​LADIES AND HEELS

As a petite woman, there are times when I try to wear stiletto, just to give me that extra confidence for the occasion. But I always have a plan B to avoid a sprained ankle (carrying extra flat slippers). I envy ladies who go all day in high heels without batting an eyelid, my guess is that they are just suffering and smiling! 

On a more serious note, frequent wearing of heels isn’t good for your lower limbs and back. When The Almighty created the feet, He made them flat and wide to serve as a comfortable shock absorber for the entire body weight. When you wear high heels, you put too much stress on your heel bones and toes. In order to maintain your balance, the stress is shifted upwards to your calf muscles. With time, the calf becomes more muscular and the veins around it become more prominent (and unsightly). This also promotes the emergence of varicose veins over time. 

By extension, the knees, hips and lower back adjust spontaneously, to give you that staccato gait as you catwalk. The result is pain radiating from the toes up to the lumbar spine. There is accelerated ageing of the joints and nerves, not to mention skin bruises and calluses on the feet. Of course, heels are “NO NO” when you’re heavily pregnant. 

Heels can make you look classy, but the long term effects outweigh the transient feelgood experience. You can look gorgeous in flats without getting a sprained ankle!

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Mental illness as a curable disorder: Debunking common myths

Kunle Omo Ijoba sits at a particular spot all day, always, with his dress tattered and hair mashed into an untidy Bob Marley style. Sometimes he would accost strangers claiming they owe him money. The market was his home and he would seldom entertain the traders with his dance moves and sometimes reveal more that they bargain for; with genitals out like a ware in a trade fair.

The picture described above is something most, if not all, Nigerians are familiar with. Mentally disordered people litter the streets and from time to time and we may or may not encounter them. Unfortunately, the description above largely defines our knowledge of mental illness. Our socio-cultural beliefs have entrenched in us several myths and misconceptions that affect our overall reaction to mental illnesses resulting in unfair and unwarranted stigma, discrimination and inappropriate or lack of treatment for sufferers.

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The World health Organization defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

In a research done by V. O. Lasebikan et.al in a primary health center in Lagos Island, Nigeria, 400 people that consisted of 88 children and young adults below aged 29 years, 55 aged 30 to 39 years, 72 aged 40 to 49 years, 63 aged 50 to 59 years, and 122 who were above 59 years, (226 (56.5%) were females, and 250 (62.5%) were married) were assessed and;

  • psychiatric morbidity was significantly highest for respondents below 39 years
  • psychiatric morbidity was significantly highest among those who were divorced 72%

The most prevalent clinical syndrome was unexplained somatic complaints (57.5%), followed by depression among half (50.0%) of the respondents, any anxiety disorder (49.3%), primary insomnia (45.3%), and alcohol use disorder (11.3%). Between 2.0 and 7.8% of respondents had disablement in various areas of life, out of which the commonest was in the domain of family relations (7.8%).

symptoms

To bring about “change”, these misconceptions and myths need to be cleared out and the correct picture painted. The following statements are tailored to iron out negativity and bring to light the facts about the illness before we take a journey on specific mental disorders and how to deal with them.

1. Myth: Mental illness is caused by supernatural forces

Evil spirits, witchcrafts have been for so long been held as the cause mental illness. Due to this perceived causes, religious institutions have been consistently sought for a cure or more appropriately deliverance.

Fact: Like every other illness mental illnesses are medical illnesses. Research shows there are genetic and biological causes for psychiatric disorders, and they can be treated effectively.

2. Myth: Mental illnesses are incurable and lifelong?

Fact: When treated appropriately and early, many people recover fully and have no further episodes of illness. For others, mental illness may recur throughout their lives and require ongoing treatment. This is the same as many physical illnesses, such as diabetes and heart disease. Like these other long-term health conditions, mental illness can be managed so that individuals live life to the fullest. Although some people become disabled as a result of ongoing mental illness, many who experience even very major episodes of illness live full and productive lives.

3. Myth/Misconception: Mental illness is innate?    

It is customary for families to sort through genealogy in search of history of mental illness in the family their child is marrying into.

Fact: Vulnerability to some mental illnesses, such as bipolar mood disorder, can run in families. But other people develop mental illness with no family history. Many factors contribute to the onset of a mental illness these include stress, bereavement, relationship breakdown, amongst other life negativities. But then, it can be managed.

4. Misconception: Mental illness only affects bad persons (karma)

The lady who bewitched her friend’s husband, the wicked stepmother, the rich ritualist; which other one? Nollywood’s favourite karma dish is “madness”.  I suppose, these pictures are what comes to mind first when you see a psychotic person on the streets.

Fact: Everyone and anyone are vulnerable to mental health problems. Many people feel more comfortable with the notion of having ‘a nervous breakdown’ rather than a mental illness. However, it is pertinent to talk openly about mental illness, as this reduces the stigma through reorientation and helps people to seek help early.

5. Misconception: People with mental illness are usually dangerous

Fact: This is about the greatest misconception that results in great stigmatization. People with mental illness are seldom dangerous; in fact people with the most severe mental illness are rarely dangerous especially when receiving appropriate treatment and support. Some mental illnesses are associated with aggresiveness and impasitivity, however, it is extrememly important such persons get help as they are more likely to harm themselves before others.

The vast majority of people with mental health problems are no more likely to be violent than anyone else. Most people with mental illness are not violent. In fact, people with severe mental illnesses are more likely to be victims of violent crime than the general population. You probably know someone with a mental health problem and don’t even realize it, because many people with mental health problems are highly active and productive members of our communities

6. Misconception: People with mental illness should be isolated from the community

Some communities have a myth that if “a mad man bites you, you’d get infected with the madness too”

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Fact: Most people with mental illness recover quickly and do not even need hospital care. Others have short admissions to hospital for treatment. Improvements in treatment over recent decades mean that most people live in their communities, and there is no need for the confinement and isolation that was commonly used in the past. Besides, mental illness is not an infectious disease and cannot be passed from one person to another through coughing or touching.

7. Fact: Stigma is one of the biggest problems for people with mental illness.

One of the greatest obstacles to recovery from mental illness is confronting the negative attitudes from the society. These often mean that people with mental illness face isolation and discrimination just for having an illness. Positive attitudes of family, friends, service providers, employers, and other members of the community toward people with mental illness are critical to ensuring quality of life for people with mental illness and supporting recovery.

8. Myth: Children don’t experience mental health problems

Once, I saw an undressed child stand in front of a moving car without fear ; no emotions at all. The driver parked and shouted “ogbanje”, a melodramatic episode followed thereafter.

Fact: Even very young children may show early warning signs of mental health concerns. These mental health problems are often clinically diagnosed, and can be a product of the interaction of biological, psychological, and social factors.  Our culture could not describe the emotionless attributes in some children nor is it able to decipher the hyperactivity of some children, they simply label them as “ogbanje” or “hard/stubborn child”. Majority are unaware of developmental mental health disorders  which show first signs before a child turns 5 years old, or even before 14 in adolescent disorders and three quarters of mental health disorders begin before age 24.

9. Myth: Postpartum mental illness “abisinwin”only occurs in cases of spiritual attack or genetic in some families.

Still on the Nollywood matter.

Fact: Mental health problems among women who are pregnant or who have recently given birth are observable in all countries and cultures. “Abisinwin” postpartum mental is not as depicted by our southwestern indigenous movies. Maternity, third day or postpartum blues occur in 80% of women who have recently birthed a child, with characteristic emotional swings from euphoria, tears (often without sadness), restlessness, anxiety, to feeling of unreality and detachment from the new born. However, the persistent presence for at least two weeks of cognitive and affective symptoms maybe suggestive of a serious mood disorder. Postpartum psychosis occurs within 48-72 hours after birth.

10. Misconception: Prevention doesn’t work, it is impossible to prevent mental illnesses.

Fact: Prevention of mental, emotional, and behavioral disorders focuses on addressing known risk factors such as exposure to trauma that can affect the chances that children, youth, and young adults will develop mental health problems. Promoting the social-emotional well-being of children and youth leads to:

  • Higher overall productivity
  • Better educational outcomes
  • Lower crime rates
  • Stronger economies
  • Lower health care costs
  • Improved quality of life
  • Increased lifespan
  • Improved family life.

Friends and loved ones can make a huge difference. Communal support can be important influences to help someone get the treatment and services they need by:

  • Reaching out and letting them know you are available to help
  • Helping them access mental health services, first aids are possible
  • Learning and sharing the facts about mental health, help correct misconceptions.
  • Treating them with respect, they are not different from other ill persons
  • Labels are for clothes; not human. Do not use labels like “crazy, mad, Kolo”

Overview of Common Mental Disorders

mental_disorders

1. Schizophrenia
It is characterized by psychotic episodes with recurring functional periods of disordered thought procecess. Symptoms include; delusions, hallucinations, disturbance of thought, disorganized speech, difficulty in concentration and poor memory.

2. Anxiety Disorders
An anxiety disorder involves an inappropriate response characterized by feelings of apprehension, uncertainty or fear. This disorders can be differentiated into Generalized Anxiety Disorders (GAD), Panic Disorder (PD) amongst others.

3. Personality Disorders
Personality disorders are a combinations of patterns and behaviors that deviates markedly from the expectations of the culture of the individual who exhibits it.

Conclusively, Mental illness like every other illness requires specialists to diagnose and provide care. it is treatable, curable, and does not require advance technology; our perception of it will affect how we get approach it positively.

To stay mentally fit, let’s continue the conversation, share some of the myths and misconceptions you know that was not highlighted, together we change the narrative.

 

 

 

Rukayat Ogunbiyi is a Pharmacist and Public mental health advocate, inclined towards child and adolescent psychiatry. She was trained as an intern at the Federal Neuropsychiatric Hospital, Yaba. She is currently set to resume post graduate studies in Child and Adolescent Mental health at the Center for Child and adolescent mental health in University of Ibadan.

POISONS AND OUR KIDS: A case study on kerosene and other toxic substances

WHEN SHE DRANK KEROSENE

 …could you please bring palm oil, mummy Jide, we want to give it to Blessing

Some minutes before, Grace’s mom had seen Blessing with a laCasara bottle containing kerosene

But, she only drank a little, said Bola, and moreover, you already gave her palm oil she would be okay

The scenario painted above is just one of those events that happen in our environment especially when there are no supervisions and in order to take care of such situations, people would proffer different solutions. As an African (A Nigerian) in particular, we have our science, our ways of “treating” conditions. Thus, in this write up we would learn if those remedies truly work and if they do, how do they work? Apart from kerosene, what other substances are injurious to the body either by ingestion (taking in through the mouth), injection, touch and so on. All these substances we term “poisons”.

What is a Poison?

A poison is a substance which causes illness or harm if someone eats, drinks, touches it or breathes it in and poisoning would mean exposure to chemical or other agents that adversely affects the functioning of an organism. It could be accidental, intentional or even for medicinal purpose.

The Swiss Alchemist and physician Paracelsus once said, ‘all substances are poisons,…the right dose differentiates a poison

For children majorly less than 6 years of age ingestion of harmful substance is the main cause of injury. This is because for the very young according to Sigmond Freud, they are in the oral and anal phase of development. But, for the adult, it is more of intentional -either by another to inflict pain or by an individual to gain attention.

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Examples of ‘poisonous’ Substances

As earlier stated any substance can be a poison depending on the dosage and poisoning may be a medical emergency depending on the substance involved.  Some of the substances are:

Those taken by children:  Cosmetics and personal care products; hydrocarbons like kerosene, lamp oil; a cough and other cold preparations; Perfume; Mouthwash;  Analgesics like paracetamol; Foreign bodies like button hole batteries; Pesticides; Topical agents for example nail polish and so on.

Other substances are Alcohol; Narcotics and Drugs of abuse; Organophosphates; Acetaminophen; Iron supplements; Benzodiazepines; Tricyclic Antidepressants

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These two kids above are taking dry gin probably from having access to parent’s stash

 

How You May Suspect an individual has taken A Poison

  • Eyewitness account and the individual might complain of

-wanting to vomit or even vomit

-difficulty with breathing or swallowing

-drooling of saliva (in children)

-drowsiness or confusion

  • Empty medication bottle
  • Chemical smelling breath or clothing
  • burn stains and odor
  • skin rash or burns around the mouth or lips

Specific poisons:

Kerosene Ingestion.

Kerosene is a chemical used mainly in paints, pesticides, lighter fluid, illuminating fuel and heating. The type and severity of symptoms vary depending on the amount of chemical involved and the nature of the exposure. Since most households store it in containers for ‘drinkable’ substances, most kids tend to go for it. Others are those who use kerosene to cure some ailment either by rubbing on the skin or inhaling.

The individual (mostly child) may present with:

– most times may not present with any symptoms if it is a little quantity.

– A cough, choking, gagging and grunting

– and the child may be breathing fast

– may feel the urge to vomit or even vomit

– there is a risk of taking into the trachea ( i.e risk of aspiration, thereby causing what the doctor might refer to aspiration pneumonitis)

– The child may feel burning sensation, belch a lot and even pass a lot of watery stool (i.e diarrhea) and so on.

Organophosphates (e.g Insecticide)

In addition to what has been said about kerosene above, the individual might be stooling and not being able to control it. Might feel restless, confused or even in a coma. Also might feel abdominal pain and may feel his heart beating faster than normal.

The differents substances that might cause the poisoning would in one way or the other present with the above-mentioned symptoms.

What Should You Do (Home Remedy)

– Call an emergency center (if it exists) to notify them of poisoning, by this, they would tell you the necessary things to do and prepare for the individual before arrival at the Emergency room (if needed).

– Remove the individual from the source of the poison if gaseous, remove clothes and expose to fresh air.

– If your child has been burned or spilled on, remove all clothing that the poison has touched and flush skin with cool or lukewarm water for 15 minutes.

– If the poison has been swallowed and is awake, small sips of water can be given.

-Please under no circumstance should you FORCE vomiting, it is no longer recommended.

– Protect yourself from coming in contact with the substance of poison either by touching, testing the taste, or even breathing it in.

– Note the substance of poison to be shown to the doctor or nurse in the emergency room or hospital.

– If the eye is affected, flush or irrigate well the eye immediately with water.

KEROSENE (AND LIKES) POISONING

Most of the above can be applied, but to reiterate

If vomiting occurs, lean patient forward or places on the left side (head-down position, if possible) to maintain an open airway and prevent aspiration.

Please do not induce VOMITING, and for the use of palm oil or milk, I would only answer with a research done by D.O Fagbule and others in a 6-year retrospective study in the University of Ilorin Teaching Hospital.

They said; “Approximately, three-quarters (74.3%) of patients with radiologic abnormalities had palm oil alone or in combination with milk as home remedies. The severity of poisoning was influenced by the type of home remedy and the interval between accident and admission”.

In essence, very early presentation at the hospital is better. Most of the scholars do not mention the use of palm oil as first aid.

At the HOSPITAL

The doctor would ask you some questions concerning the poisoning, what, how, where it happened. If the victim is awake, the kind of substance that has been ‘taking in’, the quantity and so on, what has been done and so on. He or she would ask for some tests, draw blood for some tests, do a chest x-ray if kerosene poisoning. Then he or she would go ahead with the appropriate measures to save the victim. For some poisons, antidotes are given. The hope here is, most times even for large kerosene ingestion, symptoms resolve within 2-7 days, only that chest infection may have ‘come in’

Prevention is Better Than Cure

Using the host, Agent, Environment model. The host is the victim (the child), the Agent is, for example, the kerosene or bleach and the environment are the containers. You have to take care of the three.

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The reduction in the incidence of childhood poisonings in the past half-century has been dramatic as result of the combination of highly effective active and passive methods of intervention.

Passive interventions eg: the introduction of child-resistant containers for drugs and other dangerous household products.

Active interventions, which require a change in behavior by parents and caretakers, include the safe storage of household products.

– Never transfer medicines or other harmful substances into drinking or food containers

-Store drugs (medicines), cleaning products, paints, and liquid cosmetics in a locked cabinet or out of reach of children.

-Do not put rat or insect poison on the floor or close to the reach of children.

-For kids playing with toys or other electronics which contain button hole batteries, monitor them carefully as swallowing the batteries would be more injurious to them as it could also lodge in their throat thereby causing a great problem. Note that ingestion of alkaline liquid is more dangerous than the acidic ( though both are not good).

In a nutshell, what I really want you to get from this write up is that prevention is better than cure and if it so happens that the accident has occurred, follow the necessary steps in addressing the situation and not a shortcut which may or may not have saved the day.

 

 

Ibrahim Olajide DADA is affable and a graduate of medicine and surgery. His interests are the prevention of diseases with emphasis on child and mental health. His maxim “for every child and the mentally affected there is hope”, ennobles his views to ensuring healthy lifestyles and promoting adequate wellbeing for all. He is also a prolific writer with a couple of publications to his credit. 

POLYCYSTIC OVARIAN SYNDROME

Polycystic ovarian syndrome (PCOS) is a gynaecological condition characterized by chronic anovulation (infrequent or absence of ovulation), hyperandrogenism (elevated male sex hormones) and polycystic ovaries (presence of several follicular cysts in the ovaries). At least two of these characteristics are required to make a diagnosis. PCOS is one of the commonest causes of irregular menstrual cycles and infertility in women. Also, PCOS is almost always associated with other metabolic disorders such as obesity, diabetes and cardiovascular diseases.
ANOVULATION

Women with PCOS often complain of irregular menstruation as this is the most evident symptom. Some experience scanty menses while others see their menses only 2 to 3 times per year. This also results in fertility issues because pregnancy cannot occur without ovulation. Normally, the lining of the uterus is shed every month (average of 28 days) in the absence of pregnancy. When there is no ovulation, the lining stays intact and continues to grow because of the imbalance in the hormones responsible for breaking the cycle (progesterone and oestrogen). Untreated anovulation can lead to endometrial hyperplasia and cancer later in life. 

HYPERANDROGENISM 

Every woman has a balanced amount of male and female sex hormones in the blood. PCOS causes an increase in the male hormones – androgens/testosterone. This results in virilization- hirsutism, deep voice, broad shoulders and acne. It’s important to rule out other causes of virilization such as hermaphroditism and other congenital anomalies. 

POLYCYSTIC OVARIES

According to the Rotterdam criteria, the ovary is said to be polycystic when it contains 12 or more follicles or measures more than 10 cubic centimeters. The diagnosis is based on a transvaginal ultrasound scan. This can present as lower abdominal pain but not always. These follicles mimic the normal follicles that produce the eggs and hormones, but they are ineffective and instead, produce excess androgens. 

METABOLIC AND ENDOCRINE EFFECTS 

As pointed out earlier, PCOS is strongly associated with obesity, diabetes, abnormal Lipid profile and cardiovascular diseases. Some can also have hypertension and obstructive sleep apnea manifesting as snoring and daytime somnolence. When patients get pregnant, they remain at risk of complications like gestational diabetes, hypertension and placental abnormalities. Hence, women with PCOS must be followed up, even after achieving regular menses or fertility. 

INVESTIGATIONS

After a detailed history and thorough physical examination, the diagnosis is almost always arrived at. We also need to do some test to confirm the diagnosis, determine the severity and identify coexisting metabolic disorders. These include: 

-Hormonal profile: oestrogen, progesterone, testosterone, corticosteroids etc. 

-Pelvic ultrasound 

-Abdominal CT scan or MRI

-Blood sugar levels 

-Lipid profile

MANAGEMENT 

The aim of treatment depends on the woman’s desire for fertility and concerns about virilization. In adolescents, we need to restore regular menses and treat hirsutism and acne. In married women, infertility is usually the main problem.
*Lifestyle modification and attainment of an healthy weight are the first line of management. As most patients are obese, weight reduction alone can be all that is needed to restore normalcy. 
*Plucking, epilation creams and devices, waxing and laser therapy can be used to control hirsutism. Drugs like spironolactone can also be tried in resistant cases, but patients must be warned about side effects. 
*Metformin is the first drug of choice. It helps to reduce all the symptoms of PCOS and also controls excessive weight and high blood sugar. 
*Oral contraceptives help to regulate the menses in women who are not desirous of pregnancy any time soon. 
*Ovulation induction is used for patients complaining of infertility after trying other conservative methods without success. This can be done medically (using clomephene citrate and other meds) or surgically (eg. ovarian drilling) 
*Lipid-reducing medications and antihypertensives should also be considered if needed. 
Regular follow up is essential to monitor progress and detect long-term complications such as diabetes, endometrial hyperplasia and cancer.

Diabetes

Diabetes Mellitus means your blood glucose, also called blood sugar, is too high. Your body uses glucose for energy. This is an important cause of disability and increases the risk of heart and kidney diseases and other health problems. There are three main types;

  • Type 1 diabetes often starts at a young age and is due to a lack of insulin. It accounts for 10-15% of all cases of diabetes.
  • Type 2 diabetes starts with resistance to the action of insulin and is associated with older age, overweight, and obesity. The case of type 2 diabetes is increasing rapidly in Nigeria. The largest part of the increase is due to poor diet (specifically excess energy intake), low levels of physical activity and the resulting increase in levels of obesity. Type 2 diabetes is much more common at older ages.
  • Gestational diabetes is a type of diabetes that develops only during pregnancy, is usually diagnosed during late pregnancy. If you are diagnosed with diabetes earlier in your pregnancy, you may have had diabetes before you became pregnant

 

PRESENTATION

Typical complaints experienced

  • Fatigue
  • Polyuria which is excessive urination, especially at night-time (more than 3 times)
  • Polydipsia which is drinking water more than usual due to feeling thirsty more than usual
  • Blurry vision
  • Dysuria which is discomfort while urinating
  • Weight loss or weight gain

Physical examination can reveal one or more of the following;

  • Obesity (BMI greater than 29)
  • increased blood pressure above 140/90
  • Loss of sensation especially to vibration and light touch
  • Signs of dehydration (loss of skin elasticity, dry mouth, muscle aches, concentrated urine)
  • Lower extremity edema (swelling)
  • Rash especially acanthosis nigricans which occur on her neck or around the armpit thickened, velvety, relatively darker areas of skin on the neck, armpit and in skin folds

A urine dipstick shows 0+ protein, 0+ ketones, and 3+ glucose; her non-fasting blood glucose is 180 mg/dL. A basic metabolic panel does not demonstrate renal failure (her creatinine is 0.9 and her BUN is 9) or acidosis.

You make a tentative diagnosis of chronic hyperglycemia due to type 2 diabetes. A fasting glucose test done the next day confirms the diagnosis (140 mg/dL, higher than the WHO criteria for diagnosis of equal to or great than 126 mg/dL; with her symptoms, a random blood glucose of equal to or greater than 200 mg/dL would also have been diagnostic) (1,2).

What is the most reasonable initial management of your patient’s diabetes

Mrs. S. will need a thorough discussion about diabetes, how it is treated, and why it is important to continue with these therapies even once she feels better. If her glucose was very elevated (to the >300 range) and she had signs of hypovolemia, or if she had acidosis with or without renal impairments on her labs, treatment with insulin and intravenous fluids to rapidly correct her blood glucose and prevent complications would be indicated. Mrs. S. does not appear to be dehydrated on exam, so she may be told to increase her intake of non-sugary fluids for a few days, and started on metformin. She should also be advised on increasing her exercise (for example, walking for an hour every evening), and on specifics of an appropriate diet (see answer C for more information on diet).

The use of oral medications to lower blood glucose has been shown in a number of trials to reduce the risk of diabetic complications; it may also reduce the risk of death in some populations, though this effect has not been demonstrated as thoroughly (1).

In general, metformin is presently the preferred starting medication for most (BMI of 25 or greater) patients with type 2 diabetes (1,2) who do not require insulin. When compared to other medications in trials, metformin is associated with essentially no hypoglycemia, less weight gain (often weight loss, in fact), and potentially a greater reduction in the risk for complications of diabetes. Due to a rare risk of lactic acidosis, it should be used cautiously in patients with impaired kidney function (estimate glomerular filtration rate of equal to or less than 45 ml/min/1.73 m2) (1).

It often causes diarrhea, abdominal cramping, and nausea/vomiting. These symptoms usually wane with time, and can be reduced by starting with a low dose (500mg once or twice a day, taken with food) and increasing the dose over several weeks (maximum of 2500 mg/day, split into two to three doses). Mrs. S. should be warned about these adverse effects and the importance of taking the medicines should be emphasized.

The glycemic control goal, depending on the guidelines used, is to aim for a HbA1c of 7% or less (1, 2), or a fasting plasma glucose of <115 mg/dL (1) or 70-130 mg/dL (2), or a plasma glucose two hours after a meal of <160 mg/dL (1) or <180 mg/dL (2).

In a low-resource setting such as Haiti, where more intensive monitoring is not possible, where the dangers of hypoglycemia are higher, and where the long-term benefits of ultra-aggressive glycemic control are unclear, a HbA1c goal of 7% is a reasonable target; Table 1 shows the correlation between HbA1c and the average sugar through the day. If HbA1c cannot be measured, a fasting plasma glucose can be substituted as a crude alternative (in which case the goal of a fasting plasma glucose <130 (mg/dL) would be the target); note that HbA1c is the preferred lab test to monitor long-term glycemic control whenever possible, and that fasting plasma glucose values can be skewed by prior meals, exercise, and infection. Because it is a long-term measure, HbA1c when avaiable should only be checked every three months (2).

Should Mrs. S. ever have low sugars or if there are difficulties in monitoring her sugars, more relaxed goals are reasonable to set, particularly when using agents that can cause hypoglycemia. If she cannot reach her glycemic target after a maximal dose of metformin for several months, a sulfonylurea can be added to her regimen.

Table 1. Estimated average blood glucose based on hemoglobin A1c percent