Medical Science Optional daily answer writing practice for CSE 2023 – March 31

Non-insulin dependent diabetes mellitus (NIDDM), also known as type 2 diabetes, is a chronic metabolic disorder characterized by hyperglycemia, insulin resistance, and impaired insulin secretion. Lifestyle interventions, including dietary modifications and exercise, are the cornerstone of managing NIDDM. In this answer, we will discuss the diet and exercise-related advice given to a 35-year-old male diagnosed with NIDDM.

Dietary Advice:

Dietary modifications play a vital role in the management of NIDDM. The American Diabetes Association (ADA) recommends an individualized approach to dietary management that considers the patient’s personal and cultural preferences, health literacy, and numeracy. The following are some general dietary advice that can be given to our patient:

Dietary Recommendations:

1. Carbohydrates: It is recommended to consume complex carbohydrates such as whole grains, fruits, vegetables, and legumes. The total daily carbohydrate intake should be limited to 45-60 grams per meal. Simple carbohydrates such as sweets, soda, and sugary drinks should be avoided.
2. Proteins: Proteins are an essential nutrient for building and repairing tissues. It is recommended to consume lean protein sources such as poultry, fish, eggs, and tofu. The daily protein intake should be about 0.8 grams per kilogram of body weight.
3. Fats: It is recommended to consume healthy fats such as unsaturated fats found in nuts, seeds, avocado, and olive oil. Saturated and trans fats should be limited. A higher intake of monounsaturated and polyunsaturated fats is associated with a lower risk of cardiovascular disease.
4. Fiber: High fiber intake is important for glycemic control and cardiovascular health. It is recommended to consume 25-30 grams of fiber per day from whole grains, fruits, vegetables, and legumes.
5. Sodium: It is recommended to limit the sodium intake to 2,300 milligrams per day or less to control blood pressure.

Exercise Advice:

Regular physical activity is associated with improved glycemic control, reduced cardiovascular disease risk, and improved quality of life in patients with NIDDM. The following are some exercise advice that can be given to our patient:

1. Aerobic Exercise: Aerobic exercise, such as brisk walking, cycling, or swimming, should be performed for at least 150 minutes per week, spread over at least three days per week. Patients with NIDDM should monitor their blood glucose levels before, during, and after exercise and adjust their medication or food intake accordingly.
2. Resistance Exercise: Resistance exercise, such as weightlifting, should be performed two to three times per week, targeting all major muscle groups. Resistance exercise is associated with improved glycemic control, increased muscle mass, and reduced cardiovascular disease risk.
3. Flexibility Exercise: Flexibility exercises, such as stretching, yoga, or tai chi, should be performed two to three times per week to improve range of motion, reduce the risk of falls, and improve relaxation.

Monitoring Parameters:

1. Blood glucose levels: Blood glucose levels should be monitored regularly to ensure effective glycemic control. The target range for fasting blood glucose levels is 80-130 mg/dL, and for postprandial glucose levels is less than 180 mg/dL.
2. Hemoglobin A1c: Hemoglobin A1c (HbA1c) is a blood test that measures the average blood glucose levels over the past three months. The target HbA1c level for NIDDM is less than 7%.
3. Lipid profile: Lipid profile should be monitored regularly to assess the risk of cardiovascular disease. The target values for lipid profile are as follows: LDL cholesterol less than 100 mg/dL, HDL cholesterol more than 40 mg/dL in men and more than 50 mg/dL in women, and triglycerides less than 150 mg/dL.

Acute complications of IDDM and their management

1. Diabetic ketoacidosis (DKA):

DKA is a life-threatening condition that occurs when there is a severe insulin deficiency and the body starts breaking down fat for energy, leading to the accumulation of ketones in the blood. Symptoms include nausea, vomiting, abdominal pain, fruity breath odor, and altered mental status.

Management:

The management of DKA involves fluid replacement, insulin administration, and correction of electrolyte imbalances. The American Diabetes Association (ADA) recommends the following treatment protocol for DKA:

• Intravenous (IV) fluids: Administer IV fluids such as normal saline or lactated Ringer’s solution at a rate of 15-20 mL/kg/hr until the blood pressure stabilizes and urine output is adequate.
• Insulin therapy: Administer regular insulin as a continuous IV infusion at a rate of 0.1 units/kg/hr until the blood glucose level is less than 200 mg/dL. Then, switch to subcutaneous insulin therapy.
• Electrolyte replacement: Monitor electrolyte levels and replace potassium and other electrolytes as needed.
• Treatment of underlying cause: Identify and treat any underlying cause of DKA, such as infection.

2. Hyperosmolar hyperglycemic state (HHS):

HHS is a condition that occurs when there is a severe insulin deficiency and the blood glucose level rises to extremely high levels, leading to dehydration and electrolyte imbalances. Symptoms include extreme thirst, dry mouth, confusion, and seizures.

Management:

The management of HHS is similar to that of DKA and involves fluid replacement, insulin administration, and correction of electrolyte imbalances. The ADA recommends the following treatment protocol for HHS:

• Intravenous (IV) fluids: Administer IV fluids such as normal saline or lactated Ringer’s solution at a rate of 1 L/hr until the blood pressure stabilizes and urine output is adequate.
• Insulin therapy: Administer regular insulin as a continuous IV infusion at a rate of 0.1 units/kg/hr until the blood glucose level is less than 250 mg/dL. Then, switch to subcutaneous insulin therapy.
• Electrolyte replacement: Monitor electrolyte levels and replace potassium and other electrolytes as needed.
• Treatment of underlying cause: Identify and treat any underlying cause of HHS, such as infection.

3. Hypoglycemia:

Hypoglycemia is a condition that occurs when the blood glucose level drops below normal levels, leading to symptoms such as sweating, shakiness, confusion, and loss of consciousness.

Management:

The management of hypoglycemia involves administration of glucose to raise the blood glucose level. The ADA recommends the following treatment protocol for hypoglycemia:

• Mild to moderate hypoglycemia: Administer 15-20 grams of glucose in the form of glucose tablets, juice, or candy. Repeat as needed until the blood glucose level is above 70 mg/dL.
• Severe hypoglycemia: Administer 1 mg of glucagon by injection or nasal spray if the patient is unconscious or unable to swallow. If no improvement is seen within 10-15 minutes, administer another dose of glucagon.