November 14th marks World Diabetes Day. The International Diabetes Federation (IDF) and the World Health Organization (WHO) introduced World Diabetes Day in 1991 in response to concerns over the escalating incidence of diabetes around the world. It is now an official United Nations World Health Day that unites the global diabetes community to produce a powerful voice for diabetes awareness.
In the western region of Ghana, diabetes mellitus currently is one of the top non-communicable diseases causing high numbers of morbidity and mortality amongst patients. The Western Region Diabetes Association has made it part of their aim to raise awareness about diabetes amongst patients.
This was in the form of a weeklong celebration resulting in a continuous medical development program to educate medical personnel on the current guidelines in the management of diabetes. Management of diet and nutrition is one of the most important factors of diabetes as many patients with diabetes do take medications, but do not maintain a healthy diet that contributes vastly to the poor management of diabetes.
Africa Partners Medical, Ghana decided to organize this CPD in conjunction with the western Region Diabetes Association and the Ghana Health Service (Western and Central Region).
Facilitators were from the Ghana Health Service
• Dr. Richard Anthony, Consultant Physician Effia Nkwanta Regional Hospital
• Dr. Ernest Yorke, Physician Specialist, Korle Bu Teaching Hospital
• Dr. Nana Ama Barnes, Physician Specialist, Effia Nkwanta Regional Hospital
• Mr. Isaac Baba Anagi, Nutritionist, Effia Nkwanta Regional Hospital
The program was organized in various sessions that included acute management of diabetes, foot care in diabetes, pharmacotherapy in diabetes and more. The first lecture, presented by Dr. Nana Ama Barnes, was an overview of diabetes. This was important as it allowed the participants to understand the various decisions that are involved in the management of diabetes based on the pathophysiology and also for myths about diabetes to be dismissed.
Most patients present at the hospital were due to acute complications of diabetes. Dr. Richard Anthony highlighted on the various presentations of patients including acute complications of diabetes and how best to manage them. Dr. Anthony also held a practical demonstration on how to manage high blood glucose, which has been modified to suit the medical system present in most hospitals. He also presented forms, which can assist medical personnel to manage patients with high blood glucose, a system currently being used in the Effia Nkwanta Regional Hospital.
Dr. Ernest Yorke presented on the management of the chronic complications of diabetes. Diabetes unfortunately is a major cause of morbidity in many patients when not detected early. When faced with Type 2 diabetes, the most common type of diabetes, patients present complications such as retinopathies, peripheral neuropathies, nephropathies and vascular problems. Early screening or annual medicals are important and encouraged to the general public to prevent these complications. It is also important that patients diagnosed with diabetes receive adequate education and management in order to prevent most of these chronic complications.
Dr. Yorke also emphasized the complications each medical personnel managing a patient with diabetes should look out for and work at managing these problems. Kidney disease associated with diabetes can be delayed by the addition of drugs that act on the rennin- angiotensin aldosterone system. These drugs can also help to control blood pressure potentially found in patients with diabetes.
Based on the numerous complications associated with diabetes, Dr. Yorke highlighted that diabetes care was a multidisciplinary care involving nurses, general practitioners, medical assistants, ophthalmologists, neurologists, nephrologists, cardiologists, podiatrists and psychologists, just to mention a few. In an environment where most of these personnel are not available, the medical personnel managing such patients must have some knowledge on all these in order to effectively care for these patients.
Lifestyle modification is paramount in non-communicable disease management and one of the most important components is diet. In the early management of diabetes, starvation was the mode of treatment. Current guidelines indicate healthy diet with the elimination of simple sugars from the diet.
Mr. Isaac Baba Anagi presented on the current guidelines in the dietary management of diabetes based on the International Diabetes Federation (IDF) modules modified for the local diet in the country. Dr. Anagi emphasized making the dietary care for patients as practical as possible as it helps decrease the probability of non-compliance. Dietary sheets should be given to patients when diagnosed, for patients to indicate what foods they have available in their homes and then based on this have a one-to-one consultation with them in order to guide them in planning their healthy meals. He also noted that it was important not to impose strict rules but allow for flexibility in the diets and to encourage fruits and fiber in the diet.
Dr. Anagi also commented on the need to decrease cholesterol and salt in the diet as well as encouraging patients with high body mass index to lose weight by demonstrating the plate and fist/hand model as a guide to help patient to know how much of each food group should be taken and in what quantities.
Considering the fact that diabetes is a life long condition, it is important that children with diabetes require adequate management in order to prevent complications that may occur in future. The most common type of diabetes in children is type 1 diabetes that requires management with insulin. Due to the changes occurring due to the lifestyle changes in our population, type 2 diabetes in children is gradually increasing.
Management of diabetes in children was no different from that of adults, however education and support of the family is paramount in order to effect optimal management. It is important to teach the children to identify complications such as hypoglycemia and immediate management of it. Teachers are important in managing diabetes and it is crucial to educate them on the various problems, which may be encountered by a child with diabetes and how to effectively manage them since the children spend a greater part of their days in school.
Diabetes may occur in pregnancy or patients with diabetes may become pregnant. Gestational diabetes occurs as a result of the hormones produced during pregnancy in some women and this may disappear after delivery. Management mostly involves insulin, so for patients with diabetes in the reproductive ages, it is important to plan the pregnancies as they may require switching from their oralhypoglycemic drugs to insulin and also planning delivery at a well-established heath care center if possible in the care of an obstetrician and a pediatrician.
An important educational fact is to educate patients that diabetes is not passed on from mother to child, but at delivery, babies born to mothers with diabetes are prone to low blood glucose and must be fed as quickly and often as possible. Dr. Nana Ama Barnes presented on foot care in patients with diabetes. One of the most common complications of diabetes is foot infection, which more often than not results in amputations. Due to the loss of sensation associated with poorly managed diabetes resulting in inability to detect ulcers early on the foot and poor healing, many patients present to the hospital with severe gangrene of the foot warranting amputation. Every medical personnel managing patients with diabetes must be able to educate the patients on basic care of the foot to prevent complications.
Prompt administration of appropriate antibiotics is also important as in involvement of surgeons to manage diabetic ulcers. Practical measures in foot care include daily examination of feet, wearing appropriate footwear, care of the nails, and never walking bare footed. Dr. Richard Anthony talked on the assessment of a newly diagnosed patient with diabetes. Dr. Anthony noted that it is important to stabilize a patient who comes in with diabetes, take an adequate history, fully examine the patient to detect any complications that may be present and adequately manage them. Since diabetes affects all the organs in the body, it is also important that thorough laboratory investigations be carried out.
Education about diabetes is important to relay to the patient and the patient’s family to encourage support in the management. Drug therapy in diabetes ranges from insulin in patients deficient in insulin to oral hypoglycemics for patients with insulin resistance. Mr. X talked about the various groups of oral hypoglcemics highlighting on their mode of action, dosage and side effects. He also talked about the importance of discussing the treatment options with the patients so as to allow the patients make an informed choice together with the doctor.
Administration of the drugs and storage of medications such as insulin also is important as improper insulin storage can result in denaturation and loss of effectiveness of the medication. In most communities where by electricity is not readily available, challenges with insulin storage are met and there are various appropriate technologies used to store insulin in cool environments. These include placing the bottles in earthenware pots in cool parts of rooms or placing insulin bottles in cut up foam and then in a clay pot.
The final session of the program was the group discussion of 3 problem clinical scenarios that were discussed in groups and after 15 minutes presented to the whole group.