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REVIEW ARTICLE
Year : 1997  |  Volume : 4  |  Issue : 1  |  Page : 12-23  

Guidelines for the management of diabetic patients in the health centers of Saudi Arabia


Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication31-Jul-2012

Correspondence Address:
Eiad A AI-Faris
P.O. Box 2925, Riyadh 11461
Saudi Arabia
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PMID: 23008561

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   Abstract 

This paper presents general guidelines for the management of diabetic patients within the primary health care (PHC) system in the Kingdom of Saudi Arabia (KSA). It intends to enhance PHC physicians' knowledge and improve clinical practice to ensure better management of people with diabetes mellitus. A step­wise (Algorithm) management approach for different categories of diabetic pa­tients, including diet, exercise, and drugs, is suggested. The peculiarities of Family Medicine, e.g., adopting the biopsychosocial model, the holistic ap­proach, and relations with the hospital are considered.

Keywords: Guidelines, diabetes, family medicine, Saudi Arabia


How to cite this article:
AI-Faris EA. Guidelines for the management of diabetic patients in the health centers of Saudi Arabia. J Fam Community Med 1997;4:12-23

How to cite this URL:
AI-Faris EA. Guidelines for the management of diabetic patients in the health centers of Saudi Arabia. J Fam Community Med [serial online] 1997 [cited 2014 Dec 22];4:12-23. Available from: http://www.jfcmonline.com/text.asp?1997/4/1/12/98445


   Introduction Top


Developing guidelines for the management of diabetes mellitus (DM) is given priority, as it is a common, serious and costly health problem. Saudi Arabia is a high-prevalence country (12-16%) [1],[2] according to the Ad Hoc Diabetes Reporting Group. [3] Although DM is associated with a high incidence of complications, [4] better control is associated with reduced morbidity and mortality. [5] Failure of consistency of care causes confu­sion among patients and reduces their compliance. The economic burden of the disease is enormous. A study in the Al­Khobar area (Eastern Province) found the average total cost, clinic time and investiga­tions cost for diabetic patients to be double while the drug costs were three times those of a control group of non-diabetic patients. [6] Finally, the emotional cost of diabetes is huge, as it is commonly associated with anxiety, impotence, disturbed family life, and increased fatigue and irritability. [7] A systematic review of published evaluations of Clinical Practice Guidelines (CPGs) found that the majority were successful in detecting statistically significant improve­ments in the process of medical care. [8] CPGs developed by family physicians have proved to be the most successful of several tested. [9]

CPGs for the management of diabetes formulated by diabetologists in developed countries [10],[11],[12],[13],[14] may not be applicable to Saudi Arabia, and were designed to manage patients within tertiary care centers. How­ever, as research in family medicine is relatively scarce and the newer CPGs have not been in existence long enough to be properly tested in primary care settings, it seems logical at present to use the most sensible, relevant, and evidence-based CPGs [15],[16],[17] that have been adopted by other specialities and to modify them to be more relevant. [9]

Existing guidelines are directed to Pri­mary Health Care (PHC) physicians and other PHC team members. They were de­veloped in 1988 to be used in a health cen­ter at King Saud University hospitals. They were later updated and modified to be used in the Quality Assurance (QA) Program in Primary Health Care developed jointly by the Saudi Ministry of Health and World Health Organization (WHO). [18] The update process included literature review with par­ticular emphasis on expert consensus of medical speciality societies such as the American Diabetes Association, evidence­ based analysis, and clinical reviews. As part of the QA program, the author conducted training sessions in different regions of Saudi Arabia for PHC supervisors. Their feedback on the feasibility and appropriate­ness of the guidelines was utilized to make them more practical and relevant to the PHC setting in Saudi Arabia. Furthermore, WHO and local hospital consultants were consulted.

The aim of the present guidelines is to promote better management of people with diabetes mellitus through the following objectives: (1) to enhance PHC physicians' and other team members' knowledge and clinical practice; (2) to improve patient doctor relationships and patients' compli­ance through more consistent physicians advice and management choices.

Standards of process (protocol)

1. Organization


A. Record System: The first requirement towards developing any plan that provides structured care for diabetics in a health cen­ter is to identify the patients and establish a register, [19] which should be regularly up­dated and looked after by one person. The records must always be accessible to the diabetes treatment team and organized so that they not only document what has oc­curred, but serve as a reminder of what should be done at appropriate intervals [10] (Appendix 1-5).

B. Appointments organization: The or­ ganization of diabetic care into fixed ses­sions (mini-clinics) will allow the profes­sionals (e.g. diabetic nurse, dietitian etc.) to rotate among the Primary Health Care Centers (PHCCs). Non-diabetic patients may be seen during these sessions. A dia­betic patient who finds the timing of the sessions inconvenient may be seen at other times. Twenty minutes may be required for new patients and ten for follow-up visits.

C. Frequency of consultation: For a stable Non-insulin Dependent Diabetes Mellitus (NIDDM) patient, a one-to-two monthly appointment interval is acceptable. The patient may come earlier for a repeat pre­scription, or for other reasons. The ap­pointment interval should be shorter for new patients, if there is a change in the management program, or a worsening in the patient's clinical condition.

D. Monitoring: Patients' files should be screened by a trained health professional (e.g. a nurse) before each consultation, with a reminder placed on those notes that have not complied with the guidelines. A ran­dom sample of the medical records of pa­tients seen by each doctor should be audited at regular intervals (for instance every three months) and feedback should be sent to each doctor. The use of patient-specific reminders and feedback helps to increase compliance in a busy clinic. [8]

2. Diagnosis

A. For non pregnant patients: The WHO criteria for the diagnosis of DM is adopted in [Figure 1]. (I) Fasting blood sugar (FBS) > 7.8 mmol/L or random blood sugar (RBS) > 11.1 mmol/L on one occasion for symp­tomatic patients and twice for asymp­tomatic patients establishes the diagnosis of Diabetes Mellitus. [20] (ii) If the FBS is < 6 mmol/L then the diagnosis of DM is unlikely. (iii) The value of FBS 6-7.7 mmol/L is an indication that the oral glucose toler­ance test (GTT) is required [Figure 1].
Figure 1: Biochemical Diagnostic Criteria for Non-pregnant patients22

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B. For pregnant patients (Gestational Dia­betes): After an oral glucose load of 100 gm, diagnosis of gestational DM may be made if two or more of the following equal or exceed the values (in mmol/L) as shown below. [11] (I) Fasting blood sugar (FBS) > 5.8. (ii) One hour post-prandial glucose > 10.5. (iii) Two hours post-prandial glucose > 9.1. (iv) 3 hours post-prandial glucose > 8.0. Note: Pregnant patients with impaired glucose tolerance should be managed as if they are suffering from diabetes and should be referred to the hospital specialist clinic.

3. Management at initial visit and follow-up

The steps of management suggested here are intended to be general guidelines that would never substitute for clinical judge­ment. Each patient's total clinical and psychosocial circumstances must be consid­ered. The physician should treat the patient and not the disease (the holistic approach). It is not enough to control blood sugar, as other risk factors (e.g., depression, smok­ing, hypertension, impotence, obesity etc., and other, socio-economic conditions) are important too. Recognizing that psychosocial disturbances are of crucial importance, they should be reviewed in each visit (Appendix 4) and be managed through counseling and referral to other team mem­bers who could be of some help. The in­volvement of other team members is essential during all aspects of diabetic care.

The essential points in history, examina­tion and laboratory work should be com­pleted in the diabetic record in a maximum of two visits (Appendix 1-5). Initial and annual assessment should follow the check­list in Appendix 3. Appendixes 1-4 should be filled by the physician while Appendix 5 is done by the diabetic education nurse. By writing the date in Appendix 5, both the physician and the nurse will know the edu­cational topics discussed in the previous sessions.

Certain groups of patients need shared care with the hospital through the referral system. They include: children, pregnant women, IDDM patients, those with known complications (viz., retinopathy, foot ulcers, nephropathy and neuropathy), and NIDDM patients who cannot be controlled by maximum dose of oral hypoglycemics. The specialist should provide written in­structions for both the patient and the re­ferring physician.

Individual treatment goals should take into account the patient's capacity to under­stand and carry out the treatment regimen as the risks associated with optimal control of blood sugar may outweigh the benefit of normogylcemia among certain groups of patients e.g. very young or old age or other coexisting diseases.

The following steps should be taken at the time of diagnosis and on subsequent annual visits: (I) conduct the appropriate initial work-up (history, examination, in­vestigation, treatment) and fill in the dia­betic record; (ii) refer all patients to the dietitian, diabetic nurse and dentist, and patients who need shared care to the endo­crinologist; (iii) refer NIDDM patients to the ophthalmologist at the time of diagnosis and on later annual visits. For IDDM pa­tients, the annual referral to the ophthal­mologist should start five years after diagnosis. [10],[11]

It is important to decide initially what type of diabetes the patient has (IDDM or NIDDM) [Table 1]. If difficulties in the classification are encountered, the patient may need to be referred to the hospital for further investigations.
Table 1: Characteristic features of diabetes subtypes: IDDM and NIDDM22

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The patients' body weight (BW), ideal BW, and body mass index (BMI) should be checked first. If the BMI is more than 30 or the BW is 20% over the desirable body weight (DBW), the patient's management should be as shown in [Figure 2]-A, otherwise [Figure 2]-B should be followed.
Figure 2: Algorithm for the management of obese and non-obese type 2 patients

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The exact time of transfer to further management options depends on the clini­cian's judgment, but the guidelines are that the thinner the patient (i.e., significant weight loss), the higher the blood sugar, and the more acute the other symptoms, the more the doctor should move from conser­vative management with diet alone toward (i) oral drugs or (ii) insulin, at short inter­vals. [12] The presence of ketoacidosis would make insulin therapy essential. The deter­mining factor in the choice of oral hypoglycemics (e.g., Gliben-clamide, Gliclazide) is the price and availability of the drugs. If the patient is not complying with the recom­mended treatment, then he should be moti­vated to do so and this should take precedence over other actions.

Blood Glucose Monitoring - Fasting Blood Sugar (FBS) and 2-hour postprandial glu­cose monitoring are usually needed to as­sess the level of control of Type II patients. HbAlc - if available - provides useful ob­jective information about the adequacy of control over the preceding two to three months. Measurement of HbAlc each three to four months is usually adequate.

The self-monitoring of blood glucose (SMBG) provides useful information on which to base therapeutic decisions. This is more important for IDDM patients. The effective use of SMBG encourages the pa­tient to assume greater responsibility for control, thereby increasing confidence and self-management. It is also of educational value as it provides patients with feedback on the effect of lifestyle changes such as food and exercise on glucose control. The timing of testing should be rotated, preprandially and two hours postprandially to provide a full profile. The frequency, timing and necessity of SMBG need to be individualized according to the patient's level of control and stability. Patients with stable metabolic control may test once daily at different times or before each main meal and at bed time twice weekly. Those pa­tients whose metabolic control is unstable and those requiring multiple injections need to monitor their blood glucose levels more frequently. [20]

B. Insulin Dependent Diabetes Mellitus (IDDM) - Type 1: Insulin regimens include the following: (i) A single injection of intermediate-acting insulin should not be used for Type I patients except for patients who refuse or cannot have more than one injection, per day as it is not possible to achieve reasonable glucose control with this regimen. However, Type II patients, in pe­riods of stress or in case of oral drugs fail­ure may require a single, intermediate acting insulin injection at night .[24] (ii) Two injections of a short- and intermediate acting insulin in the morning and evening (iii) Multiple injections (3-4) per day using syringes or insulin pens is associated with better glycemic control. [5]

1. Initiation of insulin: Start with intermediate-acting (NPH) insulin (0.2 units/kg) single dose before breakfast, then consider adding soluble insulin and a second even­ing dose, as described below.

2. Adjusting the insulin dosage: (a) For patients on a single, medium-acting injec­tion, unmixed, base the decision to adjust insulin mainly on the result of the FBS and 2-hour postprandial glucose monitoring. (b) For patients on more than one injection daily, adjustments should usually be made on the basis of a series of blood sugar esti­mations e.g. for patients on two injections of both short- and intermediate-acting (NPH) insulin; before lunch glucose is cor­rected by adjusting morning soluble insu­lin; before dinner glucose by morning NPH, bed-time glucose (evening soluble) and FBS (evening NPH) (c) Adjustments should normally be made at intervals of approxi­mately two to three days (d) Changes in dosage should normally be within 10% of the previous dose.

Exercise

Exercise recommendations for IDDM and NIDDM patients are different. For IDDM patients, safety and precautions against hypoglycemia are the most important. The benefits of improving lipid profile and blood pressure, and of reducing stress should be emphasized.

For NIDDM patients, exercise is more important and should be an integral part of the treatment plan as it promotes weight loss and reduces insulin resistance. [13]

Diet

Medical nutrition therapy is integral to total care and management of diabetics. Diet, exercise and drugs should be considered together. The patient should fill in a food diary for a week (or at least, a few days) to be used as a baseline for dietary manage­ment and education. Group and individual education lessons that include diabetic diet are essential (Appendix 5). The diet scale as an educational tool may prove very use­ful. Calculation of total caloric require­ments and translating them into food exchanges is the role of the dietitian. In practices with no dietitian, the family phy­sician should have a scheme for calculating the patient's diet [Table 2]. The diet should contain fewer saturated fats and no refined sugar. Regulating carbohydrate consump­tion is important for patients on Insulin or sulphonylurea to avoid hypoglycemia.
Table 2:Calculation of doily caloric requirement23

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Diabetic regime compliance and cultural practices

Diabetes control can only be achieved by effective self-management. The patients' health-belief model is an important deter­mining factor for their compliance. Pa­tients' perceived barriers (e.g. clinic wait­ing time, cost of drugs, inconvenience of SMBG) should be reduced and their per­ceived benefit (e.g. how better control can reduce the likelihood for complications) should be increased to the maximum. As the acquisition of knowledge does not guar­antee better self-management and patients' health beliefs are not fixed [21] patients' edu­cation complemented with such behavior modification strategies as motivation, sup­port and encouragement are needed on a regular basis. Initial high standards of self-care may wane, and reasons for this need to be explored with the patient and new tar­gets set.

The doctor's consultation style influences patients' compliance. He should be friendly, less dominant, listen more to his patients and encourage them to ask questions. Pa­tients' false beliefs (e.g. honey and dates do not raise blood sugar because they were mentioned in the Qur'an) and concerns (e.g. insulin causes renal failure) should be addressed.

Hypertension and Dyslipidemia

Hypertension is common among diabetic patients and is a risk factor for coronary heart disease, stroke, nephropathy, and retinopathy. [13] Most clinicians would have a low threshold for the treatment of hyper­tension among diabetics. Systolic pressure should be under 140 mmHg and diastolic pressure under 90 mmHg. In diabetic pa­tients with nephropathy or with evidence of other micro- or macrovascular complica­tions, a blood pressure > 130/85 mmHg is considered abnormal. In these patients, some evidence points to an advantage of reducing blood pressure to lower levels such as < 120/80 mmHg. [14] However, these lower blood pressure levels may result in orthostatic hypotension (e.g. in patients with autonomic dysfunction or the elderly) or an increase in serum creatinine, espe­cially in those with advanced renal insuffi­ciency or renovascular disease. [14] Mild hypertension should be treated initially with weight reduction, a low sodium diet, exer­cise, and smoking cessation. [10] If this treatment fails, an anti-hypertensive drug should be used. Angiotensin converting enzymes inhibitors (ACED are the drugs of first choice [13] especially for patients with albuminurea (<30 mg/24 hrs). [10] However, serum creatinine levels and electrolytes should be measured one week after initia­tion of ACEI, whenever the dose changes, and at least four times a year. [14] Hypertriglyceridemia and/or hypercholesterolemia should be treated with a lipid-lowering diet, weight loss, and smoking cessation. Failure to respond to these strategies justifies refer­ral to the specialist.

 
   References Top

1.Al-Nuaim A, AI-Rubeaan K, Al-Mazrou Y, Khoja T, AI-Alfas O, AI-Daghari N. National chronic metabolic diseases survey 1995. Jointly published by Ministry of Health and King Saud University. Kingdom of Saudi Arabia.  Back to cited text no. 1
    
2.El-Hazmi MAF, Warsy AS, Al-Swailem AR, Al­Swailem AM, Sulaimani R. Diabetes Mellitus and impaired Glucose Tolerance in Saudi Arabia. Ann Saudi Med 1996; 16(4):381-5.  Back to cited text no. 2
    
3.King H, Rewers M. WHO Ad Hoc Diabetes Re­porting Group. Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults. Diabetes Care 1993; 16:157-77.  Back to cited text no. 3
    
4.Famuyiwa OO, Sulimani RA, Laajam MA, Al­Jasser SJ, Mekki MO, et al. Diabetes Mellitus in Saudi Arabia: The clinical pattern and complica­tions in 1,000 patients. Ann Saudi Med 1992; 12(2):140-51.  Back to cited text no. 4
    
5.The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in Insulin - Dependent Diabetes Mellitus. N Engl J Med 1993; 329(14): 977-86.  Back to cited text no. 5
    
6.Al-Shehri ST. Direct costs of Diabetes Mellitus. Estimation of direct cost of health services offered to adult diabetic patients in Ministry of Health Cen­tres in AI-Khobar area [dissertation]. AI-Khobar: King Faisal Univ.; 1995.  Back to cited text no. 6
    
7.Surridge DHC, Willimas EDL, Lawson JS. Psy­chiatric Aspects of Diabetes Mellitus. Br J Psy­chiatry 1994; 145:269-76.  Back to cited text no. 7
    
8.Grimshaw JAI, Russell IT. Achieving health gain through clinical guidelines II: Ensuring guidelines change medical practice. Quality in Health Care 1994;3:45-52.  Back to cited text no. 8
    
9.Worral G, Chaulk P. Hope or experience? Clinical practice guidelines in family practice. J Fam Pract 1996; 42(4):353-6.  Back to cited text no. 9
    
10.American Diabetes Association. Drash AR (ed.). Diabetes Care 1996, Volume 19, Supplement 1: 51-113.  Back to cited text no. 10
    
11.American Diabetes Association. Physicians' guide to insulin dependent (type 1) diabetes-diagnosis and treatment. Sperling NIA (ed.). American Diabetes Association, Inc., Alexandria, Virginia, 1988: 20­28.  Back to cited text no. 11
    
12.American Diabetes Association. Physicians' guide to non-insulin dependent (type 11) diabetes diagno­sis and treatment. Rifkin 11 (ed.). American Dia­betes Association, Inc., Alexandria, Virginia, 1988: 109-15.  Back to cited text no. 12
    
13.Expert Committee of the Canadian Diabetes Advi­sory Board. Clinical practice guidelines for treat­ment of diabetes mellitus. Can Med Assoc J 1992; 147(5):697-712.  Back to cited text no. 13
    
14.American Diabetes Association. Consensus Devel­opment Conference on the diagnosis and manage­ment of Nephropathy in Patients with Diabetes Mellitus. Diabetes Care 1994; 17(11):1357- 61.  Back to cited text no. 14
    
15.15.Evidence-Based Care Resource Group.based care: 1. Setting priorities: how important is this problem? Can Med Assoc J 1994; 150: 1249­54.  Back to cited text no. 15
    
16.Evidence-Based Care Resource Group. Evidence­based care: 2. Setting guidelines: how should we manage this problem? Can hind Assoc J 1994; 150: 1417-23.  Back to cited text no. 16
    
17.Evidence-Based Care Resource Group. Evidence­based care: 3. Measuring performance: how are we managing this problem? Can Aced Assoc J 1994; 150: 1575-82.  Back to cited text no. 17
    
18.Al-Faris EA. Diabetes Mellitus. The scientific committee of Quality Assurance in Primary Health Care chaired by Dr. Yagob Al-Mazrou. Quality Assurance in Primary Health Care Manual 1994; Riyadh, Dar Al-Hilal Printing Press: 197-225.  Back to cited text no. 18
    
19.Waine C. Management in general practice. In Waine C (Ed.). Why not care for your diabetic pa­tients? The Royal College of General Practitioners 1988: 228-35.  Back to cited text no. 19
    
20.Tang FSN, Keen H. Diagnostic criteria, classifica­tion and presentation of diabetes. In Besser GM (ed.). Clinical Diabetes - An illustrated guide. Lon­don: Lippincott Company; 6.1-6.14.  Back to cited text no. 20
    
21.Compliance. In: Sackiet DL, Haynes RB, Tugwell P (eds). Clinical epidemiology: a basic science for clinical medicine. Boston, Toronto: Little, Brown and Company, 194-222.  Back to cited text no. 21
    
22.Maureen IH. Classification and diagnostic criteria for diabetes. US Department of Health and Human Services, National Diabetes Data Group. Diabetes in America 1985; NIH publication No. 85-1468:1­10.  Back to cited text no. 22
    
23.Shaman CR. Dietary management of diabetes mellitus. Galloway JA, Pot vin HJ, Shumn CR (eds.). Diabetes mellitus Lilly Research Labora­tories, Indianapolis, Indiana 1998: R85-104.  Back to cited text no. 23
    
24.Skyler JS. Recent advances in insulin therapy. Marshall SM, Home PD, Rizza RA (eds). TheDia­betes Annual /9 1995. Elsevier Science BV, 193­-209.  Back to cited text no. 24
    


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