SECONDARY PREVENTION

MANAGING DIABETES
MELLITUS AND LIFESTYLE
CHANGING
Melisa Aziz
PERKI Banten
 DIABETES MELLITUS
•  A metabolic disorder characterized by chronic hyperglycemia resulting from
defect in insulin secretion or action, or a combination of both
•  ≈ 95% comprised by Type 2 DM
•  Important contributor to vascular damage, macro- and microvascular
complication
•  More than half the mortality and vast amount of morbidity is related to CVD
 CAD AND DIABETES MELLITUS
•  Global burden
Increased in numbers of people diagnosed with CAD and DM
Indonesia: Riskesdas 2007 data showed 5,7% prevalence of DM in urban area
WHO predicted increased from 8,7 million in 2000 up to 2-3 fold in 2035
Estimated around 300mil individuals are at future risk of developing Type 2DM

•  Multidiciplinary strategies
Comprehensive care of DM patients often requires collaboration between
cardiology, internist (diabetology), and primary care
DIAGNOSTIC CRITERIA
GLYCEMIC CONTINUUM AND
CARDIOVASCULAR DISEASE
 CVD

Nephropathy

CAD
Cardiovascular autonomic
neuropathy
•  Persistent sinus tachycardia
•  Orthostatic hypotensionStraining
to void

•  Sinus arrhythmia
•  Decreased heart variability in
PAD
response to deep breathing
•  Near syncope upon changing
positions from recumbent to
standing

Harrison Principles of Internal Medicine, 18th edition

 TARGET THERAPY
Parameter Target
Fasting Glucose (mg/dl) 80 – 130
2h-Post Prandial (mg/dl) < 180
HbA1c (%) <7
Systolic BP (mmHg) < 140
Diastolic BP (mmHg) < 90
LDL cholesterol (mg/dl) < 100 or < 70 with high CV risk
HDL cholesterol (mg/dl) M : > 40, F: > 50
Trigliseride (mg/dl) < 150
IMT (kg/m2) 18,5 - < 23
 LIFESTYLE CHANGES
Smoking Cessation
•  All smokers shouls be encourage to permanently stop smoking all form of
tobacco
•  Stepwise strategy: 5As >> Ask, Advise, Assess, Assist, Arrange

Physically Active
•  Gradual increase in daily lifestyle activities
•  Exercise training:
≥ 150 min/week of moderate intensity aerobic physical activity and/or 90min/
week of vigorous aerobic exercise
Physical activity should be distributed at least 30 min on at least 5 days/week
 LIFESTYLE CHANGES
•  Dietary Interventions
Total fat intake should be < 35%, saturated fat < 10%, and ono saturated
fatty acids > 10% of total energy
Fiber intake > 40gr/day (or 20gr/1000 kcal/day)

•  Weight control
Aim for weight stabilization in overweight or obese patients bases on
calorie balances and weight reduction8
•  hyperglycaemia is a symptom of multiple causes, and therefore requires a multifactorial approach
and thus comprehensive lifestyle changes, especially in DMT2
•  physical activity is key to increasing caloric expenditure, combatting insulin resistance, reducing
hospitalizations and improving the prognosis
•  physical activity supported by sustainable dietary changes improves weight control and, more
importantly, induce weight loss
•  strict glycaemic control reduces the risk of microvascular and macrovascular complications; so
does a systolic blood pressure ≤140 mmHg, whereas ≤ 130 mmHg even further lessens the risks for
stroke, retinopathy and albuminuria and should therefore be the target if tolerated  
•  if tight glycaemic and/or blood pressure control are/is not tolerated, temporarily consider relaxed
targets in the elderly, frail and / or those with long-term DM and /or cardiovascular disease;
however, reconsider stricter targets after timely reassessment
•  statins are recommended in all DMT2 patients >40 years and selected younger patients at high risk
•  in DMT2 with co-existing cardiovascular disease, a sodium-glucose co-transporter-2 (SGLT2) inhibitor
should be considered early since it improves prognosis without major adverse effects
•  improved risk factor management reduces cardiovascular mortality in DMT2 – more needs to be
done to reach all patients in need, which includes initiation of prevention and/or rehabilitation
programmes in the patient’s vicinity
•  risk factor management is a Class I Level A indication often superior to medical treatment.