Diet plays an important role in management of diabetes-Dr. Shehla Akram


 Familycon 2015 Conference Proceedings-II

Diet plays an important role in management
of diabetes - Dr. Shehla Akram

2mmhg reduction in blood pressure will result in
7% reduction in IHD and 10% reduction in stroke - Waris Qidwai

ISLAMABAD: In the second session of Familycon organized by Pakistan Academy of Family Physicians here on July 26th, Prof. Waris Qidwai from Aga Khan University talked about management of hypertension by Family Physicians. He pointed out that in 1945 President Roosevelt was suffering from hypertension but instead of finding some effective drugs to treat high blood pressure, they were busy in World War and thinking how to drop Atom bomb on Japan. In those days nothing could be done as no treatment for high blood pressure was available.

At present in Pakistan there are over twelve million people suffering form hypertension and many are at greater risk of target organ damage. Two mmhg reductions in blood pressure, he said, can lead to 7% reduction in Ischaemic Heart Disease and 10% reduction in stroke mortality. Non-pharmacological therapy for treatment of hypertension consists of life style modification, exercise and salt reduction. As regards drugs therapy, diuretics became available in 1950s; thiazide diuretics and beta blockers were quite effective. Then came the ACE Inhibitors followed by ARBs, Alpha blockers, direct vasodilators. For those suffering from diabetes with hypertension the drugs which can be used includes thiazides, beta blockers, ACE Inhibitors and ARBs. Drug therapy, he further stated has to be individualized and sometime a combination of two or more anti-hypertensive’s may be needed to control blood pressure.

Dr. Shehla Akram from Lahore was the next speaker and she talked about Role of diet in diabetes management. She quoted sayings of the Holy Prophet and from religious books which state that eat good things but avoid excess. Stomach is the home of diseases and diet is the main medicine. Disturbed sleep pattern, use of fast food creates many problems. Coping with a change in life style and diet restrictions is not easy. Furthermore during pregnancy, diet assumes special importance. All efforts Dr. Shehla said, should be made to control blood glucose. She laid emphasis that while prescribing diet therapy pleasure of eating should not be taken away from the patients. However, proper diet control was also important. Weight loss, she said, improves insulin resistance. Behavior modifications were also important.

Pakistan Academy of Family Physicians organized its Mid Year Familycon 2015 at Islamabad
on July 26th 2015. Picture shows from (L to R) Dr. Altaf Cheema, Maj.Gen.M.Aslam, Dr. Aftab
Iqbal Sheikh, Prof. Javed Akram, Prof. Waris Qidwai, Dr.Naeem and Dr. Nadeem Khawaja
sitting on the dais in the inaugural session.

Patients with Type 1 diabetes mellitus should adjust their rapid acting insulin’s keeping in view the diet and meal contents. Type 2 diabetics should be encouraged to opt for life style modifications, reduce their blood pressure, dyslipidemia and cholesterol. She also emphasized the importance of meal planning strategies and nutrition counseling. Family counseling and family support system is also important in the management of diabetes. Remote control diet plan should be effective.  One should motivate the patient and limit protein control. Meal replacements, she further stated should not be a routine and fresh diet should always be preferred and patients should be advised to use low calorie diet.

Prof. Ali Java from Pakistan Institute of Medial Sciences talked about management of Type 2 diabetes and discussed in detail the impact of intensive therapy in diabetes, hypoglycemia, and mechanism of action of oral anti diabetic preparations. He also highlighted the advantages and disadvantages of various preparations as well as their cost. He suggested that patients should be advised those anti diabetic preparations which does not cause hypoglycemia.

Prof.  Jamal Zafar from PIMS discussed insulin therapy in Type 2 diabetes mellitus. He was of the view that simple life will solve most of the problems; hence we should advise the patients to have a simple life style. He then presented a few case scenarios and urged the Family Physicians to prepare the patients for insulin therapy from the very beginning while putting them on oral drug. They will eventually need insulin after taking oral drugs for eight to ten years to control their blood sugar. Put patients on cost effective affordable insulin as it is required for life long. Some of these insulin preparations have long duration of action.  Use those insulin’s which do not produce hypoglycemias. Pre mix insulin’s can be used as a starting dose. Pre mix insulin’s are convenient for patients but it does not give a good blood sugar control. Some patients may require 50/50 insulin three times a day while some may require 70/30 insulin three times a day. He concluded is presentation by stating that early initiation of insulin is very important. Long acting insulin’s is best for introduction of insulin therapy in case of emergency.

Prof. Waris Qidwai, Dr. Shehla Akram, Prof.Ali Jawa, Dr. Osama Ishtiaq and Prof. Imran Ijaz Haider speaking
at the Familycon 2015 while on right Dr. Usman Javed receving mementoe from Dr. Atfab Iqbal Sheik.

Dr. Osama Ishtiaq from Shifa International Hospital gave an Update in hypothyroidism. He pointed out that in endocrinology; this was the second most common disorder. He discussed in detail its etiology, symptoms, management aspects. TSH, he said, may rise with age. One should avoid un-necessary tests and investigations. He also talked about secondary and tertiary hypothyroidism.  Speaking about the risk factors he mentioned elderly patients, female, obesity, thyroid surgery, X-ray or radiation to the neck while those suffering from autoimmune diseases are also high risk patients. The symptoms like weight gain, urticaria resemble with many other diseases.  Depression and hypothyroidism are closely related. All depressed patients should be investigated for thyroid disorders. Increased clinical suspicion will be helpful in making diagnosis because one cannot make diagnosis only on symptoms. Screen the patients with biochemical tests and then start treatment. Abnormal thyroid function test is yet another indication.  Do not do T3 test in hypothyroidism because it is only indicated in hyperthyroidism. For screening TSH is good enough. Take careful history, look at the symptoms and if TSH is above 10, then start treatment. T4 is done for hyperthyroidism. All patients do not need thyroid nuclear uptake scan. Treatment is with Levothyroxin once daily and it should always be taken before breakfast. Then monitor TSH levels. It can also be taken four hours after dinner. It is always advisable to start with a low dose and go slow particularly while treating the elderly patients. It takes two to three weeks for the drug to show its effects. T4 is not reliable in pregnancy, he added.

Management of Depression in Primary Care

Prof. Imran Ijaz Haider from Fatima Memorial Medical & Dental College Lahore made a presentation on management of depression in primary care. He advised the healthcare professionals to plan their daily schedule, spend some good quality time with their families and spouses, and have a positive thinking. When they make themselves too busy, they feel alone, become irritable, depressed, frustrated and then it results in outbursts on others. Often there is a communication gap between husband and wife, between family members. They must think why it all happens, he remarked.

Just look at how much quality time they have spent with their families last week. Try to become good role models. Think about the parenthood we are providing to our children. While dealing with the patients, they most often do not listen to them patiently and just rush to write the prescription. Our attitude with the patient is not good and most often we doctors are not happy.

His advice to the doctors was to live within their means. We cannot change circumstances but we can definitely change our selves. Do not try to justify your actions with different excuses. You can change your attitude. Start thinking positive it will produce positive behaviour. Be honest to yourself, solve your problems. Do not look for short cuts and plan your day a night before. Even while sitting in the meeting our mind is too much occupied somewhere else. Keep your life simple, use daily check list and it will reduce your stress level significantly. Try to manage yourself, listen to others viewpoint, read and do regular exercise. Appreciate good things and do not be critical all the time. What happens is that we become defensive when challenged and tell lies. Never compare your children with others. Always be proud of our children and family. Keep up your promises. Controls how you react, test your friends, understand and cope with yourself. Remember humour is the best stress reliever. Always remember your family, look at yourself and at your family, be happy and live a happy life, he remarked.

Dr. Usman Jawaid gave an update in the art of general practice and the conference concluded with a workshop on diabetic foot care in primary care which was scheduled to be conducted by Dr. Firdous Jahan from Oman. The scientific programme and overall arrangements for the meeting as well as attendance were very good but the time management by the organizers was very poor. Most of the speakers took more than allotted time and almost all the sessions were late. The conference participants earned two CME Credits  while life membership of Pakistan Academy of Family Physicians was offered on complimentary basis to all those who participated in this meeting held for the first time in Islamabad.  Islamabad Chapter of Pakistan Academy of Family Physicians it is expected will be much more active in the days to come and help organize CME activities for the family physicians on regular basis.