Interventions for Diabetes mellitus

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Age Cohort: Pregnancy and newborn

Health Promotion	Disease Prevention	Diagnostic	Curative	Rehabilitative	Palliative
Community Level
Create awareness on diabetes including prevention measures Create awareness on health diets for the pregnant women Education to pregnant women, Families and communities on importance of physical exercise Creation of awareness on avoidance risk factors such as avoidance of tobacco use and harmful use of alcohol. Distribution of IEC materials Community Health workers training on diabetes including prevention measures	Periodic screening for diabetes Guidance on health lifestyle including A healthy diet to achieve or maintain normal body weight Advice on regular physical activity e.g. walking Advise to Overweight mothers should be advised maintaining a healthy weight Advice on avoidance of tobacco use and harmful use of alcohol.		Recognition of symptoms indicative of diabetes including thirst, frequent urination, blurring of vision and fatigue Referral to a health facility for pregnant women suspected to have diabetes Encourage the mothers with per-existing diabetes to eat a healthy balanced diet Encourage the pregnant women with pre-existing diabetes to have regular daily physical activity Recognition of features indicative of acute diabetic complications which include -headache,- hunger - irritability, anxiety - sweating, - trembling, - difficulty in speaking, - confusion, coma Adherence to medication for pre-existing diabetes -in pregnant Give glucose to the patient with signs of acute diabetic complications if the patient can swallow - before referral) - Frequent Blood sugar monitoring Emergency Referral to a health facility for pregnant women suspected to have acute diabetes emergencies	Community rehabilitation services for persons with diabetic complications (physical, occupational and speech rehabilitation to help with mobility, speech and cognitive impairments related to diabetes)	Psycho social support to incorporate total quality of life in diabetics including behavioral, mood, attitude, and emotional support and also to improve adherence to treatment Enrollment to support groups
Primary Care
Create awareness on diabetes including prevention measures Create awareness on health diets for the pregnant women Education to pregnant women, Families and communities on importance of physical exercise Creation of awareness on avoidance risk factors such as on avoidance of tobacco use and harmful use of alcohol. Health workers training on diabetes including management in pregnant women	Advice/guidance to pregnant women on maintaining healthy diet Guidance on a regular exercise routine Guidance on maintaining healthy body weight/guidance on weight loss Screening for diabetes		Pre-natal screening for Gestational diabetes Management of Gestational diabetes pre-existing diabetes through advice on Lifestyle change including- Healthy balanced diet/nutritional therapy Regular daily physical activity- Weight management depending on pregestational weight Refill of medication/(insulin) for pregnant women with pre-existing diabetes Foetal monitoring - Postpartum Follow-up Referral to a hospital for the mother suspected to have Gestational diabetes for definitive diagnosis and for initiation of treatment Recognition and stabilising pregnant women with acute diabetic emergencies (hypoglycaemia and hyperglycaemia) before referral to a hospital	Physical, occupational and speech rehabilitation to help with mobility, speech and cognitive impairments related to diabetes.	Psycho social support to - incorporate total quality of life in diabetics including behavioral, mood, attitude and emotional support and also to improve adherence to treatment Linkage to support groups
Referral Facility: General
Create awareness on diabetes including prevention measures among pregnant women Create awareness on health diets for the pregnant women Education to pregnant women, on importance of physical exercise Creation of awareness on avoidance risk factors such as on avoidance of tobacco use and harmful use of alcohol Promote ANC attendance Health workers training on diabetes including management in pregnant women	Advice/guidance to pregnant women on maintaining healthy diet Guidance on a regular exercise routine Guidance on maintaining healthy body weight/guidance on weight loss		Pre-natal screening for Gestational diabetes Management of Gestational diabetes and pre-existing diabetes through advice on Lifestyle change including. healthy balanced diet/nutritional therapy - regular daily physical activity. Weight management depending on pregestational weight Medications/use of Insulin for treating hyperglycemia in gestational diabetes mellitus as it does not cross the placenta Management of pre-existing diabetes in pregnant women through use of insulin Monitoring and prevention of pre-eclampsia in pregnant women with diabetes (use low dose aspirin 60–150 mg/day - Foetal monitoring Monitoring of the neonates blood sugar after delivery Postpartum Follow-up	Physical, occupational and speech rehabilitation to help with mobility, speech and cognitive impairments related to diabetes Physical rehabilitation services for mother with diabetic complications such as diabetic foot/i.e. those amputated sight Rehabilitation for those with retinopathy	Psycho social support to incorporate total quality of life in diabetics including behavioral, mood, attitude, emotional support &amp, also to improve adherence to treatment
Referral Facility: Specialist
Create awareness on diabetes including prevention measures among pregnant women Create awareness on health diets for the pregnant women Education to pregnant women, on importance of physical exercise Creation of awareness on avoidance risk factors such as on avoidance of tobacco use and harmful use of alcohol Health workers training on diabetes including management in pregnant women Promote ANC attendance	Advice/guidance to pregnant women on maintaining healthy diet Guidance on a regular exercise routine Guidance on maintaining healthy body weight/guidance on weight loss		Pre-natal screening for Gestational diabetes Management of Gestational diabetes and pre-existing diabetes through advice on Lifestyle change including. healthy balanced diet/nutritional therapy regular daily physical activity. Weight management depending on pregestational weight Medications/use of Insulin for treating hyperglycemia in gestational diabetes mellitus as it does not cross the placenta Management of pre-existing diabetes in pregnant women through use of insulin Monitoring and prevention of pre-eclampsia in pregnant women with diabetes (use low dose aspirin 60–150 mg/day Foetal monitoring Monitoring of the neonates blood sugar after delivery Postpartum Follow-up	Physical rehabilitation services for mother with diabetic complications such as diabetic foot/i.e. those amputated sight Rehabilitation for those with retinopathy Physical, occupational and speech rehabilitation to help with mobility speech and cognitive impairments related to diabetes	Psycho social support to incorporate total quality of life in diabetics including behavioral, mood, attitude, emotional support &amp, also to improve adherence to treatment

Age Cohort: < 5 years

Health Promotion	Disease Prevention	Diagnostic	Curative	Rehabilitative	Palliative
Community Level
Create awareness to parents, families and communities on type 1 diabetes Awareness creation on measures to prevent complications of type 1 diabetes among children Awareness creation on healthy diets for children, physical activity Community health workers education on diabetes including type 1 diabetes and its management	Interventions to prevent complications for type 1 diabetes including Helping the child maintain good blood sugar control Teaching the child the importance of eating a healthy diet and participating in regular physical activity Scheduling regular check ups for the child with the health workers -including eye check up		Recognition of signs that are indicative of diabetes in children including Increased thirst, Frequent urination, (possibly bed-wetting in a toilet-trained child), extreme hunger, Unintentional weight loss, Fruity-smelling breath Referral of child suspected to have diabetes to a health facility for definitive diagnosis and management Adherence to medication/administration of insulin injection for the child with type I diabete Giving the child healthy foods Encouraging and helping the child to Exercise regularly Frequent blood sugar monitoring Management of suspected low blood sugar in the child (with a fast-acting carbohydrate, such as fruit juice, glucose tablets, hard candy, soda Recognition of signs of acute diabetic emergencies (low blood sugar and high blood sugar) Emergency referral to a health facility	Community based rehabilitation services - physical speech rehabilitation to help with mobility, speech impairments related to diabetes	Psychosocial support to incorporate total quality of life in diabetics including behavioral, mood, attitude, and emotional support and also to improve adherence to treatment Enrollment to support groups
Primary Care
Create awareness to parents, families and communities on type 1 diabetes Awareness creation on measures to prevent complications of type 1 diabetes among children Awareness creation on healthy diets for children, physical activity Health workers training on diabetes including type 1 diabetes and its management	Interventions to prevent complications for type 1 diabetes including. Helping the child maintain good blood sugar control Teaching the child the importance of eating a healthy diet and participating in regular physical activity Scheduling regular check-ups for the child with the health workers-including eye check up		Clinical examination, Recognition of signs that are indicative of diabetes in children including Increased thirst, Frequent urination, (possibly bed-wetting in a toilet-trained child), extreme hunger, Unintentional weight loss, Fruity-smelling breath Screening for type 1 diabetes through random blood sugar test Referral of child suspected to have diabetes to a health facility for definitive diagnosis and management Recognition and stabilizing the child with acute diabetic emergencies (low blood sugar and high blood sugar) Insulin refill for a child with diabetes/type 1 diabetes Advice to parents on healthy foods for the child with diabetes Guidance and encouraging Exercise regularly Advice on Adherence to medication/(insulin injection) for the child with type I diabetes Frequent blood sugar monitoring Management of suspected low blood sugar in the child before referral Emergency referral to a hospital for management of diabetic complications	Physical, occupational and speech rehabilitation to help with mobility, speech and cognitive impairments related to diabetes	Psycho social support to - incorporate total quality of life in diabetics including behavioral, mood, attitude, and emotional support and also to improve adherence to treatment Linkage of the children and parents/families to support groups
Referral Facility: General
Create awareness to parents, families on type 1 diabetes Awareness creation on measures to prevent complications of type 1 diabetes among children Awareness creation on healthy diets for children, physical activity Health workers training on diabetes including type 1 diabetes and its management	Interventions to prevent complications for type 1 diabetes including Helping the child maintain good blood sugar control Teaching the child the importance of eating a healthy diet and participating in regular physical activity Scheduling regular check-ups for the child with the health workers-including eye check up		Physical and Clinical examination Random and fasting blood sugars for diagnosis of type 1 diabetes Advice to parents on healthy foods for the child with diabetes Guidance and encouraging Exercise regularly Management of type 1 diabetes with insulin injection Frequent blood sugar monitoring and blood glucose control Recognition and management of acute diabetic emergencies (hypoglycaemeia and hyperglycaemia emergencies) Monitoring and control of blood pressure Monitoring and management of any complications including Screening for and management of blood lipid (to regulate cholesterol levels) screening for early signs of diabetes-related kidney disease and treatment Regular examination of the feet and management of any foot ulcers to prevent diabetic foot screening and treatment for retinopathy Follow up	Physical, speech rehabilitation to help with mobility, speech impairments related to diabetes	Counseling for children with diabetes type 1 and their parents/families To help them adjust with the diagnosis and long term treatment Linkage to support groups Psychological support to he child and parents to promoted adherence to medication
Referral Facility: Specialist
Create awareness to parents, families on type 1 diabetes Awareness creation on measures to prevent complications of type 1 diabetes among children Awareness creation on healthy diets for children, physical activity Health workers training on diabetes including type 1 diabetes and its management	Interventions to prevent complications for type 1 diabetes including Helping the child maintain good blood sugar control Teaching the child the importance of eating a healthy diet and participating in regular physical activity Scheduling regular check-ups for the child with the health workers-including eye check up		Physical and Clinical examination Random and fasting blood sugars for diagnosis of type 1 diabetes Advice to parents on healthy foods for the child with diabetes Guidance and encouraging Exercise regularly Screening for and management of blood lipid (to regulate cholesterol levels) screening for early signs of diabetes-related kidney disease and treatment Management of type 1 diabetes with insulin injection Recognition and management of acute diabetic emergencies (hypoglycaemeia and hyperglycaemia emergencies) Regular examination of the feet and management of any foot ulcers to prevent diabetic foot screening and treatment for retinopathy Monitoring and control of blood pressure Monitoring and management of any complications including Frequent blood sugar monitoring and blood glucose control Follow up	Physical, speech rehabilitation to help with mobility, speech impairments related to diabetes	Counseling for children with diabetes type 1 and their parents/families To help them adjust with the diagnosis and long term treatment Linkage to support groups Psychological support to he child and parents to promoted adherence to medication

Age Cohort: 5 - 11 years

Health Promotion	Disease Prevention	Diagnostic	Curative	Rehabilitative	Palliative
Community Level
Educate community to create awareness to identify diabetes symptoms early	Integrated counselling on healthy diet, physical activity, Encourage compliance with medications, and regular clinical check-ups and prevention of complications	Recognition of diabetes mellitus signs and symptoms	Immediate transfer of suspected diabetes cases to a higher-level health care facility	Self-management education Physical activity counselling and exercise training	Emotional and psychosocial support to patients and family members
Primary Care
Health education on early identification of diabetes, early treatment and complication prevention	Integrated counselling on healthy diet, physical activity, Encourage compliance with medications, and regular clinical check-ups and prevention of complications	Presence of classic symptoms Fasting blood glucose Random blood glucose HbA1c Urine test	History and physical examination for diabetes mellitus Point of care testing Basic laboratory tests Condition-specific nutrition assessment and counselling Provision of blood glucose monitoring device and test strips Diabetic foot examination Test for visual acuity Counselling on home glucose monitoring Monitoring of blood glucose	Self-management education Physical activity counselling and exercise training	Emotional and psychosocial support to patients and family members
Referral Facility: General
Health education on early identification of diabetes, early treatment and complication prevention		History Physical examination Fasting blood glucose Random blood glucose HbA1c oral glucose tolerance test Urine test	Healthy diet Physical activity Insulin Monitoring glycaemic control Prevent and treat diabetic ketoacidosis	Self-management education Physical activity counselling and exercise training	Emotional and psychosocial support to patients and family members
Referral Facility: Specialist
Health education on early identification of diabetes, early treatment and complication prevention	Integrated counselling on healthy diet, physical activity, Encourage compliance with medications, and regular clinical check-ups and prevention of complications	History Physical examination Fasting blood glucose Random blood glucose HbA1c oral glucose tolerance test Urine test Tests for other autoimmune disorders	Healthy diet Physical activity Insulin Monitoring glycaemic control Prevent and treat diabetic ketoacidosis Monitor long-term complications Manage complications	Self-management education Physical activity counselling and exercise training	Counseling for children with diabetes type 1 and their parents/families To help them adjust with the diagnosis and long term treatment Linkage to support groups Psycho social support to he child and parents to promoted adherence to medication

Age Cohort: 12 - 24 years

Health Promotion	Disease Prevention	Diagnostic	Curative	Rehabilitative	Palliative
Community Level
Educate community to create awareness to identify diabetes symptoms early	Physical activity/exercises for weight control Achieve and maintain a healthy body weight Eating healthy diets, e.g. avoiding sugar and saturated fats Avoidance of tobacco use – smoking increases the risk of diabetes and cardiovascular disease.	Recognition of diabetes mellitus signs and symptoms	Immediate transfer of suspected diabetes cases to a higher-level health care facility	Home-based self-management rehabilitation Physical activity counselling and exercise training	Psychosocial support Behavioural, mood, attitude, and emotional support to patients and family members Enrolment to support groups
Primary Care
Health education on early identification of diabetes, early treatment and complication prevention	Advice/guidance on Physical activity/exercises for weight control Advice on achieving maintaining a healthy body weight Advice on eating healthy diets, e.g. avoiding sugar and saturated fats Advice on avoidance of tobacco use – smoking increases the risk of diabetes and cardiovascular disease Screening for diabetes	Presence of classic symptoms Fasting blood glucose Random blood glucose HbA1c Urine test	Healthy diet Physical activity Insulin Monitoring glycaemic control	Self-management education Physical activity counselling and exercise training Provision and training in the use of assistive products	Physical, emotional, social assessment and support based on cultural needs, values and preferences of patients and families Enrolment to support groups
Referral Facility: General
Health education on early identification of diabetes, early treatment and complication prevention	Diabetes-related eye examination Diabetes-related foot examination Diabetes-related neuropathy examination Diabetes-related kidney disease testing	History Physical examination Fasting blood glucose Random blood glucose HbA1c oral glucose tolerance test Urine test	Healthy diet Physical activity Insulin Monitoring glycaemic control Prevent and treat diabetic ketoacidosis	Self-management education Physical activity counselling and exercise training Provision and training in the use of assistive products	Physical, emotional, social assessment and support based on cultural needs, values and preferences of patients and families Enrolment to support groups
Referral Facility: Specialist
Health education on early identification of diabetes, early treatment and complication prevention	Diabetes-related eye examination Diabetes-related foot examination Diabetes-related neuropathy examination Diabetes-related kidney disease testing	History Physical examination Fasting blood glucose Random blood glucose HbA1c oral glucose tolerance test Urine test Tests for other autoimmune disorders	Healthy diet Physical activity Insulin Monitoring glycaemic control Prevent and treat diabetic ketoacidosis Monitor long-term complications Manage complications	Self-management education Physical activity counselling and exercise training Provision and training in the use of assistive products	Physical, emotional, social assessment and support based on cultural needs, values and preferences of patients and families Enrolment to support groups

Age Cohort: 25 - 59 years

Health Promotion	Disease Prevention	Diagnostic	Curative	Rehabilitative	Palliative
Community Level
Community engagement/sensitization on risk factors for diabetes mellitus and preventive measures such as weight control, regular exercise, healthy diet, and stress management Community engagement [community sensitization on diabetes and risk factors, healthy diets, regular blood sugar testing, and exercise]. Provision of IEC/BCC materials	Lifestyle modifications, healthier diet, quitting smoking and alcohol, exercise. Screen blood sugar through community screening services Integrated counselling on healthy diet, physical activity, Encourage compliance with medications, and regular clinical check-ups and prevention of complications	Recognition of diabetes mellitus signs and symptoms	Lifestyle management Self-monitoring of blood glucose Immediate transfer of suspected diabetes cases to a higher-level health care facility	Home-based self-management rehabilitation Physical activity counselling and exercise training Home based self management rehabilitation Addition of person-centered care services to usual care in chronic heart failure or COPD for individualised health plan	Psychosocial support Behavioural, mood, attitude, and emotional support to patients and family members Enrolment to support groups
Primary Care
Health education on early identification of diabetes, early treatment and complication prevention Community engagement [community sensitization on diabetes and risk factors, healthy diets, regular blood sugar testing, and exercise]. Provision of IEC/BCC materials	Integrated counselling on healthy diet, physical activity, weight management, and alcohol and tobacco use Regular monitoring of blood sugar levels in high risk patients Diabetes-related foot examination Integrated counselling on healthy diet, physical activity, Encourage compliance with medications, and regular clinical check-ups and prevention of complications	Classic symptoms Fasting blood glucose Random blood glucose HbA1c Urine test	Lifestyle management Oral antidiabetics Monitoring glycaemic control Comprehensive diabetes care Nicotine replacement Availability of metformin for diabetes treatment	Self-management education Physical activity counselling and exercise training Provision and training in the use of assistive products Addition of person-centered care services to usual care in chronic heart failure or COPD for individualised health plan	Physical, emotional, social and spiritual support based on cultural needs, values and preferences of patients and families Enrolment to support groups
Referral Facility: General
Health education on early identification of diabetes, early treatment and complication prevention Population wide reduction in daily salt consumption Financial incentives to consume a healthy diet	Regular monitoring of blood sugar and HbA1C in high risk patients Diabetes-related eye examination Diabetes-related foot examination Diabetes-related neuropathy examination Diabetes-related kidney disease testing Screening and treatment of CVD risk factors Integration of hypertension and diabetes screening & treatment in HIV programs Use of polypill for secondary CVD prevention in high risk candidates	History Physical examination Fasting blood glucose Random blood glucose HbA1c oral glucose tolerance test Urine test	Lifestyle management Medical nutrition therapy Oral glucose-lowering medications Insulin Monitoring glycaemic control Detect and manage DM-specific complications History and physical examination for diabetes mellitus Point of care testing Basic laboratory tests Advanced laboratory tests Condition-specific nutrition assessment and counselling Counselling on home glucose monitoring, and self-insulin administration. Provision of blood glucose monitoring device and test strips Diabetic foot examination Test for visual acuity Direct ophthalmoscopy Intravenous fluids Insulin treatment Oral hypoglycaemics Monitoring of acid base status	Self-management education Physical activity counselling and exercise training Provision and training in the use of assistive products Addition of person-centered care services to usual care in chronic heart failure or COPD for individualised health plan	Physical, emotional, social assessment and support based on cultural needs, values and preferences of patients and families Enrolment to support groups
Referral Facility: Specialist
Health education on early identification of diabetes, early treatment and complication prevention Community engagement [community sensitization on diabetes and risk factors, healthy diets, regular blood sugar testing, and exercise]. Provision of IEC/BCC materials	Regular monitoring of blood sugar and HbA1C in high risk patients Diabetes-related eye examination Diabetes-related foot examination Diabetes-related neuropathy examination Diabetes-related kidney disease testing	History Physical examination Ophthalmic examinations Fasting blood glucose Random blood glucose HbA1c oral glucose tolerance test Urine test Renal function tests	Lifestyle management Medical nutrition therapy Oral hypoglycaemic medications Insulin Monitoring glycaemic control Detect and manage DM-specific complications History and physical examination for diabetes mellitus Point of care testing Basic laboratory tests Advanced laboratory tests Condition-specific nutrition assessment and counselling Counselling on home glucose monitoring, and self-insulin administration. Provision of blood glucose monitoring device and test strips Diabetic foot examination Test for visual acuity Direct ophthalmoscopy Intravenous fluids Insulin treatment Oral hypoglycaemics Monitoring of acid base status	Self-management education Physical activity counselling and exercise training Provision and training in the use of assistive products	Physical, emotional, social assessment and support based on cultural needs, values and preferences of patients and families Enrolment to support groups

Age Cohort: 60+ years

Health Promotion	Disease Prevention	Diagnostic	Curative	Rehabilitative	Palliative
Community Level
Community engagement/sensitization on risk factors for diabetes mellitus and preventive measures such as weight control, regular exercise, healthy diet and stress management	Lifestyle modifications, healthier diet, quitting smoking and alcohol, exercise. Screen blood sugar through community screening services	Recognition of diabetes mellitus signs and symptoms	Lifestyle management Self-monitoring of blood glucose Immediate transfer of suspected diabetes cases to a higher-level health care facility	Home-based self-management rehabilitation Physical activity counselling and exercise training	Psychosocial support Behavioural, mood, attitude and emotional support to patients and family members Enrolment to support groups
Primary Care
Health education on early identification of diabetes, early treatment and complication prevention	Integrated counselling on healthy diet, physical activity, weight management, and alcohol and tobacco use Regular monitoring of blood sugar levels in high risk patients Diabetes-related foot examination	Classic symptoms Fasting blood glucose Random blood glucose HbA1c Urine test	Lifestyle management Oral antidiabetics Monitoring glycaemic control Comprehensive diabetes care	Self-management education Physical activity counselling and exercise training Provision and training in the use of assistive products	Physical, emotional, social and spiritual support based on cultural needs, values and preferences of patients and families Enrolment to support groups
Referral Facility: General
Health education on early identification of diabetes, early treatment and complication prevention	Regular monitoring of blood sugar and HbA1C in high risk patients Diabetes-related eye examination Diabetes-related foot examination Diabetes-related neuropathy examination Diabetes-related kidney disease testing	History Physical examination Fasting blood glucose Random blood glucose HbA1c oral glucose tolerance test Urine test	Lifestyle management Medical nutrition therapy Oral glucose-lowering medications Insulin Monitoring glycaemic control Detect and manage DM-specific complications	Self-management education Physical activity counselling and exercise training Provision and training in the use of assistive products	Emotional and psychosocial support
Referral Facility: Specialist
Health education on early identification of diabetes, early treatment and complication prevention	Regular monitoring of blood sugar and HbA1C in high risk patients Diabetes-related eye examination Diabetes-related foot examination Diabetes-related neuropathy examination Diabetes-related kidney disease testing	History Physical examination Ophthalmic examinations Fasting blood glucose Random blood glucose HbA1c oral glucose tolerance test Urine test Renal function tests	Lifestyle management Medical nutrition therapy Oral hypoglycaemic medications Insulin Monitoring glycaemic control Detect and manage DM-specific complications	Self-management education Physical activity counselling and exercise training Provision and training in the use of assistive products	Physical, emotional, social assessment and support based on cultural needs, values and preferences of patients and families Enrolment to support groups