- Indonesia Map
1998
1. Introduction
From epidemiological studies in Indonesia found the prevalence of diabetes mellitus (DM) of 1,5-2,3% of the population over the age of 15 years, even in an epidemiological study in Manado found 6.1% prevalence of DM. Research conducted in Jakarta to prove the increase in prevalence. The prevalence of DM in urban areas in Jakarta rose from 1.7% in 1982 Thun to 5.7% in 1993. Similarly, the prevalence of DM in Ujung Pandang (urban areas), increase from 1.5% in 1981 in Thun to 2.9% in 1998.
However, the prevalence of DM in the rural areas is still low. Obtained in Tasikmalaya DM prevalence of 1.1%; Sesean was in the District, a very remote area in Tanah Toraja, found the prevalence of DM is only 0.8% (11 patients among 1310 people aged> 30 years). In the area of East Java, rural urban differences are not so apparent. In Surabaya in epidemiological studies done in urban health center in 1991 that included 13,460 people, found the prevalence of 1.43%; are in rural areas on a study that included 1640 people (1989) also found a similar prevalence, namely 1, 47%.
Diabetes mellitus can affect people of all ages and social layers of the economy. In Indonesia today has not occupied the DM disease scale of priority health services despite the obvious negative impacts, namely a decrease in the quality of human resources, especially due to the resulting chronic penyulit.
Based on the pattern of population it is today, is expected later in the year 2020 there will be some 178 million people aged over 20 years and assuming 4% prevalence DMsebesar will get DM 7 million patients. A very large amount to be handled olegh specialist / subspesialis. Similar burdens seem more real to McCarthy and kalaudilihat number Zimmet (1993), which estimates the number of patients with diabetes in the world will reach 306 is the soul in the year 2020. In the ASEAN region found a similar pattern of improvement. The number of patients with type 2 DM in 1995 was estimated at 8.5 also people, will increase to 12.3 million in 2010. All parties, whether public or government, should participate in the Council of Ministers tackle this problem. Of course the program to prevent and cope with the emergence of this explosion of DM should have started by now.
In the health service strategy for patients with DM, which should be integrated into primary health care, general practitioner's role is very important. A simple case of diabetes mellitus can be managed without penyulit thoroughly by a general physician, especially if blood glucose levels kemudia it can be controlled either by management at the level of primary health care. Of course it should be stressed the importance of long-term follow-up on these patients. Patients who potentially will suffer need penyulit DM periodically consulted with your doctor or an expert related to DM management team at a higher level in the referral hospitals. Then they can be sent back to the regular doctor to manage it. Similarly, a hard-DM patients controlled daranya glucose levels, patients with DM penyulit, especially penyulit potentially fatal, it is necessary and should be handled by a more capable agency with a more complete perlalatan, in this case DM Center at the Medical Faculty or Hospital Education or Main Referral Hospital.
To get the right results to management and was effective for patients with DM and to suppress the number penyulit, required a minimum service standard for DM patients. Improvement and periodic revision of these standards should be adjusted to the progress of advanced science, conditions and input from the managers of DM, to obtain the maximum benefit amount bagia DM patients.
Diabetes mellitus is a chronic disease that will suffer for life, so that plays a role in managing not only doctors, nurses and nutritionists, but more importantly the participation of patients themselves and their families. Educate patients and ekluarganya would help improve their keiikusertaan efforts to improve the management of DM. Because it is necessary to set up associations of diabetes patients, which would really help increase their knowledge of DM and think about their own interests to the maximum extent possible.
This handbook contains standards for the management of DM patients who are experts kesepatan of DM in Indonesia that began pioneered PB Perkeni months since the February 1993 meeting in Jakarta. Revision and improvement of this handbook is one of the tasks mandated by Congress Perkeni to-4 in Ujung Pandang in 1997 to DM management specialist who joined in Perkeni.
Since most patients are a group of DM type-2 DM, consensus management is primarily designed for patients with type 2 DM; are for groups of type-1 DM and DM other types as well as management of diabetes in pregnancy is discussed in a separate manual.
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2. Diagnosis
The diagnosis of DM should be based on examination of blood glucose levels, can not be enforced only on the basis of glukosuria only. In determining the diagnosis of DM should be noted from blood drawn material and how to use checks. Unutk DM diagnosis, the recommended inspection is the examination of glucose by enzymatic way with materials venous blood plasma. To ensure diabnosis DM, blood glucose tests should be performed in a reliable clinical laboratory (which did stabilization program of quality control on a regular basis). To monitor blood glucose levels can be used capillary blood materials.
Today many gauges marketed blood glucose levels which means dry reagents are generally simple and easy to use. The results of blood glucose tests using these tools can be trusted as far as calibration is well done and the way tests are conducted in accordance with the recommended standard way, teruama to monitor blood glucose levels. Periodically, the results of monitoring by a dry reagent changes compared with the conventional way.
2.1. Examination filter
Examination filter specifically intended for the DM in general population (mass screening) is not recommended because in addition to the expensive cost, follow-up plan for those who have not been positive. For those who have the opportunity to filter checks with other diseases (general check-ups) of the filter checks for DM in the series is highly recommended examination. Examination is useful filters for capturing patient DM, TGT (Disturbed Glucose Tolerance), and GDPT (Fasting Blood Glucose Disturbed), which can be determined the appropriate steps to them. Active role of health managers is necessary for detection of DM can be enforced as early as possible and secondary prevention can be immediately applied.
Examination filter needs to be done in groups with one risk factor for DM, namely:
Older adult age group (> 45 years)
Obesity (BB (kg)> 120% BB dream, or a BMI> 27 (kg/m2)
High blood pressure (BP> 140/90 mmHg)
Family history of DM
BB pregnancy history with babies born> 4000 grams
History of DM in pregnancy
Dyslipidemia (HDL <35 mg / dl and / or triglycerides> 250 mg / dl)
Ever TGT or GDPT
Filter checks can be done through examination of blood glucose levels while, fasting blood glucose levels, can then be followed by an oral glucose tolerance test (TTGO) standard (See Scheme diagnostic steps DM).
For high-risk groups who penyaringnya negative tests, filter inspection tests performed each year, while for those aged> 45 years without risk factors, examination of the filter can be done every 3 years.
Patients with disturbed glucose tolerance and fasting blood glucose Disturbed is temporary stage to the DM. After 5-10 years later 1 / 3 TGT group will develop into DM, 1 / 3 remains TGT and 1 / 3 more back to normal.
Table 1. Blood glucose levels and fasting during * * as a standard filter and a diagnosis of DM (mg / dl)
Not sure yet DM DM DM
When blood glucose levels (mg / dl) venous plasma
capillary blood
<110
<90 110-199
90-199> 200
> 200
Fasting blood glucose (mg / dl) venous plasma
capillary blood <110
<90 110-125
90-109> 126
> 110
B. The steps to establish the diagnosis of diabetes mellitus
Clinical diagnosis of DM will generally be considered if there are complaints of a typical DM polyuria, polydipsia, polifagia, weakness, and weight loss that can not be explained why. Other complaints that may be the patient is tingling, itching, eyes blurred and impotensia in male patients, and pruritus vulvae in female patients. If the typical complaints, blood glucose tests as> 200 mg / dl is sufficient to make the diagnosis of DM. Results of fasting blood glucose> 126 mg / dl are also used for diagnosis of DM standards. For groups without a typical complaint of DM, blood glucose tests a new one-off abnormal, yet strong enough to menegakkn clinical diagnosis of DM. Further assurance is required to have abnormal numbers once again, both fasting blood glucose> 126 mg / dl, while blood glucose levels> 200 mg / dl in the other day, or the results of oral glucose tolerance test (TTGO) is abnormal.
Cara implementation TTGO (WHO, 1985):
3 (three) days before eating as usual
enough physical activity, as usual
fasting overnight, for 10-12 hours
fasting blood glucose levels checked
given 75 grams of glucose (adults), or 1.75 grams / kgBB (the children), dissolved in 250 ml 1air, and taken for / in 5 minutes
examined blood glucose levels 1 (one) hour and 2 (two) hours after the glucose load; during the examination examined subjects remained resting and not smoking.
For convenience, Perkeni only recommend checking blood levels at glukkosa to-2 alone. The reason for this simplicity is also recommended by the American Diabetes Association (ADA), which even used the results of fasting blood glucose> 126 mg / dl for the diagnosis criteria.
The diagnostic criteria of diabetes mellitus *
1. When blood glucose levels (venous plasma)> 200 mg / dl
or
2. Fasting blood glucose level (venous plasma)> 126 mg / dl
or
3. Plasma glucose levels> 200 mg / dL at 2 hours after 75 g glucose load in TTGO **
* The diagnostic criteria should be confirmed on another day, except for special circumstances hyperglycemia with acute metabolic dekompensasi, such as ketoacidosis, which decreased the weight quickly.
** How diagnosis with these criteria are not used routinely in the clinic. For epidemiological research on the population is recommended using the diagnostic criteria of fasting blood glucose levels. For gestational DM is also recommended that the same diagnostic criteria (See: Book Management Diabetes Mellitus Consensus gestational).
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3. Classification
DM classification recommended by Perkeni is in accordance with the recommendation of DM kalisifikasi American Diabetes Association (ADA) in 1997.
Aetiological classification of Diabetes Mellitus (ADA, 1997)
Type 1 diabetes (beta cell destruction, usually leading to absolute insulin deficiency): - autoimmune, - idiopathic
Diabetes type 2 (which primarily vary predominantly insulin resistance with relative insulin deficiency to a particular defect accompanied insuln secretion of insulin resistance)
Other types of diabetes
Genetic defect beta cell function
Genetic defect of insulin work
Maturity Onset Diabetes of the Young (Mody) 1,2,3
Mitochondrial DNA
Exocrine pancreatic disease
pancreatitis
tumors or pankreatektomi
pankreatopati fibrokalkulus
Endokrinopati
akromegali
Cushing syndrome
feokhromositoma
hyperthyroidism
Because the drugs or chemicals
vacor, pentamidine, nicotinic acid
glucocorticoid, thyroid hormone
tiazid, dilantin, interferon-alpha, etc.
Infection
Congenital rubella, cytomegalovirus (CMV)
For a rare immunological
anti-insulin antibodies
Other genetic syndromes associated with DM
Down syndrome, Kleinefelter syndrome, Turner syndrome, etc.
Gestational diabetes mellitus (DMG)
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4. Management
1. Purpose
Short term: eliminate complaints / symptoms of DM and maintain comfortable and healthy.
Long term: to prevent penyulit, both makroangiopati, mikroangiopati or neuropathy, with the aim of reducing morbidity and late mortilitas DM.
How to: normalize blood glucose, lipids, insulin.
Given the basic mechanisms of disease, type 2 DM is the presence of genetic factors, insulin resistance and pancreatic beta cell insufficiency, then the ways to improve the bottom abnormalities should be reflected in the management step.
Activities: managing the patient holistically, teaching self-care.
2. Things that need to be done on the management of DM patients.
At the first meeting:
Anamnesis of complaints and symptoms of hyperglycemia as well as complaints and symptoms of complications.
Complete physical examination:
TB, BB, BP, pulse palpation feet
Neuropathy signs sought
State inspection feet, skin, nails
Examination visus
Investigations should be done, depending on the facilities available:
Hb, leukocytes count, LED, count of leukocytes
Fasting blood glucose and after meal
Routine urinalysis
Serum albumin
Creatinine
ALT
Total cholesterol, HDL cholesterol, triglycerides
Quantitative urinary albumin or 24-hour microalbuminuria
HbA1c (optional on the first meeting)
ECG
Photo lung
Funduskopi
Guidance glimpse of:
Does DM's disease
Meaning and the need for control and monitoring of DM
Penyulit DM
Meal planning
Physical activity
Efficacious drugs and hypoglycemia hipoglkemik
Chiropody
Periodically
According to the needs: checking blood glucose levels of fasting and 2 hours after meals.
Each of the three (3) months: HbA1c
Each year:
complete physical examination
Urine albumin, urine sediment
creatinine
ALT
total cholesterol, HDL cholesterol, triglycerides
ECG
Funduskopi
Ideally all DM psien opportunity and equal treatment at all levels of health management, both primary, secondary, and tertiary. However, given limitations in the various levels of health managers and the number of investigations that examined according to existing facilities. Similarly, a review of service levels tailored to the capacity and facilities. Counseling and primary prevention can be done at all levels of health managers.
The main pillars of the management of DM
1. Guidance
2. Meal planning
3. Physical exercise
4. Berkhasial hypoglycemic drugs
Basically, the management of DM without metabolic dekompensasi meal begins with setting accompanied by sufficient physical activity for some time (4-8 weeks). If after that the blood glucose levels are still not able to meet the metabolic levels of the desired target, given the new oral hypoglycemic drugs (Oho) or insulin injections in accordance with the indication. In dekompensasi metabolic state, such as ketoacidosis, DM with stress, decreased weight quickly, Oho insuln or can be given.
Monitoring of blood glucose levels if possible can be done individually at home, after receiving special training for it.
Guidance (Diabetes Education)
Guidance for the management plan is essential to getting the most ...
Meal planning
The recommended standard is a food with a balanced composition in terms of carbohydrates, proteins, and fats, in accordance with good nutrition as follows:
Carbohydrates
Protein
Fat
60-70%
10-15%
20-25%
The number of calories adjusted to the growth, nutritional status, age, acute stress, and physical activity to achieve and maintain ideal weight.
To penetuan nutritional status, use Body Mass Index (BMI) = Body Mass Index (BMI).
BMI = BB (kg) / TB (m2)
Normal BMI women = 18,5-22,9 kg/m2
Normal BMI = 20-24,9 kg man / msup> 2
For practical clinical purposes, and calculated the number of calories, the determination of nutritional status using Broca's formula, namely:
Ideal Body Weight (BBI) = (TB-100) - 10%
Nutritional status:
BB or less if BB <90% of BBI
BB normal 90-110% BB BBI
BB better if 110-120% BB BBI
Obese if BB> 120% BBI
The number of calories required is calculated from ideal body weight multiplied by the basal caloric requirements (30 kcal / kgBB for men; 25 kcal / kgBB for women). Then coupled with caloric needs for the event (10-3%); for athletes and heavy workers may be more in accordance with the calories spent in activity), correction of nutritional status (if overweight, reduced; if thin, plus) and calories required acute stress (eg infection, etc..) in accordance with needs. For the period of growth (children and young adults) as well as pregnant women required a separate calculation (See: consensus type 1 DM and gestational DM consensus).
Food number of calories calculated by the above-mentioned composition is divided into 3 large servings for breakfast (20%), afternoon (30%) and afternoon (25%) and 2-3 servings of snack foods (10-15%) of them. The division of these portions may be adjusted as far as habits of patients for dietary compliance is good. For patients who developed DM also other diseases, the pattern of eating arrangements tailored to penyertanya disease. Need to be reminded that eating arrangements DM patients did not differ with normal people, except the amount of calories and eating a scheduled time. For the low socioeconomic groups, the food composition to 70-75% carbohydrates also gives good results.
The number of content of cholesterol <300 mg / day. Grown fat from sources of saturated fatty acids and saturated fatty acids to avoid.
The number of fiber + 25 g / day. Preferably soluble fiber (soluble fiber).
DM patients with normal blood pressure is still allowed to eat salt as a healthy person, except when experiencing hypertension, to reduce salt consumption.
Artificial sweeteners can be used sufficiently. Sugar as a spice in cooking still allowed. In the situation under control blood glucose levels, is still allowed to consume sucrose (table sugar) to 5% of calories.
To obtain compliance with a good meal arrangements, the ersatz knowledge will greatly help the patient.
Physical exercise
Recommended physical exercise regularly (3-4 times a week) for about 30 minutes, according to the nature CRIPE (continuous rhythmical, nterval, progressive, endurance training). As far as possible reached the target zone of 75-85% maximum heart rate (220-age), adjusted to the ability and the accompanying disease disease conditions. For example, moderate exercise is usually walking for 30 minutes, moderate exercise is walking fast for 20 minutes, and exercise is jogging.
Potent hypoglycemic drugs
If the patient has eaten and apply the settings that regular physical activity but daranhya control glucose levels have not been met (See Target blood glucose control), considered hikoglikemik efficacious drugs (oral or injection).
4.1. Oral hypoglycemic drugs (Oho)
In general, the use of oral hypoglycemic drugs, both the sulfonylureas, metformin, or glukosidase alpha inhibitors, should be considered correct liver and kidney function. Not advisable to give these drugs in patients with impaired liver or kidney function.
Sulfonylureas
These drugs have a major effect of increasing insulin secretion by pancreatic beta cells. Therefore, the main option for patients with normal weight and less, but still be given to patients with more weight. To avoid the risk of prolonged hypoglycemia, the sulfonylureas with longer working time should be avoided.
Biguanid
These drugs have a major effect of reducing liver glucose production as well as improve the effect of peripheral glucose uptake. These drugs are used primarily recommended as a single drug in obese patients. Biguanid is contraindicated in patients with impaired kidney and liver function, as well as patients with a tendency hipoksemia (eg patients with cerebrovascular disease). Biguanid drugs can give side effects of nausea. To reduce these complaints can be given simultaneously or after eating.
4.2. Insulin
Indication of the use of insulin in type-2 DM:
ketoacidosis, hyperosmolar coma and lactic acidosis
severe stress (systemic infection, major surgery)
weight decreased rapidly
pregnancy / gestational diabetes mellitus is not controlled by planning to eat
unsuccessful run with a maximum dose Oho or contra indicated by Oho
Table 2. Mechanism of action, major side-effects and influence on HbA1c.
The main workings of the major side effects Effect on HbA1c
Sulfonylureas increase insulin secretion BB rise, hypoglycemia 1.5-2.5%
Pressing Metfomrin liver glucose production Diarrhea, dyspepsia, lactic acidosis 1.5-2.5%
Glukosidase inhibitor alpha Flatulens Inhibits glucose absorption, soft stools 0.5-1.0%
Pressing insulin liver glucose production, stimulation of glucose utilization Hypoglycemia, BB up to normal Potential
Table 3. Oral hypoglycemic drugs
Initial dose of the drug dosage max dosage recommendations
Group sulfonylureas *
Glibenklamid
Gliklasid
Glikuidon
Glipisid
Glipisid GITS
Glimepirid **
Klorpropamid
2.5 mg
80 mg
30 mg
5 mg
5 mg
1 mg
50 mg
15-20 mg
240 mg
120 mg
20 mg
20 mg
6 mg
500 mg
1-2 times
1-2 times
2-3 times
1-2 times
1 times
1 times
1 times
Group Biguanid
Metformin ***
500 mg
2500 mg
1-3 times
Glukosidase alpha inhibitor class #
Acarbose
50 mg
300 mg
3 times
*
**
***
# Given approximately 30 minutes before eating
can be given just before eating
given before meals
given immediately after eating
Table 4. Types and duration of insulin work
Type Awitan * Peak * Long working *
Insulin short work
Insulin secondary employment
Insulin long working
Insulin mixtures 0,5-1
1-2
2
0,5-1
2-4
4-12
6-20
2-4 and 6-12
5-8
8-24
18-36
8-24
* In hours
In general, both insulin delivery Oho always begins with a low dose, and then increased gradually in accordance with the patient's blood glucose levels. If with sulfonylureas or metformin to maximal dose was the target blood glucose level is not reached, to consider a combination of two groups of drugs of different oral hypoglycemic (metformin + sulfonylureas or metformin + sulfonylureas, acarbose + metformin or sulfonylureas). Combination Oho small doses can also be used to avoid the side effects of each drug group. can also diberika Oho kobinasi when all three groups had not achieved the desired goals, or no reason in the clinic where insulin is not possible to use.
If the maximum dose Oho either individually or in combinations of glucose targets has not attained consciousness, thought of failure penakaian Oho. In such circumstances can be used a combination of Oho and insulin (see Scheme management of DM).
There are various ways and combinations insulin Oho (Oho + quick work of insulin 3 times a day, Oho + insulin work was the morning, Oho + insulin was night work). A widely used is a combination of Oho and insulin given night can be obtained although blood glucose control conditions the same, but the amount of insulin needed at least on a combination of insulin-Oho and was working nights.
5. Control Criteria
In order to prevent the occurrence of chronic complications, required a good control of DM. Well controlled diabetes mellitus does not mean that only the blood glucose levels are good, but should be thoroughly blood glucose levels, nutritional status, blood pressure, lipids and HbA1c levels as listed in Table 5.
Table 5. DM-control criteria
Good Medium Bad
Fasting blood glucose (mg / dl)
2-hour blood glucose (mg / dl)
80-109
110-159 110-139
160-199> 140
> 200
HbA1c (%) 4-5,9 6-8> 8
Total cholesterol (mg / dl)
LDL cholesterol (mg / dl) without CHD
LDL cholesterol (mg / dl) with CHD
HDL cholesterol (mg / dl)
Trigeliserida (mg / dl) without CHD
Triglyceride (mg / dl) with CHD <200
<130
<100
> 45
<200
<150 200-239
130-159
100-129
35-45
200-249
150-199> 240
> 160
> 130
<35
> 250
> 200
BMI (BMI) of women (kg/m2)
BMI (BMI) men (kg/m2) 18,5-22,9
20,0-24,9 23-25
25-27> 25 or <18.5
> 27 or <20.0
Blood pressure (mmHg) <140/90 140-160/90-95> 160/95
For patients older than 60 years, the target blood glucose levels higher than normal (fasting <150 mg / dl, and after meals <200 mg / dl), as well as lipid levels, blood pressure, etc., referring to the restrictions control criteria are. This is done considering the special properties of elderly patients and also to prevent potential side effects and drug interactions.
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5. Penyulit DM
In the course of DM disease, can occur penyulit acute and chronic.
Penyulit Acute:
diabetic ketoacidosis
hyperosmolar non ketotik
hypoglycemia
Penyulit chronic:
makroangiopati:
coronary arteries (coronary heart disease)
peripheral blood vessels
blood vessels of the brain (stroke)
mikroangiopati:
Diabetic retinopathy
Diabetic nephropathy
neuropathy
vulnerable to infection, such as pulmonary tuberculosis, ginggivitis, and urinary tract infections
Diabetic foot (combined up to 4)
For penyulit management is often required in collaboration with the field / other disciplines.
Hypertension and dyslipidemia are important risk factors penyulit makroangiopati, therefore hypertension and dyslipidemia should be sought and treated well (See Chapter Special Issues)
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6. Prevention of DM
A. Primary Prevention
Primary prevention effort is aimed at people who include high-risk groups, namely those who have not suffered, but has the potential to suffer from DM (See Risk Factors). Of course for primary prevention must be known factors that affect incidence of DM and the efforts that need to be done to eliminate these factors.
Guidance very important role in primary prevention efforts. General public through non-governmental organizations and other social institutions should be included. Similarly, all levels of government through such relevant Department of Health and Ministry of Education should include primary prevention of DM in education programs and health education. Since the preschool years ditnamkan should have an understanding of the importance of regular physical activity, patterns and types of healthy foods, keeping the body not to be too fat, and the risk of smoking to health.
B. Secondary Prevention
The purpose of secondary prevention is an effort to prevent or inhibit the emergence of penyulit with early detection measures and providing early treatment of disease. Early detection is done by checking the filter, but these activities require a large fee. Providing early treatment is to watch out for and where possible prevent the possibility of chronic penyulit. Guidance on DM and its management play an important role to improve patient adherence to treatment.
A good referral system will be very supportive of primary health care which is spearheading the management of DM. Through the steps mentioned above are expected to obtain optimal results, especially if he is supported also by the pengaobatan standard procedures that will be hold for the manager.
C. Tertiary Prevention
If it then turns out penyulit chronic DM happened, then the manager must try to prevent further disability and rehabilitate the patient as early as possible, before the disability is permanent. For example, low-dose aspirin (80-325 mg) may be recommended to be given routinely to patients who have had DM penyulit makroangiopati.
Holistic health services and integrated inter-related disciplines are needed, especially at referral hospitals, both with fellow experts specialist disciplines such as heart and kidney disease, as well as experts from other disciplines such as from the eye, orthopedic surgery, vascular surgery, radiology , medical rehabilitation, nutrition, podiatry, and so forth.
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7. Guidance
Guidance for patients with DM is not only done by doctors who treat, but also by all ranks of management related to DM, such as nurse counselors, social workers, nutritionists, and others in accordance with its respective expertise. Of course, upgrading / extension of the periodic extension is also very important for every moment can refresh and improve their outreach materials provided to the patients of DM. In the health workers carry out their duties in the field of diabetes requires a foundation of empathy, the ability to share in what is perceived by others.
Principles to consider in the process of diabetes education are:
provide support and positive advice and avoid the occurrence of anxiety
provide information in stages. do well
start with something simple, then the more difficult
use of view hearing aids
do approach to overcome the problem and do simulation
provide treatment as simple as possible for better compliance
do compromise and negotiation in order to be acceptable treatment goals
do not force our treatment goals
do motivation. give awards and discuss the results of laboratory tests
A. Guidance for primary prevention
Guidance for primary prevention should be given to:
High-risk communities:
Society needs to be increased concern that DM is a public health problem and can be prevented by controlling obesity and increase physical activity, especially in high-risk individuals.
Health policy planners:
Health policy planners need to understand the impact of socio - economic disease and the importance of the role of counseling in the management of DM, which can then Steps taken to improve health service facilities for DM patients.
Material information:
Factors that influence the incidence of DM and efforts to reduce these risk factors.
B. Guidance for secondary prevention
What is disuluh DM patient groups, especially the new. Counseling conducted at the first meeting and have often repeated and emphasized at every opportunity to return the next meeting.
Disuluhkan material on the first level are:
Diabetes: whether it is DM
General management of DM
Drugs to lower blood glucose levels (tablets and insulin)
Meal planning using food exchange for DM and physical activity
Guidance material on the advanced level:
Recognize and prevent acute penyulit DM
Knowledge of chronic penyulit DM
