Comment: Diabetes Mellitus is a chronic and degenerative disease of great. importance in Mexico. and 15% of patients with diabetes type 2 after 5-10 years …
Comment: Diabetes Mellitus is a chronic and degenerative disease of great importance in Mexico
DIABETES MELLITUS
Presented by Dra Maricela Perez-Oropeza, Internal medicine, Hospital Regional La Barca, Jalisco, Mexico October 17th,18th, and 20th of 2006 University of Northern Iowa Cedar Falls, IA
This Material is part the Screening, Diagnosis, and Treatment for Diabetes and Hypertension in Mexico: Implications for Iowa Health Care Providers Seminar Sponsored by the Wellmark Foundation, The UNI Iowa Center on Health Disparities and the UNI Iowa Center for Immigrant Leadership and Integration
Diabetes Mellitus: A World Threat The prevalence of diabetes will increase 35 1353 to 2997 million Predictions: A birthrate decrease will lead to the aging of the world population During the next 50 years, the number of people of 60 years of age or older will triple, increasing from the current 606 million to almost 2,000 million by 2050
Diabetes Care 21:1414-31, 1998
Comment: Diabetes has been recognized as a health threat worldwide Its prevalence is estimated to increase 35 between 1995-2025 due to a decrease of birthrates and the aging of the world population
1076 of the adult
population 55 Million diabetics 6 million people with abnormal fasting blood glucose 110-126 mg/dL THE PREVALENCE OF DIABETES MELLITUS IN MEXICO ACCORDING TO THE ENSA 2000
ENSA: Encuesta Nacional de Salud, The National Health Census
Comments: The prevalence of diabetes in the Mexican population is estimated to be close to 55 million diabetics between the ages 20-69 or 107
The impact of Diabetes in Mexico
Patients with : Visual disorders, 45 Renal failure, 30 Hypertensive, 65 Diabetic Necrobiosis, 15 2,700 000 1,800 000 3,900 000 900 000
The direct cost Hospitalization, medication, medical care, etc as well as the patient and familys out of pocket expenses transportation fees, time, etc are between 100 and 330 million dollars per year It is estimated that the cost only for medical care per diabetic patient is around 52,000 dollars
Estimations according to the OPS/OMS Programa de Acción de Diabetes, Mexico 2001 Diabetes Action Program
Comment: Diabetes is an important cause of amputations of lower body members resulting from a non-traumatic origin, as well as blindness and kidney failure Retinopathy, It is estimated that 50 of diabetic patients will suffer from this disease after
10 years of being diagnosed and 80after 20 years of being diagnosed 35 of patients with diabetes type 1 will suffer from kidney failure after 15-20 years of being diagnosed and 15 of patients with diabetes type 2 after 5-10 years of being diagnosed
Regional Comparison of the Prevalence of Diabetes According to the ENEC 1993 and ENSA 2000 Map 1: ENEC 1993 National:82 Map 2: ENSA 2000 National: 109 greater than or equal to 140 mg/dl greater than or equal to 126 mg/dl
Source: ENEC 1993 / ENSA 2000/ CNVE/ SSA ENEC: Encuesta Nacional de Enfermedades Crónicas or National Survey of Chronic Diseases ENSA: Encuesta Nacional de Salud or National Health Census
Comment: According to the National Health Census ENSA of 2000, diabetes is frequently seen in some northern states like Coahuila with a prevalence of 10 and Nuevo Leon 97 The lower prevalence was found in San Luis Potosi 54, Chiapas 52 , and Oaxaca 48, where the majority of the cases were Women by 53 In this slide we can see the prevalence of diabetes and how it has increased among the Mexican population according the numbers of the National Survey of Chronic Diseases of 1993 and ENSA of 2000
Comment: One of the risk factors
associated with diabetes is Obesity Clip Art taken from : wwwceacuuorg
The Prevalence of Obesity and Excess Weight in Mexico
Comment: Again, according to ENSA, 2 out of 3 Mexican Nationals are overweight or suffer from obesity with an estimated prevalence of 244 in the year 2000
Excess weight
obesity
excess weight and obesity ENSA 2000 or National Health Census
ENEC 1993 or National Survey of Chronic Diseases
Lara E A Prevention and Control of Cardiovascular risk Workshop, SSA National Center of Epidemiologic Alertness, Diseases Control and Aventis Foundation Mexico, 2004
Abdominal Obesity
Waist dimensions in Mexico Men Women
Waist dimensions in centimeters OMS or WHO Criteria of 2000 Source: ENSA 2000 ONVE SSA Preliminary results
A Sedentary Lifestyle It is considered that an individual has a sedentary lifestyle when he or she performs less than 180 minutes of physical activity, of moderate intensity, in one week
Comments: Another aspect associated with the development of chronic and degenerative diseases, like diabetes and hypertension, is a sedentary lifestyle
Estilos de vida en la sociedad actual Lifestyles in our current society
Seguridad y diversidad de
alimentos
Ingresos
Security and food diversity
Aceites vegetables asequibles
Income
Cambios Alimenticios
Diet Changes
Available Vegetable Oils
Exposición a los medios
Exposure to the Media
Desarrollo económico
Comer fuera de casa
Economic Development
Eating outside of home
Trabajos con experiencia física
Obesidad
Obesity
Jobs with physical Activities
Aumento de la recreación sedentaria
Urbanización
An increase in sedentary activity
Oportunidades para realizar actividad física
Urbanization
Actividad Física
Physical Activity
Oportunities to perform physical activities
Causas posibles de la transición y la aparición de la obesidad en los países en vías de desarrollo Adaptado de Martorell y Stein, 2000 Possible causes of the transition and the appearance of obesity in developing countries Adapted from Martorell and Stein, 2000
Comments slide 10:
The probable cause of obesity in developing countries has been attributed to the current lifestyle, where urbanization , better economic development and an increase in income have resulted in diet changes and less physical activity
Criterios diagnósticos en la diabetes mellitus Diagnostic Criteria in diabetes
mellitus
1
Síntomas clásicos de la diabetes más una glucosa plasmática casual 200 mg/dl The classic symptoms of diabetes plus a casual plasmatic glucose 200 mg/dl
2 Un nivel de glucosa plasmática en ayunas 126 mg/dl A fasting glucose 126 mg/dl 3 El valor de glucosa plasmática de 2 hrs postprandial en una prueba de sobrecarga oral 200 mg/dl The glucose level 200 mg/dl, two hours after performing the Glucose Tolerance Test
American Diabetes Association ADA
Comments: The ADA American Diabetes Association criteria to diagnose diabetes is followed in our daily practice
Prevalecía de Diabetes Mellitus en el Hospital Regional La Barca
The Prevalence of Diabetes at the Regional Hospital in La Barca
Total de consultas Enero a Diciembre 2005
Total number of consultations from January to December of 2005
3,095 Total de pacientes con diagnóstico de diabetes mellitus
Total number of patients diagnosed with diabetes mellitus
1081 349 Pacientes con diagnóstico de DM 1 Vez
Patients diagnosed with diabetes for the first time
158 146 Pacientes diabéticos con HTA asociada
Diabetic patients also suffering from hypertension
353 326 1st time 1 vez 74 68 Comments: The prevalence of
diabetes at the Regional Hospital in La Barca during 2005 was of 349 The total number of patients that received care during external consultation was of 1081 146 were diagnosed with diabetes for the first time and 326 were diabetic patients that also suffered from hypertension
Pacientes atendidos con DM en el Hospital Regional La Barca Diabetic patients that received care at the Regional Hospital in La Barca
Edad
Age
Sexo Gender
Masculino
Male
Total
141 458 482 13 423 445
Femenino
Female
45 años 45 64 años
45 64 years old
41 37 136 125 164 151
100 92 322 297 318 294
65 años
65 years old
Comment: The prevalence in our hospital varies according to the age It is higher in people between the ages of 45-65 by 423 and the lowest is found in people younger than 45 by 13 The presence of these pathologies are more frequent in women than in men
Complicaciones más frecuentes Common Complications
Nefropatía Nephropathy 24 Pie diabético Diabetic foot 21 Neuropatía Neuropathy 32 Retinopatía Retinopathy 11 Descontrol Metabólico: Hiperglucemia 26 Metabolic disorders: Hyperglycemia requirieron hospitalización that required hospitalization Comments: The complications often
found in our population are: Neuropathy, nephropathy, and diabetic foot among others
Manejo y control de los pacientes Care and treatment of diabetic patients
Historia clínica Clinical History Historia familiar Family History Factores de riesgo relacionados a ECV Risk factors related to a Cardiovascular event Factores económicos y psicosociales Economical and psychological factors Uso de tabaco y alcohol The use of tobacco and alcohol Peso y estatura Weight and height Circunferencia de la cintura Waist dimensions Presión arterial Blood pressure Examen oftalmológico Ophthalmological exam Examen de los pies Feet exam
Visita inicial
Fist visit
3 meses
Three months
6 meses
Six months
1 año
A year
X X
_ _
_ _
_ _
X
_
_
_
X X X X X X
_ X X X -_
_ X X X _ _
_ X X X x X
Comments slide 16:
The Care and treatment of diabetic patients, During the initial consultation, for every patient that is seen, we open a clinical file which includes family history and the risk factors associated with each case of diabetes We inquire about their usage of tobacco and alcohol, their diet, economical situation, as well as psychological aspects of the patient 
We do a complete physical
evaluation focusing mainly on their weight, height, blood pressure, feet condition and an eye exam
Control y seguimiento de pacientes con diabetes mellitus Treatment and Follow-Up of patients with diabetes mellitus
Pruebas de laboratorio LAB test
Visita inicial
First visit
3 meses
Three months
6 meses
Six months
1 año
A year
Glucosa plasmática en ayunas Fasting Glucose Test
X
X
X
_
HbAc1 7, 65 A1c Hemoglobin
X X X X X _
X X _ _ _ _
X X _ X X _
_ _ X _ _ X
Pérfil de lípidos
Lipid Profile Creatinina sérica Serum Creatinine Test Examen general de orina Urine test ECG EKG Depuración de creatinina y excreción de prot tot Creatinine depuration and PROT-TOT extraction
Micro albuminuria Glucosa postprandial
Postprandial glucose
_ _
_ _
_ _
X X
personas que no están logrando los objetivos de manejo / Patients that are not accomplishing the treatment goals Personas con buen control glicemíco / Patients with a good glycemic control mal control de lípidos / Poor lipid control
Control y seguimiento de pacientes con diabetes mellitus Treatment and Follow-Up of patients with diabetes mellitus
Plan de tratamiento
Treatment plan
Visita inicial
First visit
3 meses
Three
months
6 meses
Six months
1 año
A year
Evaluación nutricional
Nutritional Evaluation
x X X X
_ _ _ _
X _ _ _
_ _ _ _
Medicamentos
Medications
Auto evaluación
Self-management
Adiestramiento para el auto cuidado
Self-management training
Plan de Ejercicio
An exercise plan
X
_
_
_
Referencia a otras especialidades / Referral to see other specialists : Nutrición: Pacientes con diagnóstico reciente, que no están controlados y pacientes con complicaciones
Nutrition: Patients that have been recently diagnosed, that are not controlled, and patients with complications
Nefrología: pacientes con incremento en el nivel de azoados 25 Cr
Nephrology: Patients with an elevated Serum Urea Nitrogen level 25 Cr
Oftalmólogo: pacientes con diagnóstico reciente
Ophthalmologist: Patients recently diagnosed
Comment slides 18, 19
Considering that we are a 2nd level hospital within our healthcare system, and that we dont have all the services and specialists that some patients require, we screen our patients and refer them to a dietician, ophthalmologist, podiatrist, nephrologists, etc
Evaluación inicial Initial Evaluation
Glycemic Index Blood pressure Eye exam Foot exam Masculino /
male
Femenino / female
Comments: Patients that are diagnosed during their initial consultation, receive diabetes education individually Diabetes Education is consider an important pillar of care and treatment
Tratamiento con insulina o medicamentos orales Insulin or oral medication treatment
Ningún tratamiento No treatment
Insulina terapia oral Insulin oral therapy
Insulina Insulin
Sólo medicamentos orales Only oral medication
Comments: Out of the total number of patients diagnosed with diabetes, 53 were treated with An Antidiabetic agent, 15 also required treatment with insulin, and 12 did not follow any treatment Or didnt follow it regularly
Fallas en el objetivo para alcanzar un control óptimo en las cifras de glucosa
Elements that did not allow the patient to meet the ideal glucose levels Desconocimiento de las condiciones del tratamiento/
Not knowing the restrictions of the treatment
Negación de la enfermedad / denial Falta de implicación del paciente en el plan de atención / Lack of involvement of the patient in the treatment Costo de los medicamentos/ the cost of the medicine Dosis subóptima / Not the ideal dosage Falta de relación médico-paciente /
Lack of
patient-provider relationship
Programa de educación a los pacientes diabéticos en el Hospital Regional La Barca
Education Program for Diabetic Patients at the regional Hospital in La Barca Conceptos en diabetes tipos Concepts, Types of Diabetes Dieta y ejercicio físico Diet and Exercise Fármacos orales Oral Medication Insulina y técnicas de aplicación
Insulin and injection techniques
Objetivos del tratamiento hiperglucemia, hipoglucemia
Treatment goals hyperglycemia, hypoglycemia Self-control, Diabetes complications
Autocontrol Complicaciones de la diabetes Cuidado de los pies Feet care Aspectos sociales y laborales work and social aspects Dinámicas de grupo Group activities Comments: At the Hospital Regional La Barca, we have a Diabetes Education Program that involves both the patients and their relatives The first Diabetic Education Group was created in the year 2000 The purpose of this group was to improve the quality of life of these patients, to avoid late complications and stimulate their involvement in the treatment We follow an annual program that covers different topics
Educación Education
1- Individual durante las consultas
Individual Education in consultations
2- En
grupo a través del programa del Club de diabéticos formado en Agosto 2000 3- Durante los tiempos de espera en las salas de consulta While they wait in the waiting room 3- Mediante folletos, periódicos murales
Through pamphlets, poster boards Education as a group through the Diabetic Group Program Which started in August of 2000
4- Día de la salud
Day of Health
Comments: Self-control is considered an indispensable treatment in order to achieve the stability of our patients We also try to improve the quality of care that is provided to every diabetic patient : providing on each consultation, education about their illness Through the Diabetic group While they wait in our waiting rooms, using TV and videos Giving them pamphlets and having poster boards
Hospital Regional La Barca
SECRETARIA DE SALUD
HOSPITAL REGIONAL DE LA BARCA
Secretariat of Health Regional Hospital of La Barca Health Popular Insurance
Jalisco Secretariat Of Health
DIA DE LA SALUD 16 de JULIO 2005
Day of Health July 16, 2005
Comments: Another important goal is identifying the population at risk Since 2004, we have dedicated one day per year to be the Day of Health On this day we screen for non-transmittable
chronic diseases
HOSPITAL REGIONAL DE LA BARCA V GUERRERO 174
DIA DE LA SALUD
The Day of Health
Módulos de atención Care Booths
Detección en Diabetes Mellitus e HTA
Diabetes and Hypertension Screening Tests
Detección oportuna de Cáncer Cervico-uterino
Early detection of Cervical Cancer Comusida AIDS
Atención del Adulto y Anciano
Adult and Senior Care Salud Mental Mental Health Salud Dental Dental Health
Oftalmología Ophthalmology Mamografías Mammograms Densitometrías Densitometry Cáncer de próstata Prostate Cancer Sobrepeso Weight Problems Atención al Niño Sano Well child
Comments: These are the Care booths that are available to the entire community The day of Health takes place at the Town Plaza
Puesto de Vacunación
Immunization Booth
Comments: This event is done in collaboration and full support of the Public Health Department, county authorities, and community groups
Comments: The care for Diabetic patients includes a change in their life style, where the diet plan represents an important pillar of care so they can meet their goals
Diet Plan Goals: Delay or avoid the development of diabetes mellitus Maintain or reach ideal weight Body mass index 189 to 249 Waist
dimensions: less than 85 for women and less than 95 for men Glucose Levels: Fasting Glucose Test less than 100 mg/dL or less than 110 mg/dL blood sample 2 hour Postprandial glucose less than 140 mg/dL Maintain or achieve TBG levels less than 110 and 200 mg of cholesterol Promote healthy eating habits
Comments: The benefits of an exercise plan in diabetic patients can be seen in the decrease of glucose Levels, blood insulin and A1c Hemoglobin as well as The low-density of lipoproteins or low-density of cholesterol It improves the sensitivity to insulin Lipid profile Blood pressure
Benefits of Physical Exercise Body Fat Index Reduces Body Weight Reduces the risk of a heart disease
Ejercicio y la Diabetes Mellitus
Exercise and Diabetes Mellitus
Comments: The benefits of an exercise plan in diabetic patients can be seen in the decrease of glucose levels, blood insulin, and A1c Hemoglobin; as well as low-density lipoproteins or low-density cholesterol It improves the sensitivity to insulin Lipid profile Blood pressure
Glucose sugar in your blood Blood insulin A1c Hemoglobin Low-density lipoproteins It Improves: Sensitivity to insulin Lipid profile cholesterol, triglycerides
Fibrinolytic Activity anticoagulant High-density lipoproteins Blood pressure slight to moderate
Tratamiento farmacológico
Medical Treatment
AGENTES ORALES Antidiabetic Agents SULFONILUREAS 1 Generación Sulfonylurea 1st generation
Clorpropamida Clorpropramide Acetohexamida Acetohexamide Tolbutamida tolbutamine
2da generación 2nd generation
Glibizida Glibizide Gliburida Gliburide Glibenclamida Glibenclamide
3 generación 3rd generation
Glimepirida
Glimepiride
BIGUANIDAS
Biguanides
Metformina Metformin Fenformina Fenformin
INHIBIDORES DE LA ALFA-GLUCOSIDASA Alpha inhibitors - Glucosidase
Acarbosa
Acarbose
TIAZOLIDENDIONAS Thiazolidinediones or glitazones Pioglitazona
Pioglitazone hydrocloride Actos Rosiglitazone maleate- Avandia
Rosiglitazona
INHIBIDORES DE LA DDP-4 DDP-4 Inhibitors
Insulinas comercializadas en México
Types of insulin sold in Mexico
Insulina Regular Humulin-R, Novolin-R
Regular Insulin
Lispro Humalog Intermedia NPH Humolín N Insulina premezclada mixta 70/30
Mixed insulin
Source:nphealthcarefoundation.org
