Diabetes mellitus guidelines-final.indd

EMRO Technical Publications Series

32

Guidelines for the prevention, management and care of diabetes mellitus Editor Oussama MN Khatib (MD, PhD, FRCP) Regional Adviser Noncommunicable diseases WHO Regional Office for the Eastern Mediterranean

WHO Library Cataloguing in Publication Data Khatib, Oussama M.N. Guidelines for the prevention, management and care of diabetes mellitus / Edited by Oussama M.N. Khatib p. (EMRO Technical Publications Series ; 32) 1. Diabetes mellitus 2. Diabetes mellitus – Prevention 3. Diabetes Mellitus Management 4. Diabetes Mellitus – Guidelines I. Title II. WHO Regional Office for the Eastern Mediterranean III. Series ISBN: 978-92-9021-404-5 ISSN: 1020-0428

(NLM Classification: WK 810)

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Contents Foreword ........................................................................................................ 5 Preface ............................................................................................................ 7 Acknowledgements ........................................................................................ 8 Chapter 1. Diabetes in the Eastern Mediterranean Region ........................ 9 Regional epidemiological status .................................................................9 Regional status for diabetes care .............................................................11 Chapter 2. Definition and classification ......................................................13 Definition ...................................................................................................13 Diagnosis ..................................................................................................13 Classification .............................................................................................14 Chapter 3. Diabetes mellitus in special groups and circumstances ........20 Children and adolescents .........................................................................20 Gestational diabetes .................................................................................20 Metabolic syndrome ..................................................................................22 Hypertension .............................................................................................23 Dyslipidaemia............................................................................................25 Brittle diabetes ..........................................................................................27 Chapter 4. Screening for diabetes mellitus .................................................28 Background ...............................................................................................28 Screening approaches ..............................................................................29 Screening tools .........................................................................................30 Screening strategies .................................................................................31 Evaluation .................................................................................................33 Chapter 5. Management of diabetes mellitus .............................................34 Background ...............................................................................................34 Objectives of therapy ................................................................................34 Therapy targets .........................................................................................34 Components of the clinic visit ...................................................................36 Chapter 6. Treatment options .......................................................................38 Background ...............................................................................................38 Nutritional recommendations ....................................................................38 Exercise ....................................................................................................41

Pharmacological therapy ..........................................................................41 Multidisciplinary mini clinics ......................................................................43 Chapter 7. Management recommendations for special groups and circumstances ...............................................................................................44 Ramadan fasting .......................................................................................44 Hypertension .............................................................................................44 Dyslipidaemia............................................................................................46 Aspirin therapy ..........................................................................................52 Chapter 8. Acute complications of diabetes ...............................................53 Hypoglycaemia .........................................................................................53 Hyperglycaemic crisis ...............................................................................55 Infections ...................................................................................................56 Chapter 9. Chronic complications of diabetes ...........................................58 Atherosclerosis .........................................................................................58 Retinopathy ...............................................................................................59 Diabetic nephropathy ................................................................................63 Diabetic neuropathy ..................................................................................66 Neuropathic foot ........................................................................................69 Chapter 10. Prevention of diabetes .............................................................73 Background ...............................................................................................73 Primary prevention ....................................................................................73 Secondary prevention ...............................................................................75 Tertiary prevention ....................................................................................75 References .....................................................................................................76 Annex 1. Regional consultation on diabetes prevention and control ......80

Foreword In the Name of God, the Compassionate, the Merciful Diabetes mellitus is one of the most common noncommunicable diseases, and its epidemic proportion has placed it at the forefront of public health challenges currently facing the world. The World Health Organization (WHO) estimated the global burden of diabetes at 135 million cases in 1995, in a worldwide adult population of under 4 billion, and has projected that there will be 299 million cases by the year 2025. Although WHO recently accorded priority status to diabetes mellitus, many public health planners remain largely unaware of its magnitude and the seriousness of its complications. Of equal consequence, is the increasing prevalence of the disease and the long-term cost of therapy for both patients and the health sector, and its cost to nations in economic terms. In the Eastern Mediterranean Region, there has been a rapid increase in the incidence of diabetes mellitus, consisting mainly of type 2. It is now the fourth leading cause of death in the Region. An estimated 22 million people have diabetes, out of a total adult population of 290 million. Studies conducted in different populations of the Region have reported high prevalence rates varying from 7% to 25% in the adult population. In addition, many countries are now reporting the onset of type 2 diabetes mellitus at an increasingly young age. People are presenting with type 2 in their twenties and thirties, and in some countries it is emerging in children. This pattern of younger age of onset extends the potential burden of therapy and complications to an even younger age group and for a longer period of an individual’s lifespan. There are a number of factors that might explain the increasing prevalence of diabetes mellitus in the Eastern Mediterranean Region, not least of all the significant social and economic changes which are being experienced. Rates of obesity are increasing, while people are becoming less physically active; both of these factors increase the risk of developing diabetes. In addition, the prevalence of diabetes mellitus increases with age, and there is evidence that the current life expectancy in the majority of Eastern Mediterranean countries now exceeds 65 years. The WHO Regional Office for the Eastern Mediterranean has set goals and targets for diabetes mellitus prevention at the regional level. Because of the importance of diabetes and its complications in the Region, care should be considered a health priority and should be supported and strengthened by data collection, the establishment of national epidemiological studies, and the formulation of national plans. One promising initiative during the past few years has been the development of national diabetes control programmes in several countries of the Region; in others, committees to develop such

programmes have been set up, or diabetes has been integrated into noncommunicable disease programmes. The aim of integrating diabetes mellitus into primary health care is to establish routine screening procedures for the detection, monitoring and control of the common complications of diabetes. Treatment should not only target lowering of blood glucose level, but should also focus on the correction of other noncommunicable disease risk factors, such as smoking, dyslipidaemia, obesity, physical inactivity and hypertension. As part of the efforts to improve health care, it is hoped that these regional guidelines will be useful in helping to standardize diabetes management at the primary, secondary and tertiary levels and in guiding policy-makers, particularly at ministries of health. Above all, we all need to work towards better prevention of diabetes mellitus in order to stop this rising burden in the Eastern Mediterranean Region.

Hussein A. Gezairy, MD, FRCS Regional Director for the Eastern Mediterranean

Preface The increasing prevalence of diabetes mellitus, the emergence of diabetes complications as a cause of early morbidity and mortality, and the enormous and mounting burden on health care systems make diabetes a priority health concern. This publication aims to provide up-to-date, reliable and balanced information for the prevention and care of diabetes mellitus in the Eastern Mediterranean Region. The prevalence of diabetes in the Region and the high morbidity that is associated with it stimulated the WHO Regional Office for the Eastern Mediterranean to develop these guidelines in order to address all practical issues relevant to the day-to-day management of glucose and its metabolic disorders, with respect to reduction in related morbidity and mortality. The framework for the guidelines was discussed in the Regional Consultation on Diabetes Prevention and Care, Teheran, Islamic Republic of Iran, 2–5 February 2003. A consensus on major topics concerning diabetes prevention and care was formulated during the consultation and the conclusions reached are given in Annex 1. Because of the need for a standardized response to the challenge, the following regional strategies have been established for the prevention and care of diabetes: promotion of a healthy lifestyle; raising community awareness (eat less – walk more); primary prevention of diabetes; screening for type 2 diabetes mellitus; establishment of a regional training course for diabetes educators; and development of national strategy. Management of diabetes mellitus, standards of care and clinical practical guidelines and Health education for people with diabetes, published by the Regional Office for the Eastern Mediterranean in 1994 and 1996, respectively, provided reliable guidance on management and education for diabetes in the Region. However, during the past 10 years, new developments and rapid changes in management and prevention have occurred. The present guidelines are intended to standardize management in the Region and include the latest, evidence-based information for diabetes. They provide the information necessary for decision-making by health care providers and patients themselves about disease management in the most commonly encountered situations. The information is evidencebased and clearly stated to facilitate the use of the guidelines in daily practice. The target population includes physicians at primary, secondary and tertiary level, general practitioners, internists and family medicine specialists, clinical dieticians, nurses and policy-makers at ministries of health. Accompanying this publication are three quick reference cards relating to the management of diabetes, management of diabetes and hypertension and management of diabetes and dyslipidaemia. These will provide primary health care workers, physicians, consultants and clinicians with a readily accessible appraisal of the evidence-based facts relating to diabetes.

Acknowledgements The WHO Regional Office for the Eastern Mediterranean acknowledges with thanks the contributions of the participants at the Regional Consultation on Diabetes Prevention and Control (Annex 1) held in Teheran, Islamic Republic of Iran, 2–5 February 2003 whose discussions provided valuable input to this publication. WHO would also like to thank Fereiddoun Azizi, Imad M. El-Kebbi, Mohamad Reda Awadin and Ibrahim Sherif for their valuable input in reviewing the draft publication.

Chapter 1

Diabetes in the Eastern Mediterranean Region Regional epidemiological status In estimating the total number of persons with diabetes mellitus, we cannot rely solely on reported numbers of diagnosed cases. It is estimated that about one half of persons with diabetes are unaware of their disease and, even in industrialized countries, many individuals go undiagnosed. Although more recent data show that the proportion of undiagnosed cases has decreased, it is still at least about one quarter to one third of all persons with diabetes mellitus. It is predicted that between 2000 and 2025, the size of the world’s adult population will increase from less than 4 billion to 5.5 billion, mainly on account of a 60% increase in developing countries [1]. The number of adults with diabetes in the world is predicted to increase from 150 million in 2000 to 300 million in 2025 [2]. In industrialized countries, the number of diabetics will increase by about one third between 2000 and 2025, while in developing countries that number will more than double [2]. In 2025, more than 75% of the world’s diabetic population will be living in developing countries. Diabetes prevalence in some Eastern Mediterranean countries is among the highest in the world [3–16]. The Eastern Mediterranean Region extends from Pakistan in the east to Morocco in the west, and the population is a mosaic of several ethnic groups. The age distribution pattern of the population is pyramidal, with about 50% of the population aged below 20 years. While the majority of persons with diabetes mellitus in industrialized countries are in the older age group, the majority in developing countries tend to be middle-aged and at the most productive stage of life [3]. Many Eastern Mediterranean countries are now reporting the onset of type 2 diabetes mellitus at an increasingly young age. Subjects are presenting in their second and third decade, and in some countries type 2 diabetes mellitus is emerging in children. This pattern of onset at a younger age extends the potential burden of therapy and complications to an even younger age group and for a longer period of an individual’s lifespan [2,4–15]. In the Eastern Mediterranean Region as a whole, approximately half of the countries have published incidence rates. The highest rates are reported in Egypt, Kuwait, Lebanon, Oman and Qatar where the incidence of type 1 diabetes is reported to be 8–10 per 100 000 population per year in children aged