. Caballero E.J. Caro

Module 5 Module 6

Psychosocial and Behavioral Approaches Patient Education

8:3010:00 10:0011:30

Physical Activity Lunch Attendance Check Module 7 Daily Evaluation

11:30 12:00 12:00 1:00

END OF DAY 3

DAY 4 Breakfast Practicum Diabetes and Heart Day 7:00 8:00 8:00 11:00 C. Dazon R.E. Caballero I. Nolasco C. Dazon R.E. Caballero V. Javier E.J. Caro Training Schedules 1:00 2:00 R.E. Caballero C. Dazon R.E. Caballero C. Dazon E.J. Caro C. Dazon R.E. Caballero

Module 8

The Community Health Workers Training Physical Activity

11:00 11:30 11:30 12:00 12:00 1:00

Lunch Attendance Check Action Planning and Commitment Setting Post test Training Evaluation Closing Ceremony Awarding of Certificates END OF TRAINING

Post Test Discussion of Post test answers

2:00 3:00 3:004:00 4:004:30 4:30 5:30

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INTRODUCTION
Cardiovascular disease (CVD) is responsible for one-third of all global deaths. Nearly 85% of the global mortality and disease burden from CVD is borne by low- and middle-income countries. The majority of the estimated 32 million heart attacks and strokes that occur every year are caused by one or more cardiovascular risk factors hypertension, diabetes, smoking, high levels of blood lipids, and physical inactivity and most of these CVD events are preventable if meaningful action is taken against these risk factors. Hypertension is the most prevalent CVD, affecting at least 600 million people, and is an important contributor to cardiovascular mortality and morbidity. Diabetes currently affects more than 250 million individuals worldwide. This number is expected to rise to over 333 million by 2025 if we do not do anything about it. Obesity, changing lifestyles and dietary practices and aging populations contributed significantly to a one-third increase in diabetes during the 1990s, but the greater bulk of this increase will occur in the Indian and Asian subcontinents, due to a complex interplay of genetic, environmental and social factors, such as rural-urban migration and industrialization. People with diabetes are 2- to 4-times more likely to develop cardiovascular disease than are those without diabetes. Eight of 10 people with diabetes will die from a cardiovascular disease. The devastating complications of diabetes blindness, kidney failure, and heart diseaseare imposing an enormous burden on health care services. In some countries, up to 10% of health care costs can be attributed to diabetes.

For CVD prevention activities to achieve the greatest impact a paradigm shift is required, away from the treatment of risk factors in isolation, to a comprehensive cardiovascular risk-management approach.
In many settings, the management of hypertension is sub-optimal, mainly due to barriers related to patients, health-care providers and the health system. Furthermore, the management of cardiovascular risk, compared to treating elevated blood pressure per se, demands more skills and better-maintained and better-equipped facilities.

Excess weight abdominal fat in particular increases insulin requirements and compounds the problem of insensitivity to insulin. Therefore, Regrettably, the prevention of CVD often disturbing increases in the prevalence of type 2 focuses on single risk factors such as diabetes or diabetes reflect the rising prevalence of obesity. hypertension rather than on comprehensive cardiovascular risk. For CVD prevention activities to There are particularly disturbing trends in achieve the greatest impact a paradigm shift is adolescents thought to be exacerbated by required, away from the treatment of risk factors in decreased exercise and increased calorie and fat isolation, to a comprehensive cardiovascular intake. Research has shown that some ethnic risk-management approach. Evidence based, groups are at higher risk than others. Communities cost-effective interventions are available for of Asian Indians and people from African origin, for addressing comprehensive cardiovascular risk, example, show higher rates of type 2 diabetes and and the challenge now is to use what we know, appear to suffer more in terms of diabetes particularly in low- and middle-income countries. complications such as kidney failure compared This calls for resource-sensitive, innovative to Caucasian populations. strategies. Diabetes is a worlds leading cause of blindness, end-stage renal disease, and non-traumatic lower-limb amputations. Furthermore, diabetes is the 4th leading cause of death by disease around the world.

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Introduction

The Philippine Situation

The Philippines is one of the 23 selected countries contributing to around 80% of the total mortality burden attributable to chronic diseases in developing countries, and 50% of the total disease burden caused by non-communicable diseases worldwide
Heart disease and stroke continue to be the top causes of mortality in the Philippines in 2010. Diabetes mellitus has become the 5th cause from being the 9th cause of mortality in 2009. A cross-sectional population based study was conducted in 2002 among 7044 adults aged 20-65 years old residents of urban and rural areas in Luzon in the Philippines estimated the crude diabetes prevalence to 5.1% which represented a 54% increase over the figure (3.3%) in 1982. This study reported that diabetes were unknown by one in three diabetics. The Philippine Cardiovascular Outcome Study-Diabetes Mellitus (PHILCOS-DM), a community -based descriptive cohort study done in 2006, noted the increasing incidence of pre-diabetes states, and overt conversion to diabetes in such a short time interval. Using the newer cut-off level of 100-125mg/dl, the prevalence of impaired fasting glucose (IFG) is 30% while the prevalence of impaired glucose tolerance (IGT) is 25%. The 8-years incidence of diabetes mellitus using fasting blood glucose (FBG) is 9% and the prevalence is 19%. WHO projects that the number of diabetics in the Philippines will increase from 2.8 in 2000 to 7.8 Millions in 2030. [7] In Davao City, in 2006, diabetes was the 9th cause of death with 274 deaths or 20.1 per 100,000 inhabitants.

90% of Filipinos has one or more of these 6 prevalent risk factors

(NNHeS, FNRI 2003) 1. 2. 3. 4. 5. 6. Physical inactivity60.5% Smoking.34..8% Hypertension.22.5% (SBP>140 or DBP>90) Hypercholesterolemia ..8.5% (TC>240) Obesity4.9% (BMI>30) Diabetes..4.6%n

Current Use of Tobacco Product Among Adolescents

Both Sexes: 27% (20% in 2003) Boys: 34% (27% in 2003) Girls: 14% (13% in 2003) continued

Integrated NCD Prevention and Control Program

Vision: Improved quality of life for all Filipinos

To increase the proportion of NCD cases given appropriate treatment and care

Mission: To ensure that quality prevention and conPolicy Thrusts trol NCD services are accessible to all, especially to the vulnerable and at-risk population. Adoption of an integrated, comprehensive and Goal: To reduce mortality and morbidity due to community-based response to NCD prevention NCDs and control; Objectives: To reduce the exposure of population to risks related to NCDs primarily smoking, unhealthy diet, physical inactivity. Strengthening health promotion to effect changes that lead to significant reduction in mortality and morbidity due to NCDs; Fostering complementary accountabilities in the implementation of the program.

Introduction
Integrated NCD Prevention and Control Program
Adoption of an integrated, comprehensive and community based response to NCD prevention and control Focuses on common risk factors cutting across specific diseases guided by a life course perspective;

11

continued

Makes explicit links to other government programmes, community based organizations Emphasizes intersectoral action

Health Status Targets Reduction of mortality from lifestyle-related diseases: Encompasses the three levels of disease Heart diseases (from 79.1/100,000) prevention: primary, secondary and tertiary level Vascular diseases (from 63.2/100,000) Emphasizes strategies which would benefit entire COPD (20.8/100,000) population or large packets of population Diabetes mellitus (from 14.1/100,000) Integrates across settings; such as health centers, Malignant neoplasm all form (from 47.7/100,000) schools, workplaces and communities

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Introduction

Notes:

Introduction
Notes:

13

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Module 1 CVD OVERVIEW: RISK FACTORS, SIGNS AND SYMPTOMS, PATHOPHYSIOLOGY
Contents:
1. 2. 3. 4. 5. 6. 7. 8. Definition of Diabetes Mellitus Definition of Cardiovascular Disease (CVD) Diabetes Mellitus and CVD Risk Factors of Diabetes Mellitus and CVD Pathophysiology Signs and Symptoms Chronic Complications Misconceptions

Is a chronic illness that requires continuing medical care, on-going patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications.
American Diabetes Association Definition

Diabetes Mellitus
The human body needs energy for its survival and it is Adenosine triphosphate (ATP) that serves as the fuel that maintains the integrity as well as the normal processes that ensure survival. In order to generate ATP, we need its main substrate, which is glucose. The normal process of glucose metabolism is controlled by a negative feedback system. After food is ingested intestinal absorption and chemical breakdown of carbohydrates, proteins and fats lead to serum blood glucose elevation. The increase in blood glucose stimulates the beta cells to release insulin. Serum insulin levels begin to rise within minutes after a meal, reach a peak in about 3 5 minutes, and then gradually reach a baseline level in 2 3 hours. Diabetes is a chronic condition characterized by hyperglycemia. It is caused by deficient insulin production, resistance to insulin action or a combination of both. Knowledge of the relationship between glucose, insulin and counter-regulatory hormones and glucose homeostasis is important in understanding these defects and how they result in abnormal glucose and fat metabolism. Insulin is released in a biphasic manner. A first-phase release of stored insulin occurs in 3 5 minutes, and then a second-phase release begins after about 2 minutes and continues until the stimulus stops. Glucose is then either utilized by the different organ cells or is transported to the liver and muscles to be stored as glycogen (glycogenesis). Just as a rise in blood glucose levels stimulates the release of insulin, a low blood glucose level inhibits the release of insulin.

Normal Glucose Metabolism

For proper management of diabetes, it is important that we understand normal metabolic mechanisms In addition to intestinal absorption of food-derived and what happens in diabetes because it facilitates glucose the other major source of plasma glucose is the liver. The contribution of the liver to plasma our understanding of key areas of intervention. glucose concentration is through two important mechanisms:

Module 1
Glycogenolysis- breaking down of glycogen stores into glucose Gluconeogenesis- formation of glucose from non -glucose precursors

15

Fat is stored in adipose tissue as triglycerides (TG) and it contains the highest energy value among ingested foods. Lipolysis refers to the break down of TGs into glycerol and free fatty acids (FFA). Only odd-chained FFAs such as propionate can directly In the fasted state, glycogen is broken down into contribute to net gluconeogenesis (formation of glucose and released into the plasma, to meet the glucose). Glucose stored as fats are then used up by energy requirements of the body. This supply is rather other organs and peripheral tissues of the body while limited, so that if fasting is extended, and glycogen glucose from carbohydrate sources are then stores have been depleted, gluconeogenesis then shunted or mobilized for the use of the brain which is occurs. a vital organ for survival. The end-products of the breakdown of carbohydrates (lactate and pyruvate), fats (glycerol), and proteins (amino acids) serve as precursors of gluconeogenesis. Other substrates include lactate released from muscles during anaerobic glycolysis, and glycerol from adipose tissue mobilization of stored triglycerides. The muscles also utilize glycogen for immediate energy needs but glycogenolysis in the muscle only provides for the energy needs of that organ and the amounts produced are not enough for circulation to other parts of the body. The next sources of energy are free fatty acids (FFAs) once carbohydrate sources of glucose have been used up. Amino acids from tissue protein (mostly muscle proteins) are the most important substrates for gluconeogenesis in the fasting state. Almost all amino acids resulting from breakdown of muscle protein (except leucine) are available for gluconeogenesis.

Role of Insulin
Energy intake exceeds the energy requirements of the body during the fed state (anabolic phase) and the rise in plasma glucose concentration stimulates the release of insulin, a hormone that regulates glucose levels. Insulin facilitates the uptake of glucose into the cells of most tissues:

Normal Blood Glucose and Insulin Patterns throughout the Day with Food Intake

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Module 1

Definition of Diabetes continued

In the liver insulin decreases glucose production by: facilitating glycolysis and glucose uptake inhibiting glycogen breakdown and gluconeogenesis increasing transformation of FFA to triglycerides increasing free amino acid transport across hepatocytes (liver cells) In adipose tissues insulin increases circulating free fatty acids in the blood by inhibiting their breakdown (lypolysis) In muscles insulin facilitates glucose and free amino acid transport across cells All insulin-sensitive organs insulin facilitates glucose uptake

Types of Diabetes

The loss of beta-cells, relative insulin deficiency, and elevated blood glucose levels occur at an early stage of life. Some of the excess glucose is taken up In Type 1 diabetes, the destruction of the by fat cells or by the liver and converted to insulin-producing beta cells is usually an triglycerides. The storage of these triglycerides in the autoimmune process in people with a genetic liver leads to the fatty liver associated with insulin susceptibility. The trigger for type 1 diabetes is not fully understood but in about 95% of people with the insensitivity. condition, it is organ-specific resulting in In a nutshell, the basic pathophysiology in type 2 pancreatic islet cell destruction. diabetes is the interplay of two mechanisms: beta cell dysfunction and insulin resistance. Type 2 diabetes arises from the combination of insulin resistance followed by impaired insulin secretion leading to decreased glucose uptake in peripheral tissues, and increased hepatic glucose output. There is a natural loss of beta-cell function as we age approximately 1% per year. In people with type 2 diabetes, this loss is accelerated to 7% per year. Insulin requirements increase as part of the normal aging process. The aging process also results in the loss of beta cells.Blood glucose levels will rise when insulin requirements exceed insulin production. This is known as primary failure. In some people this does not occur until very late in life. However, other people are born with insensitivity to insulin and their pancreas produce more insulin than usual in an effort to overcome this insensitivity. In the early stages of insulin insensitivity, levels of insulin in the blood become excessively high (hyperinsulinaemia). Eventually the beta cells become exhausted and the amount of insulin produced decreases.
Insulin insensitivity

Gestational Diabetes (GDM) is defined as any

degree of glucose intolerance with onset or first recognition during pregnancy. The definition applies whether insulin or only diet modification is used for treatment and whether or not the condition persists after pregnancy.
Diagnosis and types
Curriculum Module II-1 Slide 22 of 48

The natural history of type 2 diabetes

Insulin requirements

Hyperinsulinaemia Beta-cell loss Insulin requirements with age Endogenous insulin

Age (years)

Slides current until 2008

Module 1
Diabetes and Cardiovascular Disease

17

Diabetes is a heart disease equivalent.

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Module 1

Risk Factors of Diabetes and Cardiovascular Disease Controlling individual cardiovascular risk factors is effective in preventing or slowing CVD in people with diabetes.
Prevention of CVD is the most effective way of combating the CVD epidemic in the resource poor nations. Knowledge of modifiable risk factors (smoking, lack of exercise, obesity and consumption of fatty foods) for heart diseases has been identified important for behaviour change to occur and is often targeted by prevention programs. Abdominal obesity, commonly known as belly fat or clinically as central obesity, is the accumulation of abdominal fat or visceral fat resulting in an increase in waist size. There is a strong correlation between central obesity cardiovascular disease. Visceral fat, also known as organ fat or intraabdominal fat, is located inside the peritoneal cavity, packed in between internal organs and torso, as opposed to subcutaneous fat which is found underneath the skin, and intramuscular fat which is found interspersed in skeletal muscle. Visceral fat is composed of several adipose depots including mesenteric, epididymal white adipose tissue (EWAT) and perirenal fat. An excess of visceral fat is known as central obesity, the "pot belly" or "beer belly" effect, in which the abdomen protrudes excessively. This body type is also known as "apple shaped", as opposed to "pear shaped", in which fat is deposited on the hips and buttocks. Major Modifiable Risk Factors
High Blood Pressuremajor risk for heart attack and the most important risk factor or stroke Diabetes Mellitusmajor risk for coronary heart disease and stroke Abnormal blood lipidshigh total cholesterol, LDL Cholesterol and triglyceride levels, and low levels of HDL cholesterol increase the risk of coronary heart disease and ischemic stroke. Tobacco Useincreases risk of cardiovascular disease especially in people who started young, and heavy smokers. Passive smoking an additional risk. Physical InactivityIncreases risk of heart disease and stroke by 50%. Obesitymajor risk of coronary heart disease and diabetes. Unhealthy dietslow fruit and vegetable intake is estimated to cause about 31% of coronary heart disease and 11% of stroke worldwide; high saturated fat intake increases the the risk of heart disease and stroke through its effect on blood lipids and thrombosis.

Other Modifiable Risk Factors

Low Socioeconomic statusconsistent inverse relationship with risk of heart disease and stroke. Psychosocial stresschronic life stress, social isolation and anxiety increases the risk of heat disease and stroke Alcohol use1 to 2 drinks per day may lead to a 30% reduction in heart disease, but heavy drinking damages the heart muscles

Non-Modifiable Risk Factors

Advancing Agemost powerful independent risk factor for cardiovascular disease; risk of stroke doubles every decade after 55. Heredity or Family HistoryIncrease risk if a first-degree blood relative has had coronary heart disease or stroke before the age of 55 years (for male relative) or 65 years (for a female relative) GenderHigher rates of coronary heart disease among men compared to women in premenopausal age; risk of stroke is similar to men and women.
Source: The Atlas of Heart Disease and Stroke. WHO and Center for Disease Control and Prevention

Module 1
Pathophysiology

19

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Module 1

Signs and Symptoms of Diabetes and Cardiovascular Disease

Often diabetes goes undiagnosed because many of its symptoms seem so harmless. Early detection of diabetes symptoms and treatment can decrease the chance of developing the complications of diabetes. Some diabetes symptoms include: 1. 2. 3. 4. 5. 6. 7. Frequent urination (Polyuria) Excessive thirst (Polydipsia) Extreme hunger (Polyphagia) Unusual weight loss Increased fatigue Irritability Blurry vision Because of the severity of insulin deficiency, people with type I diabetes almost always lose weight before undergoing treatment. Most people with type II diabetes don't lose weight. In people with type I diabetes, the symptoms begin abruptly and may progress rapidly to a condition called diabetic ketoacidosis. Despite high levels of sugar in the blood, most cells can't use sugar without insulin; thus, they turn to other sources of energy. Fat cells begin to break down, producing ketones, toxic chemical compounds that can make the blood acidic (ketoacidosis). The initial symptoms of diabetic ketoacidosis include excessive thirst and urination, weight loss, nausea, vomiting, fatigue, and--particularly in children-abdominal pain. Breathing tends to become deep and rapid as the body attempts to correct the blood's acidity. The person's breath smells like nail polish remover. Without treatment, diabetic ketoacidosis can progress to coma, sometimes within a few hours. People with Type 1 diabetes can develop ketoacidosis even after starting insulin treatment if they miss an insulin injection or become stressed by an infection, an accident, or a serious medical condition. People with type II diabetes may not have any symptoms for years or decades. When insulin deficiency progresses, symptoms may develop. Increased urination and thirst are mild at first and

The first symptoms of diabetes are related to the direct effects of high blood sugar levels. When the blood sugar level rises above 160 to 180 mg/dL, glucose passes into the urine. When the level rises even higher, the kidneys excrete additional water together with the large amounts of glucose lost. Because the kidneys produce excessive urine, a person with diabetes urinates large volumes frequently (polyuria). The excessive urination creates abnormal thirst (polydipsia). People with diabetes are unable to process many of the calories in the foods they eat. Thus, they may lose weight even though they eat an apparently appropriate or even excessive amount of food. Losing sugar and water in the urine and the accompanying dehydration also contributes to weight loss. To compensate, the person often feels excessively hungry (polyphagia). Other symptoms include blurred vision, drowsiness, nausea, and decreased endurance during exercise. The body is inefficient and sometimes unable to use glucose for fuel. The body switches over to metabolizing fat, partially or completely, as a fuel source. This process requires the body to use more energy. The end result is feeling fatigued or constantly tired. In addition, people whose diabetes is poorly controlled are more susceptible to infections.

gradually worsen over weeks or months. Ketoacidosis is rare. If the blood sugar level becomes very high (often exceeding 1,000 mg/dL)--usually as the result of some superimposed stress such as an infection or drugs--the person may develop severe dehydration, which may lead to mental confusion, drowsiness, seizures, and a condition called nonketotic hyperglycemichyperosmolarcoma.

Module 1
Complications of Diabetes
Acute complications
Acute complications occur suddenly and may be the first manifestation of diabetes in a person who does not know that he is diabetic. The acute complications of diabetes may also happen when insulin therapy is suddenly withdrawn, or when infection, surgery or other stressful events occur. The two acute complications of diabetes mellitus are diabetic ketoacidosis and hyperosmolar non-ketotic diabetic coma.

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Long term complications

The long-term diabetes mellitus complications occur within 10-15 years from the onset of diabetes. The increase of blood sugar level produces changes throughout the body. The thickening and narrowing of blood vessels is accelerated in a person with diabetes. This may eventually lead to a stroke or heart attack. Aside from changes in the blood vessels, diabetes may cause loss of vision (retinopathy), decrease in sensation (neuropathy), and renal failure (nephropathy).

Misconceptions ( Mga maling pagtuo)

Diabetes is caused by excessive sugar intake Diabetes is caused mainly by stress Diabetes means no sugar altogether Diabetic diet Diabetic patients cannot exercise or perform strenuous work Diabetics should not undergo surgical procedures Diabetes can be cured Once blood glucose is normal, medications may be discontinued Medications of DM should be stopped during other illness DM medications should be stopped on the day of blood glucose testing Medications prescribed for diabetes can harm the kidneys Food supplements are alternatives to prescribed medications Insulin is addictive When insulin is prescribed, it means that the patient is already dying Insulin and hemodialysis can lead to death

22

Module 1

Notes:

Module 1
Notes:

23

24
Module 2 SCREENING, DIAGNOSIS AND MONITORING
Contents:
Definition of terms. Screening of Diabetes and CVD Risks Algorithm for Diabetes Screening and Diagnosis for Adults Diabetes Risk Assessment Cardiovascular Event Risk Assessment Diagnosis of Diabetes and Hypertension Biochemical Tests for Screening and Diagnosis of Diabetes. Screening and Diagnosis of Hypertension. Monitoring of CVD Risks The 7 monitoring parameters Requesting for Biochemical Tests

The diagnostic procedure must be done properly and diagnosis fully established since the consequences for the individual is considerable and lifelong.

Definition of Terms
Diabetes mellitus describes a metabolic disorder of multiple etiology characterized by chronic hyperglycemia, with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both. Severe hyperglycemia detected under conditions of acute infection, traumatic, circulatory or other stress may be transitory and should not in itself be regarded as diagnostic of diabetes. Normoglycemia Since there are insufficient data to accurately define normal glucose levels, the term normoglycemia should be used for glucose levels associated with low risk of developing diabetes or cardiovascular disease, that is levels below those used to define prediabetes. Prediabetes Prediabetes is a state of intermediate hyperglycemia not meeting the diagnostic criteria of diabetes but is higher than normoglycemia. It is not a clinical entity but is a risk factor for future diabetes and/or adverse outcomes such as premature mortality and cardiovascular disease. There are two forms of intermediate hyperglycemia: impaired fasting glycemia (IFG) and impaired glucose tolerance (IGT). Metabolic Syndrome The clustering of hyperglycemia, obesity, dyslipidemia and hypertension has been labeled the metabolic syndrome, dysmetabolic syndrome or insulin resistance. This clustering indicates common etiological factors. Its clinical importance is its high cardiovascular risk association. Recognition of these features in people with type 2 diabetes indicates the need for aggressive CVD risk reduction which includes lifestyle intervention strategies and pharmacologic treatment.

Module 2
Screening of Diabetes and CVD Risks
Screening deals with the identification of risk factors for initiating interventions focusing on modifiable risk factors. It is usually performed on asymptomatic individuals to de able to identify diabetes, hypertension and other risk factors at an early stage for the prevention of cardiovascular diseases. Diabetes, hypertension and dyslipidemia are independent risk factors for CVD, however, the chances of a CVD event increases with more risk factors. Diabetes and CVDs also share other risk factors . Risk factors of diabetes are divided into modifiable and non-modifiable risk factors: Cardiovascular disease Polycystic ovarian syndrome Small for gestational age (SGA), intrauterine growth retardation (IUGR) or large for gestational age at birth

25

Risk Factors for Type 2 Diabetes in Children

Only children who have risk factors for the development of type 2 diabetes need to undergo biochemical testing. Screening is initiated in obese children with: A body mass index (BMI) of greater than the 85th percentile for age and sex Weight greater than 120% of ideal for height Plus any 2 of the following risk factors are present: Family history of Type 2 diabetes in a first or second degree relative Ethnic background of African-American, Hispanic, American Indian, Asian, or Pacific Islander origin Signs of insulin resistance Presence of conditions associated with insulin resistance: e.g., acanthosis nigricans, polycystic ovary syndrome, high blood pressure, and blood fat disorders. When should you screen? Started at 10 years old and repeated every 3 years if test result is normal How should you screen? Fasting blood sugar

Modifiable Risk Factors:

BMI of 23 Abdominal obesity with waist circumference of 90 cm for males and 80 cm for females Prediabetes (refer to Table 1 on page 9) Hypertension ( 140/90 mmHg ) Increased triglyceride levels ( > 250 mg/dl or 2.82 mmol/l) Low HDL cholesterol level ( < 35 mg/dl or 0.09 mmol/l) Sedentary Lifestyle Cigarette Smoking Alcohol Drinking

Non-modifiable Risk Factors:

35 years of Age Parent or sibling diagnosed with diabetes Previous gestational diabetes Female gender History of giving birth to an infant with a birth weight of > 9 pounds (4.0 kg )

The IDF Consensus Worldwide Definition of the Metabolic Syndrome Characteristics Central Obesity Values Waist Circumference : 90cm for males and 80 cm for females

Note: If BMI is > 30 kg/m, then central obesity can be assumed, and waist circumference does not need to be measured

Plus any two of the following

Raised triglycerides Reduced HDL-cholesterol

1.7 mmol/L (150 mg/dl)

or specific treatment for this lipid abnormality < 0.9 mmol/L (40 mg/dl) in males < 1.1 mmol/L ( 50 md/dl) in female or specific treatment for this lipid abnormality

Raised blood pressure Raised fasting blood sugar

130mmHg systolic or 85 mmHg diastolic

or treatment of previously diagnosed hypertension

FBS of 5.6 mmol/L (100mg/dl)

or previously diagnosed with type 2 diabetes

Source: Asia-Pacific Type 2 Diabetes Policy Group and International Diabetes Federation Western Pacific Region, Type 2 Diabetes Practical Targets and Treatments. International Diabetes Institute:Melbourne, Australia, 2005 .

26

Module 2

Algorithm for Diabetes Screening and Diagnosis for Adults

Levels of Glycemia (Plasma venous values) in mmol/L
Risk Factor Identification

Level of Glycemia Normoglycemia PrediabetesIGT

Yes
Administer Risk Assessment Questionnaire

OGTT < 7.8 7.811.0 < 7.8 11.1

FBS < 5.6 <7 5.66.9 7.0

Risk Factor Present

No

Prediabetes IFG Diabetes

No Screening

Diagnostic Criteria for Diabetes Test mmol/L 11.1 7.0 11.1 mg/dl 200 126 200 6.5% OGTT
Yes
Request for RBS or FBS or OGTT

With Symptoms

No
Risk Factors Identified

FBS RBS HbA1c

High Risk

No

Yes

Repeat Risk Questionnaire after 3 years

Request for Biochemical Testing (FBS or OGTT)

Normoglycemia

Prediabetes

Diabetes

Initiate prevention interventions and advice repeat FBS/OGTT every year

Request for FBS or OGTT on a subsequent day

Normoglycemia

Prediabetes

Diabetes Initiate diabetes management

Initiate prevention interventions and advice repeat FBS/OGTT every year

Module 2
Diabetes Risk Assessment
Screening tests for type 2 diabetes include a combination of risk assessment questionnaires and biochemical tests. Primary screening for potential type 2 diabetes is done using a non-invasive risk-factor based screening questionnaire to limit the proportion of the population that needs to undergo diagnostic glucose measurement as a second step. Questionnaires are also less labor intensive and more acceptable to patients than biochemical tests.

27

Diabetes Self Assessment Questionnaire developed for the CVD Program. This will be distributed among households to encourage persons at-risk of developing diabetes to go for diabetes screening in health centers.

28

Module 2

Cardiovascular Event Risk Assessment

Module 2
Cardiovascular Event Risk Assessment continued
The Cardiovascular Event Risk Assessment form is developed based on the World Health Organization / International Society of Hypertension (WHO/ISH) colored Risk Prediction Charts. It combined the assessment of 5 risk factors to determine the risk of a CVD event. The 5 risk factors assessed are: 1. Diabetes 2. Gender 3. Smoking Status 4. Age 5. Systolic Blood Pressure Risk prediction and the accompanying recommendations can be used by health care professionals to match the intensity of risk factor management with the likelihood of cardiovascular events. The assessment form can be used to explain to patients the likely impact of interventions on their individual risk of developing cardiovascular disease. This approach may motivate patients to change their behavior. The use of risk assessment charts or forms will help health care professionals to focus their limited time on those who will benefit from their services the most.

29

Diagnosis of Diabetes and Hypertension

Diagnosis confirms the existence of risk factors like diabetes and hypertension after the screening process or if an individual exhibits signs and symptoms. The clinical diagnosis of diabetes is often prompted by symptoms such as increased thirst and urine volume, recurrent infections, unexplained weight loss and, in severe cases, drowsiness and coma; high levels of glycosuria are usually present. A single blood glucose estimation in excess of the diagnostic values (refer to Biochemical Tests) establishes the diagnosis in such cases.

In diagnosing diabetes, the clinician must feel confident that the diagnosis is fully established since the consequences for the individual are considerable and lifelong. In the absence of a more The diagnosis of diabetes in an asymptomatic specific biological marker to define diabetes, the measurement of glucose in blood remains the basis patient on the other hand should never be made on the basis of a single abnormal blood glucose value. of the diagnostic criteria. At least one additional plasma/blood glucose test with a value in the diabetic range is essential.

Diagnostic Criteria for Prediabetes and Diabetes by OGTT, FPG and HbA1c

30

Module 2

Biochemical Tests for Screening and Diagnosis of Diabetes

TYPES OF BLOOD SAMPLES FOR BIOCHEMICAL TESTS:
Venous Plasma Glucose Venous plasma glucose should be the standard method for measuring and reporting glucose concentrations in blood. This can be done via Oral Glucose Tolerance Test, Fasting Blood Sugar or Random Blood Sugar in established laboratories. Capillary Blood Glucose Conversion of Plasma Glucose Values Ideally for self-monitoring of diagnosed diabetes patients using a portable blood glucose meter. However in recognition of the widespread use of From Conventional (mg/dl) to SI units (mmol/L) capillary sampling, especially in undermultiply by 0.05555 resourced settings where there is no access to eg. 200 mg/dl x 0.0555 = 11.1 mmol/L venous plasma glucose testing determination of Capillary Blood Glucose using a portable blood From SI units (mmol/L) to conventional units glucose meter can be done provided that it is multiply by 18.02 determined in the fasting state. This is an indirect eg. 7.0 mmol/L x 18.02 = 126 mg/dl way of determining Fasting Plasma Glucose (FPG) or FBS since fasting values for venous and capillary plasma glucose are identical. If glucose values fall on prediabetes or diabetes levels, OGTT or FBS should be recommended on a subsequent day to establish diagnosis.

TYPES OF TESTS:
Oral Glucose Tolerance Test (OGTT) OGTT should be recommended first (if acceptable to the patient) before alternative tests are considered for the screening of diabetes. WHO recommends it as the standard test to define glycemic status. OGTT should be the first choice for diagnosis in asymptomatic people since FBS alone fails to diagnose approximately 30% of cases of previously undiagnosed diabetes Intermediate hyperglycemia (prediabetes) and asymptomatic type 2 diabetes are best diagnosed by this test because it determines both fasting and 2-hour plasma glucose values. Fasting Blood Sugar (FBS) Less commonly known as Fasting Plasma Glucose (FPG) Requires 8-10 hours of fasting It is more convenient to patients, more reproducible, less costly, and easier to administer than OGTT. It should also be noted that FPG does not detect patients with Impaired Glucose Tolerance (IGT) a form of prediabetes detected by OGTT. If FBS is opted as initial screening test for non-pregnant adults an OGTT may be considered in patients with Impaired Fasting Glycemia (IFG) a form of prediabetes detected by FBS. This is to better define the risk of diabetes. Random Blood Sugar (RBS) Testing of blood sugar anytime of the day. Can be used aside from FBS to establish diagnosis of those with symptoms. HbA1c Test (NGSP-certified) The American Diabetes Association in its Standards of Medical Care in Diabetes 2010 added A1c of 6.5% as another criterion for the diagnosis of diabetes. HbA1c is the combination of glucose and adult hemoglobin (HbA). The amount of adult hemoglobinthat becomes glycated to form HbA1c is directly related to the average concentration of glucose in the blood. In the normal person, about 36% of HbA is glycated; in persons with diabetes, the percentage of HbA1c may double or even triple depending upon the degree of hyperglycemia. With normalization of bloodsugar in the diabetic , HbA 1c values will gradually approach normal levels .

Module 2
Screening and Diagnosis of Hypertension
Conditions for blood pressure measurement Participants should refrain from smoking and drinking coffee in the morning prior to BP measurement. Allow fifteen minutes of rest prior to blood pressure measurements. The participant should sit straight with both feet flat on the floor arm at slightly more than 90 degree angle on the elbow rest with crease in elbow level with the heart. Blood pressure measurement procedure 1. BP will be measured preferably using a digital or aneroid blood pressure monitor . The measurer should refer to the product manual on the operation and calibration of the apparatus. 2. Position the arm by exposing the upper arm, the elbow slightly flexed, the forearm with the palm facing upward and supported by the elbow rest. 3. Apply the cuff 1 inch above the antecubital fossa. 4. BP will be measured twice on both arms with at least a 1 minute interval between measurements. 5. If the first two measurements in the same arm will differ by 5mmHg or more, a third measurement will be taken. 6. The average of the measurements per arm will be calculated. 7. Record the results. 8. The higher average will be the reported blood pressure.

31

Correct Position for Blood Pressure Measurement

Interpretation of Blood Pressure Readings:

Interpretation

Systolic Blood Pressure < 120 mmHg 120 to139 mmHg 140 to 159 mmHg 160 mmHg or higher < 130 mmHg 130 mmHg or higher

Diastolic Blood Pressure < 80 mmHg 80 to 89 mmHg 90 to 99 mmHg 100 mmHg or higher < 80 mmHg 80 mmHg or higher

Those not taking anti-hypertensive medications Normal Pre-hypertension Stage 1 Hypertension Stage 2 Hypertension Hypertension Controlled Hypertension Not Controlled

Those taking anti-hypertensive medications

32

Module 2

Monitoring of CVD Risks

The overriding goal for diabetes management is to lower all glucose parameters to as near to normal as safely possible. These goals provide a framework for initiating and monitoring clinical management. However, targets should be individualized. All improvements are beneficial whether or not a target is reached. performed during illness or when blood glucose is > 20 mmol/L (. 360 mg.dl)

Screening of Complications

Retinopathy and Blindness Refer to ophthalmologist for a comprehensive, dilated eye examination at the time of diagnosis. Key Concepts in Setting Glycemic Goals Assess visual acuity every 1-2 years More frequent examinations are required if 1. HbA1c is the primary target for glycemic control. retinopathy is detected; 2. The goal of diabetes therapy should be to Mild Non-proliferative diabetic retinopathy achieve glycemic status as near to normal as - every 6-12 months safely possible in all three measures of glycemic More severe retinopathy every 3-6 months control ( HbA1c, fasting premeal and postmeal plasma glucose). Nephropathy 3. Certain populations (children, pregnant women, Screening should be performed annually and elderly) require special considerations. The minimum requirement is to dipstick the urine 4. More stringent glycemic goals (eg. A1c of <6%) for protein that will detect overt proteinuria. may further reduce complications at the cost of The simplest test for micro-albuminuria is a increased risk of hypoglycemia. urinary albumin:creatinine ratio. 5. Less intensive glycemic goals may be indicated If levels are abnormal the test should be in patients with severe or frequent repeated within 3 months to confirm the hypoglycemia. diagnosis. 6. Postprandial glucose may be targeted if A1c Serum creatinine should be measured annually. goals are not met despite reaching pre-prandial glucose goals. Diabetic Foot Foot screening should be performed annually in Self Monitoring of Blood Glucose (SMBG) all patients with diabetes. Risk of neuropathic foot ulceration is most easily Self monitoring of blood glucose using a glucose detected using a 5.07/10 g Semmes Weistein meter is currently the optimal method for assessing monofilament. plasma glucose levels. It allows people with Palpation of foot pulses (dorsalis pedis and diabetes and the diabetes management team to posterior tibial) is the simplest means of obtain and use information about real-time identifying peripheral arterial disease. plasma glucose levels to facilitate timely Check for skin cracks, infection, state of nails, intervention to achieve and maintain near-normal callus, deformities and suitability of footwear blood glucose levels. during each visit Frequency The frequency of monitoring will depend upon available resources, either to the individual or the community concerned. Extra tests should be performed during illness or prior to strenuous activity. Quality Control Self monitoring technique should be checked once or twice per year by the physician or healthcare team. Quality control of tests is essential, particularly if results are inconsistent with HbA1c or clinical state. Other Parameters Blood or urine ketone tests should be

Capillary blood glucose testing using a portable blood glucose meter

Module 2
Monitoring of CVD Risks continued The 7 Monitoring Parameters
Monitoring Parameters
1 Blood Sugar HbA1c Fasting / Pre-meal (Capillary) 2-hour post meal (Capillary) 2 3 Blood Pressure Cholesterol LDL Cholesterol Triglyceride HDL Cholesterol Total Cholesterol 4 5 6 7 Urine Albumin Smoking Status Waist Circumference Foot Risk

33

Target Value
< 6.5 % < 5.6 mmol/L < 7.8 mmol/L

Frequency
Every 3-6 months Done daily. Frequency depends if on insulin and the degree of blood sugar control. Every visit Once a year Once a year Once a year Once a year Once a year Every visit Depending on weight loss goals Depending on foot risk category

< 130/80 mmHg < 2.5 mmol/L (<97 mg/dl) < 1.5 mmol/L (<133 mg/dl) > 1.0 mmol/L (>39 mg/dl) 4.5 mmol/L ( 174 md/dl) Negative No < 80 cmFemales < 90 cmMales O or if with ulcer (3) for the ulcer to heal and foot risk maintained (0-2)

Requesting for Biochemical Tests

Use this laboratory request form to request for biochemical tests. Check the desired test accordingly. At the back are instructions for the patients before going for testing. Do not forget to read out loud to the patients the instructions on the back and encircle the type of test.

34

Module 2

Notes:

Module 2
Notes:

35

36
Module 3 MANAGEMENT: PHARMACOLOGIC TREATMENT, MEDICAL NUTRITION THERAPY AND LIFESTYLE INTERVENTIONS
The care of a person with CVD risks like diabetes does not only mean pharmacologic management. Equally important is the simultaneous application of non-pharmacologic interventions. Introduction
The ultimate goal of management is to improve quality of life and productivity of people with CVD risks like diabetes by: early diagnosis, prevention of complications, prevention of premature death, promotion of self-care practices and reduction of personal, family and societal burden of disease. The successful establishment of the health care team and infrastructure to support it is critical for the achievement of these goals. This includes provision of education for health-care professionals and for people with CVD risks. Essential Components of Care The care of a person with CVD risks like diabetes and hypertension does not only mean pharmacologic management. Equally important is the simultaneous application of non-pharmacologic interventions dietary, physical activity, education and psychosocial support to: Control Hyperglycemia Treat hypertension and dyslipidemia Prevent and treat complications (microvascular and macrovascular) Initial Evaluation On the patients first visit after a diagnosis is confirmed, a complete medical evaluation should be performed to: 1. Classify the patient. 2. Detect complications. 3. Assist in formulating a management plan. 4. Provide a basis for continuing care. If the patient is previously diagnosed with diabetes and/or hypertension, the evaluation should review the previous treatment and the past and present degrees of glycemic and/or blood pressure control.

Contents:
Introduction Pharmacologic Management of Diabetes Pharmacologic Management of Hypertension Pharmacologic Management of Dyslipidemia Dietary Management Weight Management Physical Activity and Exercise Tobacco Smoking Cessation

Pharmacologic Management of Diabetes

Pharmacologic treatment of hyperglycemia uses two types of drugs which address the underlying metabolic abnormalities: oral anti-diabetic agents (OADs) and insulin. The following are general principles of pharmacologic therapy: Prediabetes For individuals with IFG, IGT or both, health care providers should first actively counsel patients to maintain normal weight and exercise regularly. Because of potential side effects and cost, there is insufficient

Module 3
Pharmacologic Management of Diabetes continued

37

evidence to support the use of drug therapy as a likelihood of returning blood glucose rapidly to substitute for, or routinely used in addition to, lifestyle target levels. After symptoms are relieved, oral modification to prevent diabetes. agents can often be added and it may be possible to withdraw insulin, if preferred. Initiation of OAD Indications for the Use of Insulin in Type 2 Diabetes: Metformin therapy should be initiated ( if there are no contraindications) concurrent with lifestyle 1. Fasting Blood Sugar of > 13.9 mmol/l ( 250 mg/dl ) intervention at diagnosis. This is the first step in treating new-onset type 2 diabetes. Metformin 2. Random Blood Sugar of > 16.7 mmol/l ( 300 mg/dl) should be titrated to its maximally effective dose over 1-2 months as tolerated. 3. HbA1c of > 10% 4. Presence of ketonuria Monotherapy vs Combination Therapy 5. Symtomatic diabetes with polyuria, polydipsia and weight loss If lifestyle intervention and maximal tolerated dose 6. Failure to meet glycemic targets with OHAs of metformin fail to achieve or sustain glycemic 7. Presence of contraindications to OHAs goals, another medication should be added within 2 8. Hyperglycemic emergency to 3 months of the initiation of therapy or at any time 9. Pregnancy when the A1c goal is not achieved. 10.Peri-operative period especially major or emergency surgery Combination therapy options include: 11.Other medical conditions requiring tight glycemic control Metformin + Secretagogue ( sulfonylurea or 12.Organ failure (eg. Renal, liver, heart ) meglitinide ) Metformin + Thiazolidinedione Guidelines for Commencing Insulin: Metformin + Secretagogue + Thiazolidinedione Secretagogue + Thiazolidinedione 1. Continue oral hypoglycemic agents Secretagogue + -glucosidase inhibitor 2. Start with intermediate acting / long-acting insulin at bedtime OAD in Children 3. Initial dose of 0.2 units / kg 4. Monitor premeal glucose ( fasting plasma Patients who are not ill at diagnosis can be glucose-FPG ) managed initially with medical nutrition therapy and 5. Aim for FPG of 4-8 mmol/L (72-144 mg/dl), exercise, but most will eventually require drug individualize therapy. Although insulin is the only drug approved 6. Adjust insulin by 2-4 units every 3-4 days until FPG for treatment of diabetes in children pediatric target is met. Proceed to twice-daily insulin if diabetologists use oral agents for children with type daytime blood sugars or HbA1c are elevated, 2 diabetes. If pharmacologic therapy is indicated and nocturnal hypoglycemia is occurring. and if insulin is not available the first oral agent used Insulin Dosage: is metformin. OAD in Pregnancy No oral agent should be used in pregnancy. If a patient becomes pregnant or if a pregnant patient develops diabetes it is best to refer for initiation of insulin therapy. Initiation of Insulin If lifestyle, metformin, and a second medication do not result in goal glycemia, the next step should be to start, then intensify insulin therapy. Insulin can be titrated rapidly and is associated with greatest The correct dose of insulin is that which achieves the best attainable glycemic control without causing obvious hypoglycemic problems. For Children and Adolescents: Partial remission phase < 0.5 Prepubertal children 0.71.0 Puberty 1-2 For Adults Adult 0.51 IU/kg/day IU/kg/day U/kg/day U/kg/day

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Module 3

Medical Management of Diabetes at Health Centers

Source: Department of Health, Republic of the Philippines. Prevention and Control of Chronic, Lifestyle-Related Noncommunicable Diseases in the Philippines Manual of Operations. 2009

Module 3

39

The goal of all interventions is to achieve and maintain glycemic levels within or as close as possible to
the normoglycemic range Lifestyle intervention and metformin should be considered as the first step in the treatment of new-onset type 2 diabetes Reinforce lifestyle interventions at every visit. Check A1C every 3 months until A1C is <7% and then at least every 6 months For patients with type 2 diabetes who do not meet glycemic goal after 2 to 3 months with metformin and lifestyle intervention alone, adding basal insulin can be considered as one option Insulin analogs with longer nonpeaking profiles have a low rate of hypoglycemia Initiate basal insulin with 10 units or 0.2 units/kg, and titrate until fasting levels are consistently within target range

40

Module 3

Module 3

41

42

Module 3
Notes:

Module 3
Notes:

43

44

Module 3

Oral Anti-Diabetic Agents General Information

CLASS Sulfonylurea Primary Action insulin secretion (insulin secretagogue) Site of Action Sulfonylurea receptors in pancreatic beta islet cells Receptors in pancreatic beta islet cells Small Intestine Adverse Effects Hypoglycemia (++1st gen & + 2nd gen) Weight Gain Hypoglycemia Weight Gain Gastrointestinal Symptoms Contraindications Renal Insufficiency Liver Diseases Known Hypersensitivity Liver Diseases Known Hypersensitivity Renal Insufficiency Liver Diseases Inflammatory Bowel Disease Known Hypersensitivity Renal Insufficiency Liver diseases Alcoholism Congestive Heart Failure Known Hypersensitivity Liver Disease Alcoholism Congestive Heart Failure Known Hypersensitivity Known hypersensitivity Type 1 DM, diabetic ketoacidosis

Meglitinides

insulin secretion (insulin secretagogue) carbohydrate absorption

a-Glucosidase Inhibitors

Biguanides

Hepatic Glucose production

Unknown

Gastrointestinal Symptoms Lactic Acidosis

Thiazolidinediones

Insulin sensitivity Peripheral glucose uptake

Inhibits degradation of DPP IV Incretin enhancers to increase insulin secretion and suppress glucagon secretion

PPARg receptors in insulin-sensitive tissues Small Intestines

Weight Gain Edema Congestive Heart Failure

Uncommon: hypoglycemia, GI symptoms, peripheral edema nasopharyngitis, headache

DPP-4 Inhibitors

Time-Action Profile (hours) CLASS Sulfonylurea Types 1st Generation Chlorpropramide Tolbutamide Acetohexamide 2nd Generation Glipizide Gliclazide Glyburide or Glibenclamide Glimepiride Meglitinides a-Glucosidase Inhibitors Biguanides Repaglinide Nateglinide Acarbose Voglibose Metformin Indications Onset Peak Level 4 Duration

Difficult to control diabetes or with poor compliance Older Diabetics Older Diabetics Younger Diabetics

60

0.5 4-5 1 2-4

1-3 6-12 2-6 2-3 1 1 1-2 1-1.5 2-3

12-24 24 12- 24 16-24 4-6 1-4 4 7-12

Postprandial Hyperglycemia Postprandial Hyperglycemia Overweight patients with insulin resistance

0.25-0.5 0.3 1 0.25

Module 3

45

Time-Action Profile (hours) CLASS Thiazolidinediones DPP-4 Inhibitors Types Pioglitazone Sitagliptin Vildagliptin Saxagliptin Fasting and postprandial hyperglycemia Indications Insulin Resistance Onset 1 Peak Level 1-2 1-4 1.72.5 2-4 24 12 24 Duration

Note: For drug preparations, daily doses and maximum dose of different types of drugs please consult product inserts, the Philippine Drug Formulary, PPD or PIMS.

Oral Anti-Diabetic Agents Preparations and Dosages

CLASS Sulfonylurea Types Chlorpropramide Tolbutamide Glipizide Gliclazide Glyburide or Glibenclamide Glimepiride Repaglinide Nateglinide a-Glucosidase Inhibitors Acarbose Voglibose 50 & 100 mg 200 , 300 mcg Preparation (tablets) 250 mg 500 mg 2.5,5,10 mg 80 mg 5 mg 1,2,3 mg 0.5,1,2 mg Initial Daily Dose 250 mg OD a.m. 2.5mg OD for elderly 30 mins AC 80 mg BID-TID 30 mins AC 2.5-5 mg OD 1-2 mg OD 0.5 2 mg tab BID-QID 15 minutes before meals 120 mg TID, 60 mg TID in elderly 15 minutes before meals 25 mg tab TID after first mouthful of food 200-300 mcg tab TID after first mouthful of food 25 mg tab TID afetr first mouthful of food 500 mg BID or 850 mg OD Taken AC 15 mg OD-BID 30 mg tab OD 100 mg OD mono or combination 50 mg ODmoderate renal insufficiency 25 mg ODend-stage renal disease Can be taken without meals 50 mg OD to BID 5 mg OD mono or in combination 2.5 mg ODrenal impairment/end stage renal disease Maximum Dose (mg/day) 100-500 mg 40 mg 40-320 mg 20mg 8 mg OD 0.5-16 mg 120 mg TID 100 mg TID 600-900 mcg 100 mg TID Maximum 3 grams 45 md OD

Meglitinides

Biguanides Thiazolidinediones DPP-4 Inhibitors

Metformin Pioglitazone Sitagliptin

500 & 850 mg 15 & 30 mg 25,50 & 100 mg

Vildagliptin Saxagliptin

50 mg 2.5 & 5 mg

Abbreviations: OD once a day, BID- twice a day, TID- Three times a day, QID- four times a day, AC- before meals

Note: For drug preparations, daily doses and maximum dose of different types of drugs please consult product inserts, PPD or PIMS.

46

Module 3

Various Insulin Formulations

Action Profile Classification Description / Recommendations Type Onset (hrs) 0.15-0.35 Peak (hrs) 1-3 Duration (hrs) 3-5

Rapid Acting Analogues

Short Acting

Can be given immediately before meals because there is evidence that the rapid action not only reduces postprandial hyperglycemis but that postprandial and nocturnal hypoglycemia may also be reduced. Offer the useful option of being given after food to toddlers who are reluctant to eat. Give a quicker effect than regular insulin when treating hyperglycemia, with or without ketosis, including sick days. Most often used as prandial or snack boluses in combination with longer acting insulins given twice or more times daily. Most often used in insulin pumps. ALL CHILDREN SHOULD HAVE SOLUBLE OR RAPID ACTING INSULIN AVAILABLE FOR CRISIS MANAGEMENT. Used as an essential component of most daily replacement regimens either: in combination with intermediate acting insulin in a twice-daily regimen as pre-meal bolus injections in basal-bolus regimens (20-30 min before meals) together with intermediate acting insulin twice daily or a basal analogue given once or twice a day. Regular insulins are best suited for intravenous therapy. Rapid-acting insulins can also be given IV. However the effect is not superior to that of regular insulin and it is more expensive. Soluble insulin is used in the following crisis situations: diabetic ketoacidosis control of diabetes during surgical procedures hyperglycemic episodes at home (eg. During intercurrent illness)

Lispro Aspart Glulisine

Regular/ Soluble

0.5 -1

2-4

5-8

Intermediate Acting

Long Acting

Basal Analogues

Pre-mixed

Suitable for twice-daily regimens and for pre-bed dosage in basal-bolus regimens Isophane insulins are extensively used in children, mainly because of their suitability for mixing with soluble or rapid-acting insulins in the same syringe, vial or cartridge without interaction WHEN REGULAR INSULIN IS MIXED WITH LENTE PREPARATIONS IT REACTS WITH EXCESS ZINC, BLUNTING ITS SHORT-ACTING PROPERTIES. Designed to have a duration of action of more than 24 hours to meet basal insulin requirements and therefore could be used in basal-bolus injection regimens. Their action profile in children appears to be extremely variable and they may have to be injected twice daily to meet basal insulin requirements. Show a more predictable insulin effect with less day-to-day variation compared with NPH insulin More expensive Have not been formally approved for children younger than 6 years old Fixed ratio mixtures of premeal and basal insulins. Although they remove potential errors in drawing up insulin, they remove the flexibility offered by separate adjustment of the two types

Isophane NPH IZS/lente

2-4

4-12

12-24

3-4

6-15

18-24

Semilente

1-2

4-10

8-16

Ultralente Ultratard

4-8

12-24

20-30

Glargine

2-4

none

24

Detemir 50% 30% 70% 25%

1-2

6-12

20-24

NPH + 50% regular, 70% NPA + aspart NPH + 30% regular, 75% NPL + lispro

Source: International Society for Pediatric and Adolescent Diabetes, "ISPAD Clinical Practice Consensus Guidelines 2006-2007." Pediatric Diabetes Vol. 72006-2007 28 Nov 2007 <www.ispad.org>.

Module 3
Insulin Regimen
Regimen Basal Insulin + oral agents Indications When oral agents fail to achieve the target glycemic control Recommendations Continue oral agents at same dose Add single, evening insulin dose 10 U or 0.15-0.2 u/kg/day NPH (bedtime) 70/30 (evening meal) Glargine (bedtime or with evening meal) Titrate dose weekly according to fasting SMBG* (FPG) Increase by 4U if FPG> 140 mg/dl Increase by 2U if FPG = 120 -140 mg/dl Treat to target ( usually <120 mg/dl) Reduce morning oral agent dosage if daytime hypoglycemia occurs Oral agent options: Stop Sulfonylurea Continue Metformin for weight control Continue glitazone for glycemic stability Insulin options: NPH bedtime + morning NPH + regular/aspart/lispro with evening meal 70/30 (evening meal) + 70/30 morning Glargine + regular/aspart/lispro to main meal Oral agent options: Continue Metformin for weight control Continue glitazone for glycemic stability Insulin options: Bedtime NPH and morning NPH + regular/aspart/lispro with each meal Glargine + regular/aspart/lispro with each significant meal Start at 0.5 1.0 unit/kg/day May start at low, fixed dose of intermediate acting insulin (15-20 in AM and 5-10 at HS) Options: NPH or Premixed twice a day Single morning or bedtime NPH Increase by 10-20% once or twice a week If dose reaches >40-50 units give 2/3 total in AM and 1/3 total in PM. When requirement reaches 1-1.5 u/kg may do any of the following: Shift to multiple injections when necessary Add insulin sensitizers (Met, TZD) Increase dose to break state of insulin resistance Conventional insulin therapy PREBREAKFAST with HN, H70/30 or R/N PRESUPPER with HN, H70/30 or R/N Convenient method for taking 2 types of insulin. Eliminated errors inherent in the multi-step procedure of self-mixing Conventional insulin therapy Multiple doses of short acting insulin + 1-2 doses of intermediate or long acting insulin

47

Two Insulin injections + Oral agents

When FPG is acceptable but HbA1c is 7% or if evening NPH or 70/30 dose is large (>50 u) and targets are still not achieved

Basal-Bolus

When HbA1c is >7% on 2 injections

Monotherapy

Mixed split Premixed

Multiple components

48

Module 3

Pharmacologic Management of Hypertension

Patient with Diabetes Assess Blood Pressure
Abnormal SBP 120 mmHg DBP 80 mmHg Initiate Lifestyle Modification Pre-Hypertension SBP=120-139 mmHg DBP=80-89 mmHg Stage 1 SBP=140-159 mmHg DBP=90-99 mmHg Stage 2 SBP 160 mmHg DBP 100 mmHg Start Combination Therapy

Target: SBP < 130 mmHg DBP < 80 mmHG

NO

Complications and high risk conditions

YES

Start Monotherapy

No drug therapy

Treat conditions accordingly; some may warrant use of antihypertensives

With Complications

NO

YES
refer to Next Page

Ace inhibitor Angiotensin Receptor Blocker Thiazide Type Diuretics Beta blocker Calcium Channel Blocker

Consider: First line Antihypertensives

Use combination of First Line antihypertensives if with complications and with high risk conditions

BP Target not reached

Drug elicits no response or has intolerable side effects Replace with drug from a different class Drug is tolerable but elicits insufficient clinical response

BP Target reached Follow-up every 3-6 months

Add drug from a different class

BP Target not reached

Continue adding other drugs / refer to hypertension specialist Adapted from: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and the Treatment of High Blood Pressure. The NHLBI JNC 7 Express. NIH Publication No. 03-5233, May 2003

Module 3
Oral Antihypertensive Drugs
Drug Indications Contraindications Time Action Profile Onset of Action (h) ACE Inhibitors Captopril Enalapril Lisinopril Moexipril Quinapril Ramipril Trandolapril Angiotensin II Receptor Antagonist Losartan Irbesartan Telmisartan Diuretics Hydrochlorothiazide Furosemide Bumetanide Amiloride hcl Triamterene Spironolactone
Edema, mild to moderate hypertension (hydrochlorothiazide) Edema, hypertension, congestive heart failure (furosemide) Edema and ascites associated with CHF, liver cirrhosis, or nephritic syndrome, essential hypertension, hypokalemia, primary aldosteronisn (K+ diuretics)

49

Time of Peak (h) 1-1.5 4-6 7 3-6 2-6 3-6 4-10

Duration (h) 6-12

24

Hypertension Heart failure Acute and post-MI Left Ventricular Dysfunction Diabetic nephropathy

Idiopathic or hereditary angioedema Bilateral renal artery stenosis Pregnancy (2nd & 3rd trimester) Hypersensitivity

1-1.5 1 1 1-2 1 1-2 2-4

24 24 18-24 24 24

Hypertension with or without concurrent use of thiazide diuretics Diabetic nephropathy

Hypersensitivity Primary hyperaldosteronism Bilateral renal artery stenosis Pregnancy (2nd & 3rd trimester)
Anuria Hepatic coma Severe electrolyte depletion, imbalance Hypersensitivity Pregnancy, lactation Hypokalemia (furosemide) Hyperkalemia (spironolactone) Hyperuricemia/ Gout Severe or progressive renal insufficiency Clients receiving potassium supplements, amiloride, or triamterene (spironolactone)

24

2 1 30-60 mins 2 2-4 1-2 days

4-6 1-2 1-2 6-10 6-8 2-3 days

6-12 6-8 4-6 24 7-9

Beta Blockers Atenolol Metoprolol Propranolol

Hypertension Angina pectoris Acute and post-MI Congestive heart failure Arrhythmias

Calcium Channel Blockers Amlodipine Felodipine Verapamil Diltiazem

Angina pectoris Mild to moderate hypertension Supraventricular tachyarrhythmias

Sinus bradycardia Peripheral arterial occlusive disease 2nd and 3rd degree heart block Cardiogenic shock Pulmonary edema Bronchial asthma Hypersensitivity Left ventricular dysfunction Hypotension Cardiogenic shock Sick sinus syndrome 2 & 3 AV block Atrial flutter or fibrillation Pregnancy Acute MI Pulmonary congestion

0.25 1 0.5

1-1.5 2-4 1-1.5

6-12 24 3-5

0.5-1

2 2-3

6-8 6-11

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Module 3
Drug Indications Contraindications Time Action Profile Onset of Time of Duration Action (h) Peak (h) (h)

Oral Antihypertensive Drugs continued

Alpha and Beta Blockers Carvedilol

Hypertension Angina Congestive heart failure Myocardial infarction (MI)

Bronchial asthma or COPD Cardiogenic shock Hypersensitivity Overt cardiac failure 2 & 3 AV block Sick sinus syndrome Severe hepatic dysfunction

4-7

24

sion complicated by stroke, CAD, or nitrogen retention Hypertensive crisis Methydopa Impaired renal function Renal hypertension Direct Vasodilators Essential hypertension Drug of choice for eclampsia Hydralazine Reduce afterload of CHF Severe aortic insufficiency after valve replacement

Hypersensitivity Centrally-acting Moderate to severe hypertension Mild hypertension adrenergic blockResistant cases of hyperten- Active hepatic disease er

7-12

4-6

12-24

Coronary artery disease Angina pectoris Advanced renal disease Rheumatic heart disease Chronic glomerulonephritis

45 min

1-2

3-8

Notes:

Module 3
Pharmacologic Management of Dyslipidemia
Person with Diabetes

51

YES

Diagnosed with Dyslipidemia

NO

Manage

Monitor Lipid Profile Every 3-6 months

Monitor Lipid Profile Annually

Initial Treatment: Non-Pharmacologic interventions 1. 2. 3. 4. 5. 6. Improve blood glucose control Reduce saturated fat intake Ensure regular moderate exercise Reduce weight if indicated Avoid alcohol intake if triglyceride is elevated Discourage smoking

Add pharmacotherapy if above interventions are unsuccessful after 6 months

For LDL Use STATINS

For Triglycerides Use FIBRATES

For HDL
Use NICOTINIC ACID or FIBRATES

Specifications: Statins should be used in all those with previous CVD, irrespective of current lipid levels, with the aim of achieving LDL < 2.5 mmol/L. For those without CVD and > 40 years of age, statins should be used if LDL 2.5 mmol/L or if total cholesterol 4.5 mmol/L. For those < 40 years old, statins should be considered if other cardiovascular risk factors (hypertension, smoking, microalbuminuria, family history of premature CVD) are also present. Once LDL targets are achieved, fibrates should be considered if triglycerides are 1.5 mmol/L or HDL 1.1 mmol/L. Triglyceride lowering agents should be used if triglycerides are > 4.5 mmol/L to prevent pancreatitis. Consideration should be given to the use of other lipid-lowering drugs (e.g. ezetemibe, sustained release nicotinic acid, concentrated omega 3 fatty acids) in those who fail to reach lipid targets or who are intolerant of conventional drugs. All patients with abnormal lipid levels should have intensified lifestyle interventions.

Source : 1. Asia-Pacific Type 2 Diabetes Policy Group and International Diabetes Federation Western Pacific Region, Type 2 Diabetes Practical Targets and Treatments. International Diabetes Institute:Melbourne, Australia, 2005. 2. International Diabetes Federation and World Diabetes Foundation. Type 2 Diabetes Clinical Practice Guidelines for Sub-saharan Africa. IDF Africa Region Task Force on Type 2 Diabetes Clinical Practice Guideline. July 2006.

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Module 3
Oral Lipid-Controlling Agents
Drug Indications Contraindications Dosing Informaton Initial Dose HMG-CoA Reductase Inhibitors Atorvastatin Fluvastatin Lovastatin Pravastatin Simvastatin Fibric Acid Derivatives Gemfibrozil Fenofibrate
triglycerides Increases HDL cholesterol Gallbladder disease Hepatic disease Hypersensitivity Primary biliary cirrhosis Renal disease Coadministration of genfibrozil and cerivastatin Hypersensitivity Active liver disease Active peptic ulcer disease Arterial bleeding Uncontrolled hyperglycemia First line for LDL Maybe added to nonpharmacologic therapies for hyperlipidemia Coronary artery disease and concomitant hypercholesterolemia

Dosage Range

Regimen

Active liver disease Unexplained elevations of serum transaminases Hypersensitivity Pregnancy and lactation

10-20 mg 20-40 mg 20 mg 40 mg 20-40 mg

10-80 20-80 10-80 10-80 5-80

mg OD mg OD mg OD mg OD mg OD

1200 mg divided twice daily

Starting doses: Hypocholesterolemia 160 mg OD Hypertryglyceridemia 54-160 mg/day With Rrenal impairment 54 mg/day 67-201 mg/day taken with food

Fenofibrate, micronized Nicotinic Acid Niacin Niacin extended release

triglycerides LDL HDL

100 mg 500 mg

1-6 1-2

g TID g OD

Notes:

Module 3
Setting Dietary Management Goals
Screening or Diagnosis of Diabetes

53

No

Patient with Diabetes

Yes

No

With Prediabetes

Yes

Recommend the basic Filipino Pyramid Food Guide And Weight Management Algorithm if overweight or obese

Assess patients nutritional status according to the following: Patients diet history Anthropometric Measurements Glucose , lipids and metabolic profile Clinical findings

Determine BMI and Waist Circumference

No

Overweight or Central Obesity?

Yes

Determine: Glucose levels (if controlled) through self monitoring or HbA1c levels Lipids

Consider weight loss by: total caloric intake by 250-500 kcal physical activity Refer to Weight Management Algorithm

No

Persistently high glucose?

Yes

Recommend balanced varied meal plan with lots of fiber Refer to physician for further assessment Recommend less saturated fat intake and more monosaturated fat

No

Elevated Lipids?

Yes

Determine patients food choices and eating habits

Nutrient abnormalities

Yes

Nutrient deficient: incorporate food items rich in the needed nutrient and modify diet prescription. Nutrient excess: identify and lessen intake of food items rich in nutrients found in excess, and modify diet prescription.
Source: An Evidence-Based Approach to Diabetes Management for Health Care Professionals ( A Learning Module Series), First Edition.

No Follow Dietary Mgt. recommendations

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Module 3
WHO Protocol for Counseling on Diet and Physical Activity

Source: World Health Organization CVD Risk Management Package for Low and Medium Resource Settings 2002

Module 3
Basic Nutrition Education Using the Idaho Plate Method

55

56

Module 3
Using the Food Diary
The food diary is a tool to document a patients actual food intake based on the Idaho plate method. This can be used by the health care team especially the Nutritionist-Dietitian for: 1. Meal planningso that meals can be based on actual food that are available and the patient can afford. 2. Monitoringif the actual prescribed diet is practiced by patients.

Module 3
Meal Planning Using the Plate Method
Actual meals can also be planned using the plate method for easy understanding by patients. Nutritionists can place the actual menu on the designated portions of the plate. The corresponding amount of the food is also placed. A 1-week sample meal plan can be made per patient as a food reference.

57

58

Module 3

Calculating Individualized Dietary Prescription

Calculate the patients Desirable Body Weight (DBW) Get the Total Energy Requirement (TER)
Tannhausers (Broca) Method: [ Height (cm) 100] 10% of difference= DBW in kg (eg. [165cm-100] 6.5 = 58.5 kg) DBW in kg x Energy requirement based on physical activity
Table 5. Energy Requirement Based on Physical Activity

Classification
Bed rest Sedentary Light Moderate Heavy

Description
Hospital patients Mostly sitting Tailor, nurse, physician, driver Carpenter, painter, housework Swimming, lumberman

kcal/kg DWB/day

27.5 30 35 40 45

Source: Food Exchange Lists For Meal Planning Food and Nutrition Research Institute and Department of Science and Technology.

If the patient is a driver: (eg. 58.5 x 35 = 2048 kcal or 2050 kcal) Determine the carbohydrate, protein and fat percentage distribution of the TER. Consider the health and nutritional status of the patient.
Eg. Carbohydrates Protein Fat 60% 20% 20%

Note:

No single diabetic diet is appropriate for the general population of patients with diabetes. Such patients have different needs depending on their nutritional and health status, physical activity and lifestyle. A short method of diet computation is based on the prescribed caloric contributions of carbohydrates, proteins and fats distributed as: CARBOHYDRATE = 55-70% ( 60% - normal diet ) PROTEINS = 10-20% ( 20% - normal diet ) FATS = 20-30% ( 20% - normal diet )
Eg. 2050 x 0.60 2050 x 0.20 2050 x 0.20 1230 kcal / 4 410 kcal / 4 410 kcal / 9 = 1230 kcal CHO (Carbohydrates) = 410 kcal CHON (Proteins) = 410 kcal FATS = 307.5 g CHO (Carbohydrates) = 102.5 g CHON (Proteins) = 45.5 g FATS

Translate the percent distribution into kilocalories.

Convert calories into GRAMS.

Eg.

Plan a menu distributing the serving portions for values at breakfast, lunch and dinner MEAL PLANNING BY THE NUTRITIONIST-DIETITIAN Refer to the following tools for meal planning: 1. Food Exchange list by FNRI and DOST 2. Nutritional Guidelines 3. Food Pyramid

For simplicity and practicality of the diet prescription, round off calories to the: Nearest 50 for calories Nearest 5 for proteins, fats, & carbohydrate

Diet Prescription TER : 2050 kcal Carbohydrates= 310 g Proteins = 100 g Fat = 45 g
Source: An Evidence-Based Approach to Diabetes Management for Health Care Professionals ( A Learning Module Series), First Edition.

Module 3
Practice Diet Prescription

59

Carbohydrates
Carbohydrate should approximate 55-70% of calories/day. Total carbohydrate content rather than type should be considered. When added to monounsaturated fats, carbohydrates should make up 70% of total calories/day. 25-50 grams of carbohydrates from fiber per day may be given. Sucrose need not be restricted and could be substituted as carbohydrate as long as total energy requirement (TER) is not exceeded. However sucrose should be eaten in the context of a healthy diet. Non caloric sweeteners are acceptable within prescribed levels. Sugar alcohols may be used with caution and should not be taken in amounts of >10g/day. Fructose consumption should be limited to 60g/day for a patient with a daily caloric requirement of 2000.

Proteins
Should approximate 10-20% of calories/day If patient has good glucose control, there is no need to decrease amount of protein intake. In cases where hyperglycemia is present, protein intake may be > 0.8 g/kg of body weight but no more than 1g/kg BW per day. If patient has renal problems, protein intake should not be less than 40g per day, and can be as much as 0.60.8 g/kg BW/day (10-15% of TER). If the patient has cardiovascular risk factors, replace animal-sourced protein with plant sources. If source of protein has limited amino acids, complementing proteins should be added.

Fats
Should approximate 20-30% of calories/day Saturated fat, trans fatty acids should be < 7% of TER Dietary cholesterol should be < 200mg/day Polyunsaturated fatty acids should be 10% of TER. Monounsaturated fatty acids should be >10-15% of TER. Use mono- and polyunsaturated fats in place of saturated fat

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Module 3

Weight Management
The achievement of a normal weight is often unrealistic and does not have to be the ultimate goal of a weight reduction strategy. Moderate weight loss can have significant benefits. Long term goals for weight management include: 1. 2. 3. 4. 5. 6. Reduction of excess weight by 5-6 kg or 10% of the initial body weight Maintenance of BMI < 23 kg/m Any reduction of blood pressure Any reduction of blood glucose Any improvement of glycemic control Any reduction of the modifiable risk factors

Before initiating weight loss management patients should have a full medical assessment to evaluate the following: 1. Presence of co-morbidities such as diabetes, hypertension and dyslipidemia. These should be managed accordingly. 2. Age older than 40 years, or who have a history of heart disease, a cardiovascular examination may be necessary prior to exercise prescription. 3. Secondary causes of obesity including Cushings syndrome, hypogonadism and hypothryoidism that should be referred to specialists and managed accordingly. 4. Symptomatic complications of severe obesity such as obstructive sleep apnea, osteoarthritis, reflux esophagitis, gravitational edema should be treated actively regardless of whether the patient is losing weight.

Classification of Weight by BMI in Adult Asians

Classification of Weight by BMI in Adult Asians and Co-morbidities risk associated with the combination of BMI and Waist Circumference
Classification BMI Risk of co-morbidities Waist circumference < 90 cm men < 80 cm women Underweight Normal Range Overweight At risk Obese I Obese II < 18.5 18.5 22.9 23 23 24.9 25 29.9 30 Increased Moderate Severe Moderate Severe Very Severe Low (but increased risk to other clinical problems) Average 90 cm men 80 cm women Average Increased

Source: International Diabetes Institute, World Health Organization-WPRO, International Association for the Study of Obesity, International Obesity Task Force, The Asia-Pacific Perspective: Redefining Obesity and its Treatment. Australia: Health Communications Australia Pty Limited, 2000.

Module 3
Weight Management Algorithm
Weight Problem Suspect

61

CLASSIFYING PATIENTS
Hypothyroid signs and symptoms?
No

WORK-UP FOR CAUSES OF OBESITY

Yes

Measure BMI and review dietary history Overweight or obese?

No
Yes

Determine TSH / FT4

Elevated?
Yes No

Refer to Specialist
Yes
Determine Serum Cortisol
(done between 8-10 am)

Cushings signs and symptoms?

Elevated?

Measure WC Central Obesity?

No Yes

No

Check for plasma glucose, BP, sleep apnea, venous stasis, cardiac disease

EVALUATION OF CO-MORBIDITIES

Normal

Presence of co-morbidities?
No Yes

Yes

Treat with appropriate disease therapy or refer to specialist

Treat risk factors before starting weight management or refer to specialist

Risk factors?
No

PREPARATION
Advice patient to at least address risk factors and prevent further weight gain Monitor twice a year

Presence of exclusion criteria for weight management?

No

Yes

TREATMENT ACCORDING TO RISK

Determine patients BMI + Waist Circumference related health risk Yes

Offer weight management

Patient ready to start the program?

Increase physical activity Lifestyle change LOW CALORIE DIET Increase physical activity Lifestyle change Low calorie diet PHARMACOTHERAPY Increase physical activity Lifestyle change Pharmacotherapy VERY LOW CALORIE DIET
Increase physical activity Lifestyle change Pharmacotherapy Very low calorie diet REFER FOR SURGERY

No

Monitor for 3-6 months Weight loss of >5kg or 5-10% of initial BW?
No Failure

FOLLOW-UP

Moderate
No

Yes

Yes

Successful

Severe
No

Yes

Very severe
No

Yes

Extremely severe

Reassess and redefine treatment Adequate weight loss?

Yes

Yes

Recommendation from the Philippine Association for the Study of Overweight and Obesity (PASOO). CPM 7th Edition.

Continue, maintain and prevent weight gain

Refer

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Module 3

Weight Management

Formulas
Conversion of kilocalories to grams
For Carbohydrates (CHO) divide by For Proteins (CHON) divide by For Fats divide by 4 4 9

Determining the Body Mass Index BMI

= Weight (kg) Height (m) or Weight (kg) Height (m) x Height (m)

Determining Significant Weight Loss

% weight loss = usual weightactual weight Usual weight Interpretation Duration 1 week 1 month 3 months 6 months x 100 % Severe Weight loss % >2 >5 > 7.5 > 10

Significant weight loss % 1-2 5 7.5 10

Module 3
Notes:

63

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Module 3
Physical Activity and Exercise
Before starting an exercise program, a patient has to be screened for presence of risk factors in which exercises may be contraindicated. Patients are screened and evaluated for these contraindications to prevent potential complications of exercise. It is for this reason that exercise prescriptions are best done in consultation with exercise specialists.

Exercise Prescription
An appropriate exercise prescription formulates a persons physical activity program that suits the present physical condition and status (refer to page 16). Parameters of the exercise prescription are: Intensity - Amount of exertion done in terms of Target heart rate and perceived exertion. Target Heart Rate should be 50 70% of the maximum heart rate (moderate physical activity) For the Middle aged start at 50-60% of maximum heart rate For 50 years old and above start at 40-50% of maximum heart rate For Weight loss 60-75% of maximum heart rate for 20-30 minutes 75-85% of maximum heart rate should be reserved for a training goal The objective measurement of the heart rate must be balanced with the subjective perception of how hard one feels when exercising. There is a need to observe and listen to the bodys breathing, leg and arm fatigue or a general feeling of being tired. If these are felt there is a need to slow down and seek appropriate consultation.

Duration - How long a certain physical activity is done. High intensity exercises should only last for a short period of time. Persons with diabetes should avoid longer exercise sessions because they result to greater decrease in blood glucose levels. The recommended duration is a total of 30 minutes of moderate physical activity on most days of the week. Frequency - How often an exercise program is done. As a general rule, short duration activities must be done with more frequency to achieve desired effects. On the contrary, heavy activities (70% of HRmax) must be done less frequently to avoid fatigue. The recommended frequency is: 3 non-consecutive days in a week. Obese patients may need to exercise 6-7 days a week. Patients on insulin may exercise everyday to decrease difficulty in balancing insulin and caloric needs Timing - Time of the day an exercise is done. Generally, the schedule for exercising depends on convenience. However, patients who are taking anti-diabetic medications should avoid exercising during peak drug absorption as it may lead to hypoglycemia during and after the exercise. Type - Kind of physical activity done. Provided that there are no contraindications, the choice of activity is completely based on personal preference. The patient must be involved in planning the program so that he/she could choose activities that are of interest and therefore avoid boredom. Frequently, exercises consist of a combination of aerobic and anaerobic exercises It is also equally important to start with a 20-30 minute warm-up of low intensity aerobic and static stretching activities and end the exercise with a 10-15 minute cool down gradually slowing down the intensity of activity. Sources
1. 2. International Diabetes Federation and World Diabetes Foundation. Type 2 Diabetes Clinical Practice Guidelines for Sub-saharan Africa. IDF Africa Region Task Force on Type 2 Diabetes Clinical Practice Guideline. July 2006. American Diabetes Association. Standards of Medical Care in Diabetes-2007. Diabetes Care. Volume 30, Supplement 1, January 2007.

Module 3
Physical Activity Prescription

65

Frequency Intensity Type Timing Duration

FITT-D

Patient diagnosed with Diabetes Mellitus or Prediabetes

Screening and exercise risk assessment (Identification of Contraindications)

Refer to Appendix 4 on page 34

No

Exercise

Yes

Screening for complications

Pharmacologic Stress Test c/o cardiologist

No

Presence of Complications ?

Yes Proliferative Retinopathy LOW IMPACT ACTIVITY

Do stress test/ETT before exercise prescription

Identification of Risk Factors

Cardiovascular Disease
Vascular/Orthopedic Peripheral Neuropathy

No

With one or more of the following risk factors ? 1. Hypertension 2. Smoking 3. Hyperlipidemia 4. Family History of CVD

LOW IMPACT ACTIVITY

Yes

LOW IMPACT ACTIVITY

Determine Age
MODERATE PHYSICAL ACTIVITY Stress Test is recommended before vigorous physical activity

No

35 years old

Yes

Source: An Evidence-Based Approach to Diabetes Management for Health Care Professionals (A Learning Module Series), First Edition. Adapted from Texas Diabetes Council.

MODERATE OR VIGOROUS PHYSICAL ACTIVITY

3. Department of Health Philippines, University of the Philippines Manila., A Training Manual for Health Workers on Promoting Healthy Lifestyles. Manila Philippines: Publications Unit of WHO-WPRO, 2003. 4. Johnson and Johnson, An Evidence-Based Approach to Type 2 Diabetes Management for Health Care Professionals A Learning Module Series. First Edition. 2003. 5. Food and Nutrition Research Institute and Department of Science and Technology, Food Exchange List for Meal Planning. 3rd Revision. Philippines: Philippine Information Agency, 1996. 6. Asia-Pacific Type 2 Diabetes Policy Group and International Diabetes Federation Western Pacific Region, Type 2 Diabetes Practical Targets and Treatments. International Diabetes Institute:Melbourne, Australia, 2005 7. International Diabetes Institute, World Health Organization-WPRO, International Association for the Study of Obesity, International Obesity Task Force, The Asia-Pacific Perspective: Redefining Obesity and its Treatment. Australia: Health Communications Australia Pty Limited, 2000.

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Module 3

Selected Physical Activities Defined by Level of Intensity

Less than 3.0 METs (<3.5kCal/min)
Walking casually , < 3 mph In the house or yard Window shopping Light Activity Moderate Activity

3.0 to 6.0 METs (3.5-7kCal/min)

Greater than 6.0 METs (> 7 kCal/min)

Racewalking and aerobic walking, 5 mph or faster Jogging or running Walking and climbing briskly up a hill Marching rapidly (military ) Mountain climbing, rock climbing, rapelling Roller skating, fast pace

Vigorous Activity

Walking at a moderate or brisk pace, 3-4.5 mph on a level surface, inside or outside, such as To class, work or store For pleasure As a break from work Walking downstairs or down a hill Racewalking, < 5mph Hiking Roller skating, leisurely pace Bicycling 5-9 mph, level terrain Stationary bicycling, using moderate effort Calisthenics, light gymnastics General home exercises, light or moderate effort, getting up and down from the floor Jumping on a trampoline Boxing, punching bag Ballroom dancing Folk dancing Modern dancing, disco, Ballet Table tennis, competitive Tennis, doubles Golf, wheeling or carrying clubs

Bicycling, < 5 mph Stationary bicycling, using very light effort Stretching exercises, slow warmup

Bicycling, > 10mph , or bicycling on steep uphill terrain Stationary bicycling, using vigorous effort Calisthenics, push-ups, vigorous effort Karate, judo, tae kwondo, jujitsu Jumping rope Performing jumping jacks Boxing, in the ring, sparring Wrestling, competitive Professional ballroom dancing, energetically Folk dancing, energetically Tennis, singles Wheelchair tennis

Ballroom dancing, very slowly Table tennis or Ping-pong, leisurely Golf, riding a powered golf cart Golf, driving range Playing miniature golf Playing catch, football or baseball Throwing a baseball

Softball, fast or slow pitch Basketball, shooting baskets Coaching children or adult sports Volleyball, competitive Badminton Fencing Archery (non hunting) Playing Frisbee Juggling Swimming, recreational Treading water, slowly ,moderate effort Aquatic aerobics Diving, springboard or platform Water skiing Snorkeling Surfing, board or body Paddle boating Canoeing or rowing a boat, at < 4 mph Sailing, recreational or competition Kayaking, on a lake, calm water

Volleyball, recreational Billiards Darts Pistol or rifle target practice Throwing a Frisbee Bowling, or lawn bowling Swimming, floating

Most competitive sports Football game Basketball game Wheelchair basketball Soccer, Rugby, Kickball Beach volleyball, on sand court Handball, general or team Racquetball

Swimming, steady paced laps Synchronized swimming Treading water, fast vigorous efforts Water jogging Water basketball Scuba diving Canoeing or rowing, 4 or more mph Kayaking, in whitewater rapids

Boating, powerboat Yachting

Module 3
Less than 3.0 METs (<3.5kCal/min)
Sitting and playing a board game or video game Sitting while reading, writing, coloring, painting, using a computer Sitting and playing most musical instruments Light Activity Moderate Activity

67

3.0 to 6.0 METs (3.5-7kCal/min)

Greater than 6.0 METs (> 7 kCal/min)

Jumping rope Running Skipping Performing jumping jacks Roller-skating or in-line skating, fast pace Playing heavy musical instrument while actively running in a marching band

Vigorous Activity

Playing on school playground equipment, moving about, swinging, or climbing Skateboarding Roller-skating or in-line skating, leisurely pace Playing instruments while actively moving; playing in a marching band; playing guitar or drums in a rock band Twirling a baton in marching band Singing while actively moving about- as on stage or in church Gardening and yard work: raking the lawn, digging, hoeing, light shoveling (< 10 lbs/min), weeding while standing or bending Planting trees, trimming shrubs and trees, hauling branches, stacking wood Pushing a power lawn mower Moderate housework: scrubbing the floor or bathtub while on hands or knees, hanging laundry on a clothesline, sweeping an outdoor area, washing windows, moving light furniture, walking and putting household items away , carrying water or firewood General household tasks requiring considerable effort Actively playing with children: walking, climbing, running Walking while carrying a child < 50 lbs Walking while pushing or pulling a child in a stroller or an adult in a wheelchair Carrying a child weighing < 25 lbs up a flight of stairs Child care: handling uncooperative young children (chasing, dressing) or handling several young children at one time Bathing and dressing an adult

Gardening and yard work: weeding while sitting or kneeling, pruning Using a riding mower or driving a tractor on firm ground

Gardening and yard work: heavy or rapid shoveling (> 10 lbs/min), digging ditches, or carrying heavy loads Felling trees, carrying large logs, swinging an ax, hand- splitting logs, or climbing and trimming trees Pushing a non motorized lawn Heavy housework: moving or pushing heavy furniture (75 lbs or more), carrying household items weighing 25 lbs or more up a flight of stairs, or shoveling coal in a stove Standing, walking, or walking down a flight of stairs carrying objects weighing 50 lbs or more

Light housework: dusting, sweeping floors, making beds, cooking or serving food, washing dishes, folding and putting away laundry , sewing Most other household tasks done while sitting or standing

Sitting and playing with children Child care: dressing, bathing, feeding or occasionally lifting young children

Vigorously playing with children: running longer distances or playing strenuous games with children Carrying an adult or a child weighing 25 lbs or more up a flight of stairs Standing or walking while carrying an adult or a child weighing 50 lbs or more

Light home repair: wiring, plumbing, or repairing appliances

Home repair: cleaning gutters, refinishing furniture, sanding floors with power sander, or laying or removing carpet or tiles General home construction work: roofing, painting inside or outside the house, wall papering, scraping, plastering, remodeling Outdoor carpentry, sawing wood with power saw Automobile bodywork Hand washing and waxing a car

Home repair or construction: very hard physical labor, standing or carrying heavy loads of 50 lbs or more, taking heavy loads of 25 lbs or > up a flight of stairs or ladder ( e.g. carrying roofing materials to the roof), or concrete or masonry work. Hand-sawing hardwoods

Workshop carpentry

Light automobile repair Motorcycle or bicycle repair

Pushing a disabled car

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Module 3

Contraindications to Exercise Participation

Cardio-Pulmonary
Abnormal ECG readings Unstable angina pectoris Abnormal heart rhythm Severe symptomatic aortic stenosis Abnormal dilatation Heart infections Presence of atherosclerosis Sudden blockage of pulmonary arteries Uncontrolled hypertension with resting blood pressure of >200mmHg systolic or >110 mmHg diastolic Severe autonomic neuropathy with exertional hypotension. Functional abnormalities of the heart Other forms of outflow tract obstruction Abnormal heart rate Abnormal impulse conduction dilatation in any of the heart chambers

Renal
Absolute Contraindications Acute or inadequate controlled kidney failure

Others
Untreated high-risk diabetic retinopathy Recent significant retinal hemorrhage. Infections

Relative Contraindications electrolyte abnormalities (eg. Hypokalemia, hypomagnesemia) FBS of > 300mg/dl or > 250 mg/dl with urinary ketone bodies. Hypoglycemia Uncontrolled metabolic disease (eg. Thyrotoxicosis, myxedema) Chronic infectious disease (eg. Hepatitis, TB, AIDS) Neuromuscular, musculoskeletal, or rheumatoid disorders that are aggravated by exercise Complicated pregnancy

Complications of Exercise in Type 2 Diabetes

Cardiovascular
Cardiac dysfunction abnormal rhythm due to ischemia Very high or low blood pressure during exercise Decrease of blood pressure when changing body position

Microvascular
Bleeding of the retina Increased protein in urine (proteinuria) Aggravation of lesions

Metabolic
Worsening of hyperglycemia (high blood glucose) and increase in ketone formation Hypoglycemia (low blood glucose) in patients maintained on diabetes drugs

Musculoskeletal
Foot ulcers Bone and muscle injuries Joint diseases Eye injuries

Two Basic Types of Exercise

Aerobic
Uses large group of muscles in rhythmic motion for an extended period of time Uses oxygen as muscles burn a greater percent of fat for fuel Improves cardiovascular conditioning and overall physical fitness Improves muscle efficiency and tone Helps lose fat weight Examples: Walking, jogging, cycling, dancing, skating, rope skipping Short term effects usually not felt in healty adults especially if done in low intensities and volumes

Anaerobic
Short burst of energy, quick or of very high intensity Burns mostly glycogen and glucose for fuel. Minimal conditioning benefits for the cardiorespiratory system Improves muscle strength and spped of activity Builds muscle tissue, ineffective for fat loss Examples: Weight lifting, sprinting, calisthenics (push-ups, sit-ups), resistance training programs May cause orthopedic and vascular problems, may also be bad for patients with poor metabolic control, and those with active proliferative

Source: Johnson and Johnson, An Evidence-Based Approach to Type 2 Diabetes Management for Health Care Professionals A Learning Module Series. First Edition. 2003.

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The Activity Pyramid

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Computing Target Heart Rate (THR )

First, determine maximum heart rate (HRmax) by:

Short method:

HRmax= 220 age in years

Best-Fit Formula: HRmax= 210 50% of age 5% of body weight (lbs) + 4 (if male only) Then compute for the Target Heart Rate based on the intensity of exercise desired Intensity Light / very light Moderate Vigorous Target Heart Rate (THR) < 50% of HRmax 5070% of HRmax >70% of HRmax

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WHO: 5A Steps Protocal for Tobacco Cessation Counselling

Module 3 Key statistics

Every seven seconds, someone in the world dies from a tobacco-related illness. The annual death toll of more than five million could rise to more than eight million by 2030 unless One in five tobacco-related deaths occurs in the Western Pacific. Tobacco kills up to half of its users. Smokers are exposed to over 4000 toxic substances in cigarette smoke. Over 25 of these are known Tobacco causes over 40 diseases, many of them fatal or disabling. Smoking is responsible for over 90%
of all cases of lung cancer, 75% of chronic bronchitis and emphysema cases and nearly 25% of cases of ischemic heart disease. Chewing tobacco causes a significant proportion of oral cancer More than 80% of the world's one billion smokers live in low- and middle-income countries. Total consumption of tobacco products is increasing globally, though it is decreasing in some high-income and upper middle-income countries. human carcinogens. urgent action is taken to control the tobacco epidemic.

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Leading cause of death, illness and impoverishment Tobacco use is one of the biggest public health threats the world has ever faced. It kills more than five million people a year an average of one person every six seconds and accounts for one in 10 adult deaths. Up to half of current users will eventually die of a tobacco-related disease. More than 80% of the one billion smokers worldwide live in low- and middle-income countries, where the burden of tobacco-related illness and death is heaviest. Tobacco users who die prematurely deprive their families of income, raise the cost of health care and hinder economic development. In some countries, children from poor households are frequently employed in tobacco farming to provide family income. These children are especially vulnerable to "green tobacco sickness", which is caused by the nicotine that is absorbed through the skin from the handling of wet tobacco leaves. Gradual killer Because there is a lag of several years between when people start using tobacco and when their health suffers, the epidemic of tobacco-related disease and death has just begun. Tobacco caused 100 million deaths in the 20th century. If current trends continue, it will cause up to one billion deaths in the 21st century. Unchecked, tobaccorelated deaths will increase to more than eight million per year by 2030. More than 80% of those deaths will be in low- and middle-income countries. Surveillance is key Good monitoring tracks the size and character of the epidemic and indicates how best to tailor policies. Two-thirds of countries more than four in five of them low- and middle-income do not have even minimal information about tobacco use. Second-hand smoke kills Second-hand smoke is the smoke that fills restaurants, offices or other enclosed spaces when people burn tobacco products such as cigarettes, bidis and water pipes. There is no safe level of second-hand tobacco smoke.

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Module 4 FOOT, WOUND AND STUMP CARE
Contents:
Foot Care Importance of foot care Foot complications due to diabetes Pathways to the development of foot ulcers The 5 cornerstones of foot management Basic foot care practices Appropriate footwear Identifying the Foot At-risk for Amputation Conducting Foot care sessions in health centers Wound Care Introduction to wounds Definition and classification of wounds Wound assessment Wound care Wound Monitoring Stump Care Definition of amputation. Levels of amputation common to diabetes. Importance of stump care. Proper residual limb positioning Stump skin care. Proper stump bandaging Criteria for Artificial Leg Fitting Referring patients for prosthetic device acquisition Patient follow-up and monitoring

Every 30 seconds someone loses a lower limb due to diabetes in the world.
Kada 30 segundo usa ka tao ang maputlan ug tiil sa tibuok kalibutan tungod sa diabetes
International Diabetes Federation

Importance of Foot Care

Diabetic foot problems are common, very expensive and life-threatening. However, diabetic foot problems are often not perceived as important by both the patient and the health care provider. Every year, more than 1 million people undergo a lower limb amputation due to diabetes. With the rising incidence of diabetes, the number of amputations may increase. Foot care then is an integral part of diabetes management. Persons with diabetes should be able to practice basic foot care to prevent the occurrence of foot ulcers that may lead to amputations. It is the role of health care providers to both routinely check patients feet and teach persons with diabetes how to take care of their feet.

Know the numbers

70% Up to 70% of all lower-leg amputations

are performed on people with diabetes.

70% Up to 70% of people who undergo a

lower extremity amputation die within 5 years of amputation.

4 million Approximately 4 million people

develop a new diabetic foot ulcer every year.

85% Up to 85% of amputations are preceded

by an ulcer and are therefore preventable.

49-85% A multidisciplinary approach to

diabetic foot care has been shown to bring about a 49-85% reduction in amputation rates.

50% Up to 50% of people with type 2 diabetes

have significant neuropathy and at-risk feet

Module 4
Foot Complications due to Diabetes
The most important causes of diabetic foot ulcers are neuropathy or nerve damage and peripheral arterial disease or damage to blood vessels of the feet. Diabetic foot lesions frequently result from two or more risk factors occurring together. In the majority of cases, diabetic peripheral neuropathy plays a central role. Up to 50% of people with type 2 diabetes have neuropathy and at-risk feet. Neuropathy leads to an insensitive and sometimes deformed foot, often with abnormal walking pattern. In people with neuropathy, minor trauma caused for example by ill-fitting shoes, walking barefoot or an acute injurycan precipitate a chronic ulcer. Loss of sensation, foot deformities, and limited joint mobility can result in abnormal biomechanical loading of the foot. Thickened skin (callus) forms as a result. This leads to a further increase of the abnormal loading and often, subcutaneous hemorrhage. Whatever the primary cause, the patient continues walking on the insensitive foot, impairing subsequent healing. Peripheral vascular disease, usually in conjunction with minor trauma, may result in a painful, purely ischemic foot ulcer. However, in patients with both neuropathy and ischemia(neuro-ischemic ulcer), symptoms may be absent despite severe peripheral ischemia. There are 3 main types of neuropathy seen in diabetes: 1. Autonomic (heart and blood vessels, digestive system, urinary tract, sex organs, sweat glands, eyes) 2. Sensory (sensation) 3. Motor (movement) Symptoms of nerve damage may include: 1. Numbness, tingling, or pain in the toes, feet, legs, hands, arms, and fingers 2. Wasting/atrophy of the muscles of the feet or hands 3. Indigestion, nausea, or vomiting 4. Diarrhea or constipation 5. Dizziness or faintness due to a drop in blood pressure after standing or sitting up 6. Problems with urination 7. Erectile dysfunction in men or vaginal dryness in women 8. Weakness Risk factors for developing neuropathy are: Age persons diagnosed with diabetes later in life have a far greater risk of developing neuropathies related to diabetes mellitus. Sex the risk for men to develop neuropathies is far greater than for women diagnosed with diabetes mellitus.

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Callus formation

Subcutaneous hemorrhage

Breakdown of skin

Deep foot infection with osteomyelitis

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Foot Complications due to Diabetes continued

Glycemic (blood sugar) control if the blood sugar levels are not controlled it drastically increases the risk of neuropathies. Length of diabetes the longer the persons has been diagnosed with diabetes, the greater the risk of developing neuropathies especially autonomic High Cholesterol the increased LDL levels have been shown to damage the smaller blood vessels that feed the nervous system. Smoking the effects of nicotine and other carcinogens in tobacco have been shown to harden and impair blood flow to the lower extremities and damage the nervous system. Early symptoms of diabetic foot The following are consequences of neuropathy: Loss of motor nerve function causes weakening of the intrinsic foot muscles causing distal muscle atrophy. This imbalance produces changes in foot structure and gait. Common foot deformities include: Claw toes Hammer toes Mallet Toe The resulting deformity and limited range of motion contribute to increased mechanical stress on corresponding areas of the foot. Charcot Foot / Diabetic Osteoneuropathy is a progressive degenerative condition that affects the joints in the feet. It is associated with nerve damage that decreases the ability to sense stimuli, including pain, and decreases muscular reflexes that control movement. As a result, the joints in the feet are subjected to repeated trauma and injury, causing progressive damage to the ligaments, cartilage, and bones. This results to a permanent deformity where the foot becomes large, broad and flat if not treated or managed. Acute and Chronic infection result from impaired ability of the body to heal the affected area usually in the foot osteomylelitis. Other opportunistic infections and complications of neuropathy: 1. Urinary tract infection 2. Sexual dysfunction 3. Digestive problems 4. Increased or decrease in sweating due to autonomic neuropathy

Charcot Foot Common foot deformities due to neuropathy

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Pathways to the Development of Foot Ulcers

Mellitus

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The 5 Cornerstones of Foot Management-IDF-International Consensus on the Diabetic Foot

There are 5 key elements of foot management: 1. Education for patients, family, and health care providers. 2. Appropriate footwear 3. Identification of the at-risk foot 4. Regular inspection and examination of the at-risk foot. 5. Treatment of non-ulcerative pathology
Education for patients, family, and health care providers Education, presented in a structured and organized manner, plays an important role in the prevention of foot problems. People with diabetes should learn how to recognize potential foot problems and be aware of the steps they need to take in response. It is essential to evaluate whether the person with diabetes has understood the messages, is motivated to act, and has sufficient self-care skills. Items that must be covered when instructing a high-risk patient include: 1. Daily feet inspection including areas between the toes and the need for another person with skills to inspect the feet, should the people with diabetes be unable to do so. 2. Regular washing of feet with careful drying, especially between the toes. 3. Water temperature for washingalways below 37C. 4. Not to use heater or hot water bottle to warm your feet. 5. Use lubricating oils or lotions for dry skin but not between the toes. 6. Not to use chemical agents or plasters to remove corns and calluses. 7. Corns and calluses should be cut by a health care provider. 8. Avoidance of walking barefoot indoors or outdoors and of wearing shoes without socks. 9. Daily inspection and palpation of the inside of the shoes. 10. Not to wear tight shoes/socks or shoes/socks without rough edges and uneven seams. 11. Change socks daily. 12. Never wear tight or knee-high socks. 85% of amputations can be 13. Cutting nails straight across. prevented by simple foot care. 14. Ensure that the feet are examined regularly by a health care provider. 15. Notify the health care provider at once if a blister, cut, scratch or sore has developed. Appropriate footwear Inappropriate footwear is a major cause of ulceration. Appropriate footwear should be used both indoors and outdoors, and should be adapted to the altered biomechanics and deformities. This is essential for prevention. Identification of the at-risk foot People with high risk for future ulceration can be identified with simple foot examination. Following examination of the feet, each patient can be assigned a risk category which should guide subsequent management. People with high risk for future ulceration can be identified with simple foot risk assessment tools like the 10g Semmes-Weinstein Monofilament and tuning fork. Regular Inspection and Examination All people with diabetes should be examined once a year for potential foot problems. Patient with demonstrated risk factor (s) should be examined more often (every 1-6 months). Health care providers must make a habit of inspecting the feet of people with diabetes during every visit to the health center for early detection of wounds. Persons with diabetes must also check their feet daily before going to bed. The patients feet should be examined with the patient lying down and standing up, and their shoes and socks should also be inspected. Treatment of Non-ulcerative Pathology In high-risk patients, callus, and nail and skin pathology should be treated regularly, preferably by a trained foot care specialist. If possible, foot deformities should be treated non-surgically (eg. with an orthosis)

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Basic Foot Care Practices

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Appropriate Footwear
Shoe-related trauma is the most frequent event precipitating an ulcer. It is therefore important to explain the benefits of good footwear choice and selection. General Criteria for Footwear Selection Criteria for shoe selection should include the amount of walking, activity type and environment they will most often be worn in. Ideally the shoes should provide support for the foot structure without applying excessive pressure on any part of the foot The shoe should be a comfortable fit, not too tight, or loose. The shoes should comfortably fit the largest foot (often one foot is slightly larger than the other) In low risk levels most feet can be accommodated in commercially available shoes In High risk feet it is often necessary to have special extra depth shoes or shoes made up to fit the foot and the deformity present. A soft shoe is preferred. The shoe should be wide enough to prevent pressure on the metatarsal heads and on the dorsum of the foot. Ideally there should be a soft innersole in the shoe which is easily removable for modification or cleaning Buying new shoes: The shoes should be measured and fitted in the afternoon Wear new shoes two hours at a time to prevent blisters. Fashion vs. the Foot Fashion and foot care have very seldom been complimentary. Affects of the feet are usually felt in later life. Most common problems are related to the heel heights and the narrow shape and size of the toe box Footwear Modifications It is often possible to do limited modifications to existing shoes for pressure relief. This should be done preferably on new or fairly new shoes. It involves removing the sole of the shoe and modifications to the inside and soles of the shoe. Most common practice in Diabetic Foot care is the use of Rocker Soles. Toe Only Rocker Sole Provides relief at toe off by placing weight bearing and forces more proximal in the foot, away from ulcers in the great toe or metatarsal region

Heel to toe Rocker Sole Used to provide relief for pressure on the heel and the metatarsal region of the foot. Allows a normal rolling gait action

Double Rocker Sole The W shape alleviates pressure from the arch area used often in Charcot Foot

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Anatomy of the Appropriate Shoe

The internal width of the shoe should be equal to the width of the foot.

Lace up shoes, or Velcro closure shoes are preferred. Seamless, smooth inner and outer lining.

The shoes should be closed at the heel for better fit and stability

Deep toe box to allow space for the toes There should be about to 1cm space to the front of the shoe from the furthest toe.

The heel should provide support and stability to the heel of the foot The sole of the shoe should be firm and provide support for walking over uneven terrain

Heel height should not exceed 2 inches (5cm)

With padded insole for cushioning

Sandals should NOT be the type that goes between toes, but rather the type that goes over the top of the foot

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Identifying the Foot At-Risk for Amputation

Neuropathic foot characteristics: 1. Dry skin, fissures, cracks 2. Deformities such as claw feet, helix valgus, hammer toes, flat foot and pes cavus 3. Callus 4. Abnormally shaped foot 5. Plantar neuropathic ulcer on bony prominences 6. Prominent veins on dorsum of the foot 7. Nail pathologies 8. Limited joint mobility Neuropathic foot with peripheral vascular disease : 1. Loss of peripheral pulsation 2. Loss of hair on dorsum 3. Dark, dusky skin 4. Feet turning red in dependent positions 5. Neuro-ischemic ulcer Infected Foot: 1. Discharge from foot 2. Maceration 3. Reddish skin with swelling

Plantar neupathic ulcer on bony prominence Dry, cracked skin

Nail pathologies such as fungal infection

Maceration between toes Abnormally shaped foot (charcot foot) with neuropathic ulcer at the midfoot

We need to detect neuropathy and peripheral arterial disease at its early stage to help people with diabetes avoid amputations.

Neuro-ischemic ulcer with discharge

Source: Step-by-Step Project instructional video with academic support from the International Diabetes Federation Consultative Section on the Diabetic Foot, International Working Group on the Diabetic Foot, Muhimbili University College of Health Sciences Dar es Salaam Tanzania, Diabetic Foot Society of India with funding from the World Diabetes Foundation,

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Conducting Foot Care Sessions in Health Centers

Step 1: Introduction 1. Explain to the patient the importance of foot examination 2. Explain that a simple painless examination will be done to assess the risk for amputation. 3. It is best to conduct the examination with the patient lying down. Step 2: Conduct the foot examination 1. Look at the dorsum of the feet and palpate 2. Look for growth of hair at the medial border of the dorsum. 3. Look at the medial and lateral borders. 4. Feel the back of the foot at the heel. 5. Observe the tip of the toes. 6. Look in between toes. 7. Observe the nails. 8. Look at the plantar part of the foot and feel for bony prominences 9. Palpate for peripheral pulses at the dorsalis pedis and posterior tibial 10. Feel the temperature of the skin and look for any swelling 11. Check for mobility of toes especially the great toe. 12. Test for protective sensation using a 10 gram Semmes-Weinstein monofilament Step 3: Assess foot risk 1. Fill up the Foot Risk Assessment Form (page 88) 2. Assign a risk category. 3. Advice the timing of follow-up check-up. Step 4: Conduct an education session 1. Educate patient on basic foot care using the Diabetes Diary or the foot care poster. 2. Examine the patients footwear including the socks and advice accordingly. Point out protective features of the patients shoes or advice appropriate footwear. Step 5: Further management: 1. If with callusremove or refer 2. If with ulcertreat accordingly or refer 3. Recommend offloading methods such as bed rest, use of walker or crutches and appropriate footwear. (refer to stump care if patient was amputated) Step 6: Schedule the next visit Do not forget to encourage the patient to continue visiting the health center.

Make it a habit to look at the patients feet during every health center visit.

Palpating the dorsalis pedis artery

Palpating the posterior tibial artery

Sensory foot examination using the

10g Semmes-Weinstein monofilament

Examination should be carried out in a quiet and relaxed setting. First apply the monofilament on the patients hands (or elbow or forehead) so that he or she knows what to expect. 2. The patient must not be able to see where the examiner applies the filament. Test the sites indicated in the foot risk assessment form. 3. Apply the monofilament perpendicular to the skin surface. 4. Apply sufficient force to cause the filament to bend or buckle. 1.

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Foot Risk Assessment

5. The total time for skin contact and removal of the filament should be approximately 2 seconds. 6. Apply the filament along the perimeter of, not on, an ulcer site, callus, scar or necrotic tissue. 7. Do not allow the monofilament to slide across the skin or make repetitive contact at the test site. 8. Press the filament to the skin and ask the patient whether they feel the pressure applied (yes/no) and next where they feel the pressure (left foot/right foot) 9. Repeat this application twice at the same site, but alternate this with at least one mock application in which no filament is applied (total three questions per site) 10. Protective sensation is present at each site if the patient correctly answers two out of three applications. Protective sensation is absent with two out of three incorrect answersthe patient is then considered to be at risk for ulcerations. 11. Encourage the patients during testing by giving positive feedback. 12. The healthcare provider should be aware of the possible loss of buckling force of the monofilament if used for too long a period of time.

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Introduction to Wounds
WOUNDS are any breaks in the skin. It can result from a planned event, such as surgery, or from an unexpected event, such trauma or exposure to pressure, heat, sun or chemicals. Our skin is composed of three layers: 1. Epidermis is the outer layer of the skin that you can see. Lacking blood vessels, the epidemis gets oxygen and nutrients from the lower layers. It continually creates new skin cells to replace dead cells on the surface. The epidermis also produces melanin which gives the skin its color. 2. Dermis is the middle skin layer. It contains many cells and structures including hair follicles, nerves, blood vessels and oil and sweat glands. 3. Hypodermis or subcutaneous tissue is the third or bottom layer of the skin. It is made up of fat and and connective tissue that contains larger nerves and blood vessels. The depth of the subcutaneous tissue varies from person to person.

Wound Healing Wound healing is a complex process during which the skin is repaired. It involves inflammation, re-epithelialization, blood vessel and connective tissue formation subsequent degradation and resynthesis of extra-cellular membranes. Injury initiates the rapid onset of a vigorous, multicellular wound healing reaction, which then gradually, during following weeks or months, proceeds towards a rather acellular scar. When a wound fails to heal, it results in a chronic, nonhealing ulcer. Recurrency rate

of a chronic leg ulcer is high. Leg ulcers are a common problem of the elderly. The most common causes of leg ulcers is chronic venous insufficiency, arterial disease and diabetic neuropathy. Other causes include vasculitis, malignancies and bacterial infections.

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Definition and Classification of Wounds

Ulcers are classified into: 1. Pressure Ulcers 2. Venous stasis ulcers 3. Arterial Ulcers 4. Neuropathic ulcers Staging of Pressure Ulcers Stage 1

PRESSURE ULCERS are local areas of tissue trauma

over soft tissue where pressure has compressed one area of tissue between a bony prominence and any external surface for a prolonged period. Characteristics of pressure ulcers: Location: most often over bony prominences, but may be over soft tissue. Size: may be any size or depth Edema: often present in early stages Pain: Stage I and Stage II most common. Stage: I,II,III,IV OR unstageable if wound base cannot be visualized. Exudates: With or without Periwound Skin: often involved with edema, induration (hardening) ,temperature, pain, itching, and coloration changes Wound Edges: varies, may have undermining, tunneling, hypergranulation 2007 Staging System for Pressure Ulcers ( NPUAP) Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer,or cooler as compared to adjacent tissue. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.may include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough yellow, tan, gray,green,or brown)and/or eschar ( tan,brown,or black) in the wound bed. Stage 4 Unstageable Stage 2 Stage 3

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Definition and Classification of Wounds continued Understanding the underlying cause of an ulcer and its classification is important in ulcer management.
VENOUS STASIS ULCERS may be partial or full
thickness loss (usually partial) as a result of chronic venous insufficiency and/or venous hypertension. Characteristics of venous stasis ulcers: Location: Usually occurs in the gaiter areamedial aspect of the lower leg. Size: Large although may start small. Wound edges: diffuse, flat, and sloping although the wound is usually shallow and may be beefy red in color. Pain:

ARTERIAL ULCERS occur as a result of arterial

insufficiency therefore causing cellular ischemia. Also called ischemic ulcers. Characteristics of arterial ulcers: Small craters with well defined borders with a punched out appearance. Location: On a toe or at a traumatic injury site. Edema: localized if present. Wound edges: sharp and well defined Wound Base: devoid of healthy granulation tissue Periwound skin: most often pale and mottled. Pain: (+)nocturnal pain, during rest( rest pain)

Venous Stasis Ulcer

NEUROPATHIC ULCERS are caused by trauma,

pressure, peripheral neuropathy, peripheral arterial disease and infection Characteristics of neuropathic ulcers: Location: plantar surface of the foot. Size: often very small with even, well-defined edges Surrounding skin: often dry with fissures and callus formation Common orthopedic changes: plantar flexion contractures, hammertoes, or Charcot foot. Pain: painless

Arterial Ulcer

MIXED VENOUS AND ARTERIAL ULCERS are

ulcers caused by both venous and arterial disease. The majority of patients diagnosed with mixed venous ulcers have ulcers of venous origin and develop arterial insufficiency over time.

NEURO-ISCHEMIC ULCERS take longer to heal Neuropathic Ulcer

and are more likely to lead to amputation. The patients vascular status is the strongest predictor of healing rate and outcome.

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Steps in Wound Management

Steps in wound management: 1. Assess your patient and the wound 2. Treat underlying pathology and the wound 3. Monitor the wound to evaluate the effect of the treatment. If the wound is healing as expected, continue the treatment as planned. If not, adjust treatment according to the reassessment.

ASSESS

MONITOR

TREAT

Wound Assessment
ASSESS THE PATIENT
Full medical history e.g. diseases such as: - Diabetes - Vascular diseases - Immune compromise - Connective tissue disorders - Allergies Medication Nutritional status Lifestyle -tobacco/alcohol habits Impaired mobility Psychological/psychiatric problems Quality of Life

Drainage Descriptors
This chart provides terminology that you can use to describe the color and consistency of wound drainage. Description Serous Sanguinous Serosanguinous Purulent Color and Consistency Clear or light yellow Thin and watery Red (with fresh blood) Thin Pink to light red Thin, watery Creamy yellow, green, white or tan Thick and opaque

ASSESS THE WOUND

Location Drainage (color, consistency, amount) Wound Bed Size Depth and tunnel measurement Color and texture Moisture Odor Margins and surrounding skin condition Pain Drainage Is drainage well contained, is it oozing? Is the dressing saturated or dry? How much drainage is there? Scant, moderate, large Color and consistency of drainage?

Size Wound length is the longest distance across the open area regardless of the orientation. The width is simply the longest distance across the wound at right angle to the length. Also note the area of reddened, intact skin and white, macerated skin. These areas would be measured and recorded as surrounding erythema and macerationnot as part of the wound itself.

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Wound Assessment continued

Measuring wound size

Depth and Tunnel Measurement Use a cotton-tipped swab. Gently insert the swab into the deepest portion of the wound and then carefully mark the stick where it meets the edge of the skin. Remove the swab and measure the distance from your mark to the end to determine depth. Measure tunnels or sinus tracts as you would the depth. Use a cotton-tipped swab or palpate with a gloved finger (if the tunnel is large). Depth is reported as : Partial Thickness involve only the epidermis or extend into the dermis but not through it. Full Thicknessextend through the dermis into the tissue beneath and may expose adipose tissue, muscle or bone. These wounds heal by granulation and contraction which require more body resources and more time than the healing of partial thickness wounds.

Check the wound and the skin only after they have been cleaned. Flushing the wound bed with normal saline solution is the best method of cleaning diabetic foot ulcer.
Full Thickness Wound

th Wid

Len

gth

Partial Thickness Wound

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Wound Assessment continued

Types of Wound Bed Color Color and Texture Wounds can be also classified by the color of the wound bed. Wound color helps you determine whether debridement is appropriate. Blackbe alarmed. This signals necrosis (tissue death). Eschar (dead, avascular tissue) covers the wound, slowing the healing process and providing microorganisms with a site in which to proliferate. When eschar covers a wound, assessment is deferred until eschar is removed. Typically debridement is indicated. However ulcers caused by ischemia and uninfected heel ulcers are exceptions. Yellowbeware. A yellow color may be a film of fibrin on the tissue. Fibrin is a sticky substance that normally acts as a glue in tissue rebuilding. However, if the wound is unhealthy or too dry, fibrin builds up into a layer that cant be rinsed off and may require debridement. Redyoure ahead. The wound bed is healthy and normal healing is underway. When a wound begins to heal, a layer of pale, pink granulation tissue covers the wound bed. As this layer thickens, it becomes beefy red. The texture of the wound bed provides just as much information about the wound and healing as its color. If you note very smooth red tissue in a partial-thickness wound, its most likely the dermis. In full-thickness wound, its probably muscle tissue not granulation tissue. Healthy granulation tissue has a soft, bumpy appearance. Moisture The wound bed must be moistbut not overly moist. Moisture allows cells and chemicals needed for healing to move about the wound surface. Describe wound beds as dry or moist. Odor If kept clean, a non-infected wound usually produces little, if any, odor (one exception is the odor normally present under a hydrocolloid dressing that develops as a by-product of the degradation process.) A newly detected odor might be a sign of infection.

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Wound Assessment continued

Margins and Surrounding skin Check for induration (hardness) and the color of the skin around the wound. This can alert you to impending problems that can impede healing: White skin indicates maceration or too much moisture, and signals the need for a protective barrier around the wound and a more absorbent dressing Red skin can indicate inflammation, injury (for example tape burn, excessive pressure, chemical exposure) or infection. Purple skin can indicate bruising, one sign of trauma. Pain Note not only pain associated with the injury itself but also pain associated with healing and with therapies employed to promote healing. Ask the following: Where is the pain located? How long does it last? How often does it occur? What does the pain feel like? What relieves the pain? What makes it worse? How would you rate your pain from the scale of 1 to 10 with 10 representing the worse pain.

Wound Assessment and Monitoring Tool

Assessment Parameters Location Drainage Wound Bed 1 Size 2 Depth and tunnel 3 Color and texture 4 Moisture 5 Odor Margins and surrounding skin Pain Type of wound? Stage? Presence of infection Others Management How should I clean? Dressing? Compression? Antimicrobials? Offloading? Footwear? Referral? To whom? Date of next visit? Others: Initial Assessment Date: First Follow-up visit Date: Second Follow-up visit Date

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Wound Care
Basic wound care centers on cleaning and dressing the wound. The goal of wound cleaning is to remove debris and contaminants from the wound without damaging healthy tissue. The wound should be cleaned initially; repeat cleaning as needed or before a new dressing is applied. The basic purpose of dressing is to provide an optimal environment in which the body can heal itself. Functions of the wound dressing include: 1. Protecting the wound from contamination or trauma 2. Providing compression if bleeding or swelling is anticipated. 3. Applying medications 4. Absorbing drainage or debrided necrotic tissue 5. Filling or packing the wound 6. Protecting the skin surrounding the wound.

With any wound, healing is promoted by keeping the wound moist, clean and free from debris. The cardinal rule is to keep moist tissue moist and dry tissue dry.
Chemicala selective method using enzymatic agents applied topically to areas of necrotic tissue only. Stop using enzymes when the wound is clean with red granulation tissue. Mechanicalincludes wet-to-dry dressings, irrigation and hydrotherapy.

Wound Irrigation
Use sterile water or sterile normal saline solution. Irrigation cleans tissues and flushes cell debris and drainage from an open wound. It also helps prevent premature surface healing over an abscess pocket or an infected tract. After irrigation, pack open wounds to absorb additional drainage. Attach a 19G needle or catheter to a 35-ml piston syringe. This setup delivers an irrigation pressure of 8 psi which is effective in cleaning the wound and reducing the risk of trauma and wound infection. Avoid forcing the needle or catheter into the wound to prevent tissue damage. Make sure the solution flows from the clean to the dirty area of the wound to prevent contamination of clean tissue.

Cleaning the wound

Flushing the wound bed with normal saline solution is the best method of cleaning diabetic foot ulcer. Sterile normal saline provides a moist environment, promotes granulation tissue formation, and causes minimal fluid shifts in healthy adults. Most commercial wound cleaners are somewhat toxic to cells in the wound bed, and their use can slow healing. Use clean, warm water and mild soap to clean the surrounding skin.

Continue until the solution returns clear. Keep the patient positioned to allow further wound drainage. Wound healing cant take place until necrotic tissue Clean the area around the wound and apply dressing. is removed. Necrotic tissue may present as moist yellow or gray tissue thats separating from viable Wound Dressings tissue. It this moist tissue becomes dry, it presents as thick, hard, leathery black eschar. Areas of necrotic Moist wound therapy speeds healing in diabetic tissue may mask underlying fluid collections or foot ulcers. Dressing that maintain the necessary abscesses. Although debridement can be painful, it wound environment include: Alginates is necessary to prevent infection and promote healing. Transparent films Foams Hydrocolloids Types of debridement are: Sharpuse of cutting tool such as scalpel, Hydrogels Collagen-based dressings scissors or a laser. Autolyticuse of moisture retentive dressings to Composites (combination of the other dressings) cover the wound bed. Necrotic tissue is then dissolved through self-digestion of enzymes in Choice of dressing depends on the condition of the the wound fluid. If the wound is infected, this ulcer. Diabetic foot ulcers tends to produce low to method is not the treatment of choice. Although moderate drainage. However, if the wound bed is this takes longer than other methods, it isnt dry, its needs a dressing that adds moisture. painful, its easy to do, and its appropriate for patients who cant tolerate any other method.

Debridement

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Wound Care continued

Gauze dressing Made of absorptive cotton or synthetic fabric, gauze dressings are permeable to water, water vapor and oxygen and may be impregnated with hydrogel or another agent. When uncertain about which dressing to use, you may apply gauze dressing moistened in saline solution until a wound specialist recommends definitive treatment. Hydrocolloid dressing Adhesive. Moldable wafers made of a carbohydrate-based material and usually have waterproof backings. Theyre impermeable to oxygen, water, and water vapor, and most have some absorptive properties. Transparent film dressing Clear, adherent and non-absorptive. These polymer-based dressings are permeable to oxygen and water vapor but not to water. Their transparency allows visual inspection. Because they cant absorb drainage, theyre used on partialthickness wounds with minimal exudate. Alginate dressing Made from seaweed, are nonwoven, absorptive dressings available as soft white sterile pads or ropes. They absorb excessive exudate and may be used on infected wounds. As these dressings absorb exudate, they turn into a gel that keeps the wound bed moist and promotes healing. When exudate is no longer excessive, switch to another type of dressing.

Dressings for Diabetic Foot Ulcers

Type of Ulcer Dry Ulcer Wet Ulcer Recommended Dressing Hydrogel Alginate Foam Collagen Hydrogel Hydrocolloid Transparent film Hydrocolloid Alginate ropes (wet ulcers) Hydrogel impregnated gauze (for dry ulcers) Iodosorb (a gel that cleans the wound by absorbing fluid, exudate, and bacteria) Acticoat or Arglaes (products with antimicrobial component) Alginate

Necrotic Ulcer Shallow Ulcer Tunneling or deep ulcer Infected ulcer

Bleeding ulcer

arterial ulcer cannot be treated with compression. If the leg ulcer is arterial, always refer to a specialist.

Topical Antimicrobials

Routine wound cleaning handles most of the surface microbial population. However, applying a topical antimicrobials directly to the wound bed can help control microorganisms in the wound bed and improve healing. Commonly used topical antibiotics include: Foam dressing 1. Bacitracin Spongelike polymer dressings that may be 2. Metronidazole impregnated or coated with other materials. 3. Mupirocin Somewhat absorptive, they may be adherent. These 4. Silver sulfadiazine dressings promote moist wound healing and are useful when a nonadherent surface is desired. Off-loading Relieving pressure from plantar tissues is the Hydrogel dressing cornerstone of diabetic neuropathy treatment as Water-based and nonadherent, polymer-based well as prevention for those patients at risk for dressings that have some absorptive properties. recurrent breakdown. Off-loading is particularly Theyre available as a gel in a tube, as flexible important because patients with diabetic sheets, and as saturated gauze packing strips. They neuropathy can no longer feel the growing may have a cooling effect, which eases pain, and discomfort that precedes tissue damage. are used when the wound needs moisture. Non surgical off-loading techniques include: 1. Therapeutic footwear, possibly with rocker soles Compression 2. Custom orthotics like shoe inserts Ascertain the underlying disease, e.g. venous / 3. Walking casts arterial. A venous leg ulcer should be treated with 4. Use of crutches or wheelchair graduated compression therapy, whereas an 5. Bed rest

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Wound Monitoring
The next step is to monitor the patient throughout the healing process, periodically reassessing his status and documenting progress to full healing. Your initial assessment sets the benchmark for subsequent monitoring and reassessment activities. A series of assessments becomes a moving picture illustrating the dynamic aspects of the healing process.

Recognizing Failure to Thrive

Sign Wound Bed Too Dry Exposure of tissue and cells Add moisture regularly normally in a moist environment Use a dressing that maintains moisture to air such as hydrocolloid or hydrogel dressing Inadequate hydration Pressure or trauma to the area Poor nutrition, poor circulation, inadequate hydration, or medications Poor control of blood sugar Inadequate pain control Infection Reassess the patient for local or systemic problems that impair wound healing, and intervene as necessary Cause Intervention

No change in size and depth for 2 weeks

Increase in size or depth

Debridement If debridement of necrotic tissue is being Ischemia due to excess pressure done, no intervention is necessary. or poor circulation Poor circulation may not be resolvable, Infection but consider adding warmth to the area and administering a vasodilator or antiplatelet medication Ischemia Infection Autolytic or enzymatic debridement Perform debridement if the remaining living tissue has adequate circulation No intervention is necessary if caused by autolytic or enzymatic debridement. Increase in drainage or change of drainage color is expected because of the breakdown of dead tissue. If debridement is not the cause, assess the wound for infection Protect the area from pressure using offloading measures Irrigate and inspect the tunnel as carefully as possible for a hidden suture or leftover bit of dressing material If the tunnel doesnt shorten in length each week, thoroughly clean and obtain a tissue biopsy for infection and, with a chronic wound, for possible malignancy

Necrosis Increase in drainage or change of drainage color from clear to purulent

Tunneling

Pressure over bony prominences Presence of foreign body Deep infection

Proper documentation of the wound assessment is important. The information that you have in the initial assessment plays an important role in wound monitoring. It serves as a benchmark for wound healing.

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Wound Monitoring continued

Recognizing Failure to Thrive continued
Sign Wound Edges Red, hot skin, tenderness, and induration White skin (maceration) Inflammation due to excess pressure or infection Excess moisture If pressure relief doesnt solve the inflammation within 24 hours, topical antimicrobial therapy may be indicated. Protect the skin with pertrolatum ointment or barrier wipe. Use a more absorptive dressing Use moisture-retentive dressing If rolling is not resolved in 1 week, debridement of the edges may be necessary. Initiate measures to protect the area, especially during patient transfers. Cause Intervention

Rolled skin edges

Too-dry wound bed

Excess shearing force to the Undermining or ecchymosis or surrounding skin area (loose or bruised skin edges)

Factors that Affect Healing include:

1. 2. 3. 4. 5. 6. 7. Nutrition Oxygenation Infection Age Chronic Health Conditions Medications Smoking

Nutrition Proper nutrition is the most important factor affecting wound healing. Protein is critical for wounds to heal properly. It is needed to form collagen during the proliferation phase. In fact, a person needs to double the recommended dietary allowance of protein before tissue even begins to heal. Aside from protein, collagen synthesis requires zinc, carbohydrates, fats, vitamins A and C, iron and copper. Oxygenation Healing depends on regular supple of oxygen. Possible causes of inadequate blood flow to the area of the wound include pressure, arterial occlusion, or prolonged vasoconstriction associated with peripheral vascular disease and atherosclerosis. Other possible causes of low blood oxygenation include: anemia, chronic obstructive pulmonary disease, hypothermia or hyperthermia, etc.

Infection Infection can be systemic or localized. A systemic infection increases the patients metabolism and thus consumes body fluids, nutrients and oxygen. A localized infection in the wound itself is more common. When the inflammatory phase lingers, wound healing is delayed and the metabolic by-products of bacterial ingestion accumulate in the wound. This build-up interferes with the formation of new blood vessels and the synthesis of collagen. Age Skin changes that occur with aging cause healing time to be prolonged in elderly patients. It is usually complicated by other problems associated with aging, such as poor nutrition and hydration, the presence of a chronic condition, or the use of multiple medications. Chronic Health Conditions Diabetes, atherosclerosis, respiratory problems and malignancies can increase the risk of wounds and interfere with systemic and peripheral oxygenation and nutrition.

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Introduction to Stump Care

Levels of Amputation
Above the Knee Amputation (AKA) Transfemoral amputation amputation through the femur, under level of greater trochanter Below the Knee Amputation (BKA) Transtibial amputation amputation through the tibia and fibula Symes Amputation Trans-ankle amputation Through ankle-transection tibia and fibula above articular surfaces, through ankle joint Partial Foot Amputation Transmetatarsal, metatarso-phalangeal, phalangeal amputation removal of part of the foot, below the ankle

Transfemoral Amputation

Importance of Stump Care

To prevent secondary complications like contractures, ulcerations and infections To prepare the stump for prosthesis acquisition Components of proper stump care: 1. Proper residual limb positioning 2. Stump skin care 3. Proper stump bandaging

Transtibial Amputation

Stump Skin Care Wash stump at least once a day with lukewarm water & a mild soap Wash stump, usually, at night to minimize swelling Treat any minor irritations or problems on the stump immediately Bandaging Action of wrapping a material around a body part Decrease swelling & edema

Symes Amputation

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Proper Residual Limb Positioning

Do.

Neutral hip rotation with no abduction

Extend hip and knee when lying down

Extend knee when in bed

Extend knee when sitting

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Transtibial Residual Limb Wrapping

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Transtibial Residual Limb Wrapping continued

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Begin by placing a double-length 4-in. elastic bandage above the kneecap. Wrap around once to secure the bandage comfortably, but not too tightly. Continue the bandage around the back, and cross to corner D. Bring the bandage around corner D, and cross upward in a direction toward B. Continue around the back toward A. Wrap the bandage across and down to corner C. Continue to wrap around the end and cover corner D. Move upward and across the front towardB. Continue to move across the back and down toward corner D. Move upward and across the front toward B. Continue to move across the back toward A. Move down and across the front toward corner C. Continue to wrap across the end and cover corner D. Move up and across the front toward B. Continue across the back, and move down and across the front toward corner C. Move around corner C toward corner D and continue up and across the front toward B. This is the figure-of-8 pattern guide. 17. Continue with the figure-of-8 pattern, and move the bandage higher on the residual limb until completely covered in a figure-8-pattern. Remember to apply less pressure as you move up. Complete the wrap by anchoring it with tape

Transfemoral Residual Limb Wrapping

PART 1 1. Begin by placing a double-length 6-in. elastic bandage at letter D, and cross down to corner B. Note that the pressure should be uniform throughout part 1 (Nos. 1 to 8) of the wrapping procedure. 2. Continue the bandage around corner C, and cross the front up toward A 3. Wrap around the waist, with the thigh extended, and then back toward A 4. Continue around the back of the thigh toward D. 5. Cross to A, and wrap the uppermost part of the inner aspect of the thigh. 6. Again, wrap the bandage around the waist to A and then around the back of the thigh to D, and cover the upper inner part of the thigh again. 7. Return toward A, wrap the bandage down and across the back to corner C, and then again return toward A. 8. Wrap around the back, and anchor with tape. This completes part 1 with the 6-in. bandage. PART 2 1. Begin by placing a double-length 4-in. elastic bandage on the residual limb between the corners A and B. Wrap diagonally around corners B and C. 2. Cross upward toward A, and anchor the wrap. 11, continue around the back and down to corner C. 3. Wrap upward and across to A and then around the back toward D. 4. Continue down and across to cover cornersB and C. 5. Continue upward and across to A This is the figure-of-8 pattern guide. 6. Wrap around the back toward D. 7. Continue down, and wrap corners b and C, but wrap slightly higher than the previous time around. Continue wrapping higher on the residual limb until the figure-of-8 bandage is completed. 8. Remember to apply less pressure as you move up. Complete the wrap by anchoring it with tape. Note that the angle between the figure 8s should be 80 to 90 degrees at the crossover point to avoid a tourniquet effect.

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Transfemoral Residual Limb Wrapping continued

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Criteria for Artificial Leg Fitting

6 months after amputation- minimum period prior to fitting Good physical and mental state condition Good mobility/strength No wound, contracture, and infections Free, good scar Controlled Blood Pressure Controlled Blood Sugar

Referring to Davao Jubilee Foundation for Artificial Leg Acquisition

PAYING PATIENTS: Refer to any Rehabilitation Medicine Doctor for Prosthetic prescription then proceed to Davao Jubilee Center INDIGENT PATIENTS: Call Davao Jubilee Center every Thursday morning for free consultation services

Davao Jubilee Foundation Address: Sitio Escuela, Catalunan Grande, Davao City in-front of Barangay Hall Telephone Number: 2971398

Monitoring of Prosthesis and Stump

Use this simple monitoring tool modified from the Davao Jubilee Foundation Patient Monitoring and Follow-up sheet to assess patients with prosthesis. Prosthetic Device 1. Are you regularly using your prosthesis? 2. How is the prosthesis fitting? 3. How is the prosthesis functioning? 4. Are you satisfied with the fit of the prosthesis? 5. Are you satisfied with the function of the prosthesis? Do you feel it necessary for the technician to checkup your prosthesis? Stump Are you experiencing any problems with your stump? No Yes Yes Good Good Yes Yes No Refer to DJF If the answers are in this column No Not Good Not Good No No Yes

If there are wounds, blisters or signs of infection on the stump refer to district health center doctor or nurse for medical management before referring to Davao Jubilee Foundation.

References
1. 2. International Working Group in the Diabetic Foot/Consultative Section of the International Diabetes Federation, International Consensus on the Diabetic Foot and Practical Guidelines on the Management and Prevention of the Diabetic Foot. International Working Group on the Diabetic Foot. 2007. Wound Care made Incredibly Easy. Lippincott, Williams and Wilkins: United States of America, 2003.

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Module 5 PSYCHOSOCIAL AND BEHAVIORAL APPROACHES
Contents:
Psychological Reactions to the Diagnosis of Diabetes Types of Coping 5 Cs Behavioral Change Intervention Professional Attitudes and Behavior

Asking questions and helping patients to work through their issues can enable diabetes care providers to improve outcomes with relatively little consumption of resources.

Psychological Reactions to the Diagnosis of DIABETES Denial No! Not Me! Fear What if.... Anxiety How will I live? Depression Life has no meaning anymore Anger I hate you! Bargaining Not now. Hope When I get cured Acceptance I can die anytime Other Psychological & Psychiatric Problems Persons with Diabetes May Suffer Eating Disorders Phobia Obsessive Compulsive Disorder Alcohol And Drug Dependence Panic Disorder Self-care issuesRegimen acceptance & adherence Emotional issues Diabetes related distress & depression

5 Cs Behavior Change Intervention

Constructing a problem
Start with the patients problem Specify the problem

Collaborative Goal Setting

Translate patients self-management and behavior change intentions into goals

Collaborative Problem-solving
Problem solving ABILITY is associated with improved health outcomes Problem-solving INTERVENTIONS are often effective in improving health outcomes. Identify barriers to goal attainment Cognitions (belief that treatments are not effective) Emotions (Lack of self-efficacy) Social networks (Lack of Support) Resources (Lack of time or money) Physical Environment (Lack of facilities)

Contracting for Change

Patients should be encouraged to keep a Types of Coping record of successes and lapses and reasons why Problem-focused CopingStrategies that are each occurred. appropriate for problems that can be directly Continuing Support remedied Patients should be prepared to handle relapse Emotion-focused Coping- Strategies appropriate and re-establish self-care regimen for problems that cannot be directly remedied.

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Emotional Support Interventions
Health Consequences of Emotional problems: poorer self-care poorer metabolic outcomes morbidity mortality functional limitations poorer quality of life All Clinicians Should Be Able to: demands of diab. Management? Do you get the support you need from your family? Do you worry about getting diabetes complications? Primary Intervention: Cognitive Behavior Therapy Goal Address lack of self-confidence Unrealistic expectations Lack of Motivation to change behavior

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1. Identify patients who are suffering from diabetesIdentifying psychiatric disorders related distress. 2. Apply effective treatments to relieve diabetesAsk the following questions: related distress. During the past 2 weeks, have you felt down, 3. Identify patients who are suffering from depressed or hopeless? psychiatric disorders. During the past 2 weeks, have you lost interest or 4. Refer patients for specialized mental health care pleasure in doing things? when appropriate. Identifying Diabetes Distress Ask the following questions: Are you having trouble accepting your diabetes? Do you feel overwhelmed or burned out by the

Professional Attitudes And Behaviors

Traditional Medical Model
Diabetes is a physical illness Relationship of provider and patient is authoritarian based on provider expertise

Empowering Person Centered Model

Diabetes is a biopsychosocial illness Relationship of provider and patient is democratic and based on shared expertise

Problems and learning needs are usual- Problems and learning needs are usually identified by professionals ly identified by patient Professional is viewed as a problem solver and caregiver, i.e., professional is responsible for diagnnosis, treatment, and outcome Goal is compliance Behavioral strategies are used to increase compliance with recommended treatment. Patient is viewed as problem-solver & caregiver i.e., professional acts as a resource & both share responsibility for treatment and outcome Goal is to enable patients to make informed choice. Behavioral strategies are used to help patients change behavior of their choosing.

Lack of compliance is viewed as failure Lack of good achievement is viewed as by the provider or patient . feedback & used to modify goals & strategies

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Module 6 SELF-MANAGEMENT EDUCATION
Diabetes is a personal responsibility
People with diabetes want information People with diabetes want to be in control of their condition Diabetes needs to be self-managed Education is more effective when it is patient-centered We educate so that our patients can make informed decisions

Contents:
Introduction to Self-Management Education The Health Educator The E.A.S.E Approach Using Patient Education Materials The Diabetes Diary The Medical Nutrition Therapy Kit

Introduction
Diabetes Education It is a means of attaining health promotion It allows the individual to gain knowledge, correct attitude, behavior and practices for health improvement An integral part of patient care and selfmanagement Why education and self-management? The first step is to educate in order to facilitate informed decision making. Although many people with type 2 diabetes do not view their condition as serious, it needs to be acknowledged and understood that complications occur with all types of diabetes. Diabetes is largely managed by the person with the condition on a day-to-day basis. Thus, caring for diabetes is a personal responsibility. What is the difference between education and behavioural change? The two are not distinct entities, but rather overlap to a great degree. We can think of education as the body of information, skills and technologies that a person with diabetes needs to learn. As discussed in the teaching and learning module, how they learn will have an impact on whether or not behavioural changes follow. In this module we will discuss how to help people take the steps to behavioural change once they have the necessary knowledge. Patient Education planned learning experience using a combination of methods, such as teaching, counseling and behaviour modification techniques, which influence knowledge and health behavior. Patient education entails more than just teaching or learning. It involves a combination of techniques and methods, all of which are aimed at increasing knowledge, skills and confidence in order to make appropriate healthy choices and establish new habits. Patient-centered Education Interventions are more effective when they: Are tailored to peoples preferences Are tailored to a peoples socio-cultural environment Actively engage people in goal-setting Incorporate coping skills Provide follow-up support This is a summary of critical factors for successful educational interventions. Adult learners generally have preferences about how they learn best and the topics they want to address. Information needs to be culturally relevant and appropriate. One of the critical factors in ensuring success is the ongoing nature of self-management and professional support. Education is not a one-time event that will provide people with all they need to manage diabetes for a lifetime. Without ongoing support, behaviors return to pre-intervention levels after about six months. Health Education Consists of learning experiences that promote behavior change conducive to good health. Provides tools for developing physical, emotional, spiritual and sound mental health.

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9. All communities, no matter how small, have an organizational structure on which to build on. 10.Secure the coordination and cooperation of people and existing organizations. 11.Start with simple educational measures or projects most likely to succeed in a short time to gain peoples confidence. 12.Start with project in a pilot area than on a wide-scale basis. 13.A fundamental faith and belief in peoples ability to contribute to the solution of their own problems is essential for effective and lasting health education. Philosophy of Health Education The focus of health education is on people and on action. In general, it aims to persuade people to adopt and sustain healthful life practices, to use judiciously and wisely the health services available to them and to make their own decisions, both individually and collectively, to improve their health status and environment.

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The Health Educator

Concept of Health Education It is a learning process growing out of health needs, nourished by health knowledge and producing intelligent constructive and healthful individual and community action. It is a means of creating opportunities for the people to participate and assumes responsibility for the solution of their own problem in cooperation with health specialist and educators. The facilitator or implementer of health education Initiator of the process whereby people learn to improve their health attitude and habits and to work together for the improvement of health condition of the family, community and the nation.

Qualities of a Health Educator Efficient plans with the people, organizes, conducts, directs health education activities according to the needs of the people. Communicator provides participant with clear and relevant information. Principles of Health Education Active listener hears what is being said and 1. Health education is a teamwork endeavor. whats behind the words. It is everybodys business. Keen observer keeps an eye on the 2. Health education must be an integral part of all proceedings, processes and participants health planning. behavior. 3. All health workers need to be trained and make Systematic knows how to put in sequence or use of educational methods, approaches and logical order the parts of the session. media. Creative/resourceful uses available materials, 4. Health education is concerned with the involves participants changes in the knowledge, attitude and feelings Analytical a critical thinker and behavior of the people. Tactful brings about issues in smooth, subtle 5. Health education program must be built on manner. already existing structures. Preliminary survey of Knowledgeable imparts relevant, updated and what has been done and what needs to be sufficient input done is required. Open invites ideas, suggestions, criticisms, 6. Program should be based on clearly stated involves people in decision making. goals. With sense of humor knows how to place a touch 7. Health education is concerned with working with of humor to keep audience alive. rather than for the people. Change agent involves participants actively in 8. Needs and interest of the people should be assuming the responsibility for his own learning. considered.

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The E.A.S.E Approach

The E.A.S.E Approach is..

A tip for diabetes educators to guide him/her during the counselling session be it individual or group An easy way to deliver an education process A tool that is easy to remember

Strategize your learning approaches based on the

patients needs Once you have assessed your patients learning needs, you can develop an education plan that fit his/her needs. The plan must be developed together with the patient, and if possible with the spouse or significant other. In teaching patients about diabetes management, encourage participation and create an environment in which the patient can freely ask questions and express opinions. Topics can be classified into three main groups: The needs to know are the essential information that the patient needs to survive. These include medication, diet, self-monitoring and motivation. These are the absolutely essential information that a patient needs to leave you care safety. The wants to know are the things that patients ask about. They may not be the most important things to you, but if the patient asks you something and you cut them off, you will lose your patients trust and they will no longer hear anything else you say. If there is something more important to discuss, you can tell your patient that the subject will be covered later on, but if they are really concerned about it, you will discuss it with them after the current topic. The nice to know are the topics that may be interesting and fun, but no one needs them to survive. Teach people what they need, not what they enjoy.

Establish rapport
Make friends with the patient. As we all know, effective learning can only take place when we have gained the patients trust and acceptance. It starts with being genuinely interested about the person. listen actively when he/she speaks. remember to make eye contact. respect his/her beliefs and opinions and be sensitive to his/her emotions and needs. In the course of your conversation, try to learn the following things about the patient: 1. Who is this patient as a person? 2. What is his/her psychological needs? 3. Is there a significant other to help her through the learning process? 4. Are there barriers to learning? 5. Can he/she afford to live with this disease? 6. What parts of the health system will she utilize? 7. What referral will she require? 8. Which member of the health care team is needed at this time or will be required later?

Assess the patients needs

This involves finding out: What he/she has been told about his/her illness What does the person know? how does he/she learn? How ready is he/she to learn? What are the barriers? Patients NEEDS NNutrition EExercise EEducation Ddrugs: oral anti-hyperglycemic agents & Insulin SSelfmonitoring; Selfcare; Special Consideration; Stress Management; Smoking Cessation Suggested questions? What has the doctor told you? What does having diabetes mean to you? How do you feel about having diabetes? What do you know about diabetes?

Evaluating what the patient has learned

Ask for your patients feedback regularly during the session, in case there are points that need to be clarified or if he has a different opinion. At the end of the session, ask your patient to demonstrate or tell you what he has learned. For example, after the session on self monitoring, you may ask your patient the following: How will you know if you have low/high blood sugar? What will you do if you have low/high blood sugar? Show me how to test your blood sugar (allow patient to demonstrate)

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Learning does not automatically lead to doing. Therefore, we must know if the patient will be able to do things that he/she has learned. If not, we must know what the barriers are, and what can be done to overcome them. The following are the guide questions you might want to consider: Do you think you will have difficulty doing things? What will make it difficult for you to do these things? Can you think of some ways that will help you do this? What would be a better way for you to monitor blood sugar, follow a diet, exercise etc.?

E. A. S. E. Approach
E - establish rapport A - assess the patients need S - strategize your learning approaches
based on the patients needs E - evaluate what the patient has learned

Using Patient Education Materials

The common wisdom used to be that if you wanted to save money on educational materials, just check the trash can in the parking lot. Although health professionals cannot guarantee that their patients will use the materials provided, there are some ways to increase the likelihood that they will benefit from such resources. Rather than just handing patients a stack of materials: Choose one or two items about which the patient has expressed a particular interest. Let patients know that you chose these particular materials because you think they will benefit from them. Take the time to highlight one or two key points or make a handwritten note of something to which patients should pay particular attention. This increases the likelihood that patients will follow through with recommendations in those areas. Match materials to patients. Both content and pictures need to be representative of a patients age, sex, ethnicity, and culture. Patients are more likely to read something if it looks as if it applies directly to them. Match reading levels to patients. Look for thorough but simply written materials that are adult in tone. Pay attention to tone and avoid materials that have a lot of shoulds and musts or that preach or talk down to patients. Give a few patients you trust several different handouts or printouts and ask that they give you their candid opinions. Ask specifically what they do and do not like about these materials and whether they found them to be informative and inspiring. Make sure that the materials match the reality of diabetes. Patients struggle with making changes and dealing with the anger, fear, and frustration that often go with diabetes. Materials need to address these issues just as they address the clinical aspects of diabetes care. Source:
Finding and Using Patient Education Materials, Volume 27, Number 1, 2009 Clinical Diabetes, Martha M. Funnell, MS, RN, CDE

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The Diabetes Diary

The Diabetes Diary The Diabetes Diary is used for.. Patient Identification Patient Education Patient Monitoring Patient Recording
Remind the patient to always bring their diary during Diabetes and Heart Days and during consultation with any health care provider.
1. Given only to persons with diabetes. 2. Persons with diabetes are those diagnosed by a doctor to have diabetes. 3. One diary is given per patient. 4. The diary is not for sale. 5. An orientation on how to use the diary must be done immediately after giving the diary. 6. A list of persons with diabetes who are given a copy of the diary should be maintained at the health center. 7. The diary should be used to record monitoring activities including results and consultations done before, during or after the Diabetes and Heart Days. 8. Although the diary records consultations with the physician, it does not totally substitute hospital, clinic or health center or CVD Program consultation forms. 9. Data in the diary of the patients are confidential. Avoid showing it to other patients. 10. The diary contains sections on patient education. These are meant for self-reading or self-study. Do not remove pages from the diary to conduct patient education sessions.

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The Diabetes DiaryParts to be filled up by Persons with Diabetes

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The Diabetes Diary - Parts Filled Up by The Health Care Team

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The Diabetes Diary - Sections for Patient Education

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Medical Nutrition Therapy Kit

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The Medical Nutrition Therapy Kit is designed for use by Nutritionist-Dietitians for one-on-one nutrition counselling and for group education sessions. It contains the following items: 1. Food models of common local food items like rice, suman (rice roll), loaf bread, pan-de-sal, sweet potato, chicken, pork, fish, papaya, banana and durian. 2. Table top weighing scale. 3. Measuring cups and spoons 4. 9-inch diameter plate for Plate-method demonstration.

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Module 7 SETTING UP SERVICES FOR CVD RISK MANAGEMENT IN PRIMARY HEALTH CENTERS
Contents:
Team Management Functions of the Health Care Team Making Health Service Physically Accessible Setting up services for CVD risk management in primary health centers Equipment and Facility Requirements Physical space, equipment and facilities must be available and conducive to service delivery and learning and allow members of the diabetes team to carry out their respective functions.

CVD PROGRAM TOOLS AND EQUIPMENT

Service Tool Diabetes Risk Self-Assessment Form Screening , Diagnosis and CVD Risk Assessment Form Monitoring Blood glucose meter with strips HbA1c point-of-care machine Sphygmomanometer with adult and pediatric cuff sizes Stethoscope Cholesterol meter with strips Urine strips for proteins and ketones Tape Measure Height Chart and Weighing scale Foot Care Kit Monofilament Hand mirror Foot Risk Assessment Form

Team Management

The management of diabetes and other CVD risk factors is an active partnership between people with diabetes and other CVD risks, their family and Management HCP Training Manual Containing their healthcare team. An integration of clinical Clinical Practice Guidelines care and self-management education is best Foot and Wound Care Kit provided by a multidisciplinary health care team . Medical Nutrition Therapy Kit The core health care team consists of the physician, Food Models the nurse, the nutritionist-dietitian and may also Table top weighing scale include health workers, lay educators, psychologists, Measuring cups and spoons pharmacists, laboratory technologists, podiatrists. Plate (9-inch diameter) Index Cards for Patient Records The Team Approach is. FNRI Food Exchange list Referral Form Patient education (clinical care and self Laboratory Request Form management education) Diabetes Diary Information Diabetes Prevention Flipchart and given by a multidisciplinary health care team Education Patient Education Flipchart Risk Factors Poster with members having different expertise and Signs and Symptoms Poster responsibilities Foot Care Poster Footwear Poster working together with persons with diabetes CVD Program Services Flowchart by constant communication and coordination to provide continuous, integrated and quality care. Recording Patient Record Form (Folder) Consultation Form Patient Registry Barangay Report Form District Laboratory Report Form District Monitoring Form

Reporting

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Functions of the Health Care Team
PHYSICIAN (DHO)
Center-based

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THE DISTRICT HEALTH OFFICER (DHO) Leads and coordinates the activities of the entire health care team Performs opportunistic primary screening and initial assessment Advices screening and diagnostic procedures Establishes diagnosis and identifies existing complications Provides initial diabetes education and orientation to team management Initiates and adjusts pharmacologic therapy ( OAD or insulin ) Prescribes specialized medical nutrition therapy based on computed caloric requirements, dietary needs and restrictions Prescribes specialized physical activity Initiates the use of patient monitoring tools (eg. diaries ) and explain its importance Determines when and where to refer patients for further assessment or management Makes referrals to other specialized health care providers

PERSON WITH DIABETES

EXTENSION TEAM
Communitybased

DISTRICT NURSE/ MIDWIFE

Center-based

NUTRITIONIST
Center-based

THE PERSON WITH DIABETES Performs self-management practices Provides peer education and support. THE DISTRICT NUTRITIONIST-DIETITIAN Assesses patients dietary habits Develops specialized medical nutrition therapy based on the physicians prescription Develops the patients meal plan Provides continuous dietary management and counseling including monitoring of patients BMI and WC Provides patient/ family education including food preparation methods. THE BARANGAY EXTENSION TEAM Barangay Health Station In-charge, Barangay Health Workers, Barangay Nutrition Scholars Performs risk assessment Performs Capillary Blood Glucose testing or recommends FBS for persons at risk for Diabetes Refers to the physician for diagnosis and initiation of management Provides community-based self management education Performs monitoring procedures (BP, blood glucose, waist circumference, foot examination) Refers persons with suspected complications to the physician Administers diabetes education to the general population and high risk groups Prepares and updates records and reports

THE DISTRICT NURSE OR MIDWIFE In the absence of the physician, performs opportunistic primary screening ,advices screening and diagnostic procedures and refers to nutritionist for dietary assessment Performs monitoring procedures (BP, blood glucose, foot examination) Assesses patients self-management practices (eg. through patient diary, interview, etc), identify potential treatment problems, and discuss with the patient the ways for improvement Monitors drug compliance Discuss concerns and fears with patient and family and provide patient/ family support Bring to the physicians and nutritionists attention any patient concerns relevant to their roles Interface with physicians and other diabetes management team members Endorses patients to the barangay extension team for monitoring. Prepares and updates records and reports Property custodian of team equipment

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Making Health Services Physically Accessible

REMEMBER

RECU
Reach Enter Circulate Use

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Setting Up Health Services for CVD Risk Management in Primary Health Centers

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The Diabetes and Heart Day

The Diabetes and Heart Day, operationalizes the knowledge and skills gained from the CVD Program trainings into services for people in the community. The Diabetes and Heart Day is.. Dedicated to screening, management of diabetes and hypertension and health promotion through patient education Operated by a multidisciplinary team of health care professionals and community health workers Designed to be a regular service at the health center level aimed to regularly monitor patients registered in the CVD Program Conducted at a place accessible to all Frequency may vary (eg. once, twice or thrice a month).

Other Ways of Setting Up Health Services

Aside from the Diabetes and Heart Day, the health care team can also opt to schedule different components of the Diabetes and Heart Day on different days: Integration of services into regular consultation times by: Conducting opportunistic screening of diabetes and CVD risks Medical Consultations done during existing medical consultation schedules Regular Medical Nutrition Therapy and nutrition counseling is set on another day depending on Nutritionist Schedule Regular monitoring of blood sugar by FBS, blood pressure, waist circumference, smoking status and foot risk category done more frequently by Barangay Health Workers (eg. once a week)

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Information Dissemination

The distribution of this flyer per household in the barangays and puroks is the first strategy in informing the people in the community of the services available in the health center. Fill up the appropriate data first before distributing the flyers such as name of barangay, venue of the Diabetes and Heart Days and schedule of services. Community Health Workers can facilitate the purok-level distribution of the flyers to guarantee that this information reaches the majority of the population. Inside this flyer is the Diabetes Self Assessment Questionnaire. Be sure to explain to one responsible member of the household how to use the questionnaire and the corresponding recommendations.

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Flow of Services for New Patients REGISTRATION

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IF patient has ANY of these three conditions:

ASSESSMENT
Vital signs and BP measurement Risk Grading based on the criteria on the left

1. With existing cardiovascular disease and/or 2. Without established CVD with persistently elevated BP of >160-170/100-105 mmHg and/or 3. Without established CVD but with either one of the following biochemical test results:: TOTAL CHOLESTEROL LEVEL OF 8mmol/L LDL CHOLESTEROL OF 6 mmol/L TC/HDL-C of > 8 PATIENT IS ALREADY CONSIDERED HIGH RISK of a very fatal or non-fatal vascular event Refer to CVD Screening tool for recommendations.

SCREENING
DM Screening CVD Screening

CONSULTATION
Diagnosis Management Referral

RECORDING
Generation of Patient Record Recording in the Patient Registry

EDUCATION AND COUNSELLING

Diabetes Education Medical Nutrition Therapy Give Diabetes Diary

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Generating the Patient Record

Case Number will be generated once the patient is entered in the Patient Registry. The case number is made up of two parts: the first part is the Barangay Code (refer to page 145) and the second part is the patient number. Patients will use the same case number every time they visit the health center. The case number is also written in their Diabetes Diary for identification purposes. Fill up the patient information accordingly. Assign trained members of your team to fill up different parts of the patient record. The entire first page can be filled up by trained community health workers or the Barangay Midwife.

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Generating the Patient Record continued

The second page contains vital information on the patients initial visit. Trained Community Health Workers can fill up the information inside the circle. The BMI (Body Mass Index) although not part of the 7 monitoring parameters is included as baseline for Medical Nutrition Therapy purposes. Use the BMI table. The next parts of this page is filled up by the District Health Officer during the first consultation. A specially-trained nurse, nutritionist or midwife may do the ASSESSMENT (Review of Systems, History of Present Illness) and make the Diet and Physical Activity prescription which will be reviewed by the DHO.

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Generating the Patient Record continued

The second and third pages of this folder-type patient record is for recording the 7 monitoring parameters. If the patient comes once a month regularly for monitoring, this portion will be good for 5-6 years. Fill the part inside the circle for easy filing and retrieval. A pocket is provided to hold loose-leaf consultation records, foot risk assessment forms and laboratory results.

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Generating the Patient Record continued

This loose leaf, back-to-back consultation form is for District Health Officers to document their management during patient visits. 4 visits can be documented per leaf. Do not forget to write the patients name and case number just in case this gets separated from the patients folder. Write the date of each consultation. Please write the same information in a simplified manner on the Diabetes Diary Consultation records.

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Recording in the Patient Registry

Type of test (HbA1c in %, FBS, OGTT in mmol/L) and Result

A1c 6.4

LDL 3.7

Each patient is assigned just one case number

Lipid Type and Result mmol/L

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Recording in the Patient Registry

Filling up the Patient Registry:

The first page of the registry can accommodate 10 patients. Ensure that all data are written properly. Use a black or blue pen when making an entry. A summary of important indicators is included on the right top portion of this page. Please accomplish this when 10 patients have been registered in this page for easy data monitoring. The succeeding pages contain monitoring boxes that is good for at least two years of monthly monitoring. Note that not all pertinent data found in this page are re-written on the succeeding pages.

Classification of Patients in the Registry:

Newnewly registered regardless if newly diagnosed or previously diagnosed (with referral or previous medical records from other health facility) Oldpatients already registered who regularly visit the health center for monitoring and those registered on the previous month (regardless if they visit the health center on the current month) Defaulterpatients who did not visit the health center for 2 consecutive months Returned after defaultregistered patients returning to avail of the health services after not coming for follow-up for at least 2 months. Trans-inTransferring patients previously registered in another health center with CVD Risk Management Services with proper endorsement/referral . The previous case number is disregarded and a new case number of the current barangay is assigned. Tran-outPatients who transfers to another barangay health center with CVD Risk Management Services. An endorsement note is given to the receiving health center. Deceased

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Flow of Services for Old Patients (Those coming for follow-up monitoring)

REGISTRATION
Queuing Retrieve Patient Record

ASSESSMENT
Vital Signs 7 Monitoring Parameters Record in Patient Record + Diary

CONSULTATION
Diagnosis Management Referral

RECORDING
Update Patient Registry

EDUCATION / COUNSELLING
Diabetes Education Medical Nutrtion Therapy Give Diabetes Diary

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Indications for Referral of Patients

CHO to SPMC SPMC to CHO

Medical (Stable) send to Out Patient Department: Medical Mindanao Diabetes Center or Cardio Clinic For CVD Risk factor monitoring Stable patients are those who are ambulatory and Follow-up medications For follow-up Medical Nutrition Therapy afebrile with the following conditions: Uncontrolled blood sugar despite medications For Patient education High serum creatinine and other highly abnormal lab results Surgical With concomitant disease such as TB For further tertiary evaluation and management For wound monitoring and dressing Medical (Unstable) send to Emergency Room Difficulty in breathing Febrile Jaundice Surgical (Stable) send to Out Patient Department Wound and Ostomy Care Clinic Stable with non-healing wounds Surgical (Unstable) send to Emergency Room Cellulitis Necrotic Tissue Abscess Fever Afbrile with WBC > 14,000 or < 2,000

CHO to Davao Jubilee Foundation

For Prosthesis and orthosis fitting Physical Therapy

Davao Jubilee Foundation to CHO

Stump Care and basic education on proper positioning Follow-up proper stump bandaging Monitoring of prosthesis

City Health Office

Southern Philippines Medical Center Out Patient Department Emergency

Davao Jubilee Foundation

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Referral Form

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Referral Form continued

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Reporting

Handicap International

1. Data is first generated at the Barangay Level. Monthly barangay reports will be submitted to the District Health Office. 2. The District Health Center collates data from all the barangays and submits this data to the City Health Office. 3. The City Health Office (CHO) collates data from all district health centers and forwards this data to Handicap International. 4. Handicap International collates data from CHO, Southern Philippines Medical Center and Davao Jubilee Foundation, and submits reports to the heads of each partner. Note: Handicap Internationals reporting duties will gradually be turned over to the City Health Office within 1-2 years.

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Module 8 COMMUNITY HEALTH WORKERS TRAINING
Training Design (to be submitted to CHO and HI at least 2 weeks before the training)
Barangay/ District Session Title: Basic Training for Community Health Workers for the Implementation of the Cardiovascular Disease Program in Davao City Number of Barangay Health Workers: __________ Number of Barangay Nutrition Scholars: ________ Number of Facilitators: ________ (total of 2 days)

Target Participants:

Venue: Date and Time: Facilitators Background: Diabetes management requires a multidisciplinary approach that involves all members of the health care team. As such, there is a need to train and capacitate the community health workers, comprised mainly of Barangay Health Workers (BHWs) and Barangay Nutrition Scholars (BNS) on how to provide basic services for persons with cardiovascular disease risk factors. Based on the action plan generated during the Basic Training for Primary Health Care Professionals for the Implementation of the Cardiovascular Disease Program in Davao City conducted in the 1st Quarter of 2011, the training for the CHWs on the implementation of the CVD Program shall commence beginning May until September of 2011. Objectives: General: Community Health Workers are able to provide basic services for cardiovascular disease risks as part of a multidisciplinary health care team through the implementation of the CVD Program: Specific: At the end of the session, Community Health Workers are able to: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Conduct information dissemination on the CVD health services offered in the health centers. Perform diabetes self assessment and interpret the results. Instruct others on how to perform a diabetes self assessment. Recommend the next steps based on the result of the diabetes self assessment. Perform CVD Risk Assessment. Recommend the next steps based on the result of the CVD risk assessment. Enumerate the 7 monitoring parameters and state their significance. Perform blood sugar monitoring using a portable blood glucose meter. Performs blood pressure monitoring. Measure waist circumference. Perform foot risk assessment Educate patients on the hazards of smoking. Conduct basic foot care education Enumerate the target values Refer patients to the District Health Office based on the target and actual values of the 7 monitoring parameters.

Module 8
Program Opening Process Registration Opening Prayer National Anthem Getting to know you activity Levelling of Expectations and Presentation of the training objectives General Orientation to the Training Program Nature and the objectives of the training Correct incongruent expectations Rules and regulations of the training emphasis on punctuality, attendance and participation Overview of the CVD Program Introduction of the 4 partners of the program Pretest Diabetes Basics Definition of Diabetes and CVD Risk Factors Signs and Symptoms Basic principles of diagnosis and the importance of following diagnostic procedures Enumerate the components of Diabetes/ CVD Risk Management: Medications Proper Nutrition Physical Activity Smoking Cessation Regular Monitoring Foot Care Diabetes and CVD Prevention focus on lifestyle change Information Dissemination and Screening Information Dissemination using the flyers The importance of screening. Performing DM Self Assessment Performing CVD Risk Assessment Monitoring The 7 monitoring parameters and their target values Blood sugar testing using portable blood glucose meters Blood Pressure monitoring Measuring waist circumference Performing Foot Risk Assessment Refer patients to the District Health Office based on the target and actual values of the 7 monitoring parameters using the referral form. Date /Time

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Facilitator/Materials

Introduction

Module 1

Module 2

Module 3

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Module 8
Program Process Recording the monitoring results in the following: Diabetes Diary Patient Record Patient Registry Education Education tools of the CVD Program 1.Diabetes Prevention Flipchart 2.Diabetes Diary 3.Foot Care Poster The Idaho Plate Method The Physical Activity Pyramid Basic foot care education Smoking cessation education Diabetes Prevention education Reporting Reporting system and schedules How to fill up the Barangay Health Station Monthly Statistics Diabetes and Heart Day Action Planning Scheduling Identifying different stations and corresponding assignments Filling up basic information in the following: 1. Diabetes Diary 2. Patient Record 3. Patient Registry Post test Participants are asked to evaluate the training program through a formal questionnaire Participants, at the end of the evaluation, may speak before the group to express his or her thoughts about the training Date/Time Facilitator/Materials

Module 3
continued

Module 4

Module 5

Module 6

Evaluation

BUDGET REQUEST ( Note: This part will be finalized by Handicap International only) Item Venue Lunch Snacks Materials : (PhP ________ per person) (PhP ________ per person) Frequency 2 days ____pax x 2 ____pax x 4 _______pax Total

TOTAL Training Design Submitted by:

Name and Signature:

_________________________________ Designation: ____________________DHO:_______________

Reviewed by: Name and Signature__________________________ Designation: ______________ - City Health Office Approved by: Name and Signature__________________________ - Project ManagerHandicap International CVD Project

Module 8
Training Documentation (to be submitted to CHO and HI after the training)
Training Title Barangay: District: Date: Venue: Total Number of Community Health Workers Trained: _______________ ATTENDANCE: Name (Participants only) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10 11. 13. 14. 15. 16. 17 18. 19. 20. Name (Facilitators only) 1. 2. 3. 4. 5. 6. 7. Designation
Day 1 AM PM AM Day 2 PM

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Basic Training for Community Health Workers for the Implementation of the Cardiovascular Disease Program in Davao City

Submitted by : Name and Signature: ________________________________ Designation: ___________________________

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