Diabetes Flashcards
What are the different types of diabetes?
- Type 1
- Type 2
- Gestational diabetes
- Steroid induced diabetes usually resolves once finished steroid treatment
- Type 3C rare, caused by pancreatic conditions such as pancreatitis, pancreatic cancer
- Maturity onset diabetes of the young (MODY) rare condition, gene mutation
What is required for a clinical diagnosis of diabetes?
- HbA1c over 48mmol/mol or over glucose attached to haemoglobin, gives an idea of average blood sugar over past 3 months due to RBC half-life of 3 months not used with children, anaemics and pregnant women
- Random plasma venous glucose < 11.1mmol/l
- Fasting glucose (usually overnight) > 7.0mmol/l
- Plasma glucose >111mmol/l at 2 hours after a 75g oral glucose tolerance test
What are the symptoms of diabetes?
- Increased thirst (polydipsia) high blood sugars causes the body to want to excrete glucose, causing more urine output dehydration increased thirst
- Frequent urination (polyuria) attempting to excrete glucose
- Weight loss calories being lost through excretion
- Extreme tiredness brain not receiving glucose
- Genital itching fungus thrive in warm sugary environment
- Blurred vision – linked to diabetic retinopathy
- Poor healing
- May not present any symptoms
Symptoms generally more rapid onset in type 1 diabetes
What is type 1 diabetes?
Autoimmune disease
No insulin produced so treated by insulin and diet
Diagnosed earlier than T2
Symptoms visible in children – can be quite dramatic and cause the child to become very unwell
What is type 2 diabetes?
Characterised by insulin resistance and insufficient pancreatic insulin production
Usually treated by lifestyle and sometimes oral medications of injectable therapies including insulin
Estimated over 1 million people undiagnosed often doesn’t present symptoms
90% of adults with diabetes have type 2
Type 2 more common in people of African, African-Caribbean and South Asian origin
Costs NHS £10 billion per year (2022)
What is gestational diabetes?
Diabetes during pregnancy, occurs usually between 24-28 weeks.
Affects 4/5% of women
Increases risk of developing type 2 diabetes later in life
Increases risk of gestational diabetes is subsequent pregnancies
Associated with overweight and obese people
Common in those with PCOS
All women screened for it when pregnant
Blood sugars closely monitored
What is prediabetes?
What is the clinical presentation?
Risk factor for developing T2D
Risk questionnaire such as Diabetes UK or QDiabetes will indicate risk and if they should go to see their GP for a blood test
HbA1c 42-47mmol/mol
Fasting plasma glucose 5.5-6.9mmol/l
Oral glucose tolerance test 2-hour post 75g glucose load >7.8-11.1mmol/l
What is the oral glucose tolerance test?
Where people fast and have 75g of carbohydrate, blood glucose levels measured and monitored to see how the body is handling the glucose.
Used in pregnancy
What is the healthy blood glucose levels?
4-7mmol/l
What is the cause of type 1 diabetes?
Autoimmune response attacks B cells cause unclear, possibly triggered by a virus
Genes and gut microbiome may play a role but complicated
What is the cause of type 2 diabetes?
Linked with metabolic syndrome
Associated with excess weight, waist circumference higher levels of visceral fat which impairs insulin sensitivity
Family history
Ethnic origin
Not causes by eating sweets, stress or contagion
What are some other causes of diabetes?
- Steroids
- Haemochromatosis 3C
- Polycystic ovary syndrome
- Abnormal levels of growth hormones
Can symptoms of diabetes be reversed?
Yes, with good management of blood glucose levels, most symptoms can be reversed.
Does depend on severity of diabetes, and length of time gone untreated.
What are some long-term macrovascular complications of diabetes?
Who is more at risk of these complications?
At all ages mortality rates are higher in people with diabetes than those without.
Macrovascular complications:
- Cardiovascular disease
- Stroke
- Peripheral vascular disease
2-5 times higher in patients with diabetes
Blood vessels become damaged, hardening and narrowing of vessel walls from higher levels of glucose in blood. More likely for clots to form
Risk factors:
- Smoking blood vessel damage
- Dyslipidaemia high lipid levels in blood
- Hypertension
- Hyperglycaemia
What are some long-term microvascular complications of diabetes?
Diabetes is the most common cause of blindness, amputation and end stage kidney disease
Diabetic nephropathy
- A major cause of established renal failure
- Microalbuminuria, proteinuria, hypertension
- Screened for by checking for protein in urine
- Hypertension is a risk factor
Diabetic retinopathy
- Strongly related to hyperglycaemia
- Build-up of excess sugar can damage blood vessels in the eyes
- Annual retinal screening
Diabetic neuropathy
- Strongly related to hyperglycaemia
- Damage of periphery nerve damage
- E.g.to feet where they don’t feel pain when damage occurs, the damage can the develop and may lead to needing an amputation
- Feet checks at routine diabetes appointments
Discuss some research that explored complication development
UKPDS (1998)
- 5000 diabetes patients over 20 years
- Complications that were previously considered inevitable can be reduced by improving blood sugar and blood pressure control
DCCT trial
- Type 1 diabetic patients followed for 6 and a half years
- Intensive therapy delayed the onset and slowed the progression of complications such as retinopathy, nephropathy and neuropathy.
What are the diabetic treatment?
Reduce the risk of developing long-term complication symptom management
Maintain near-normal control of blood glucose levels
- 4-7mmol/l
- HbA1c <48mmol/mol (desirable)
- Blood pressure <140/90mmHg
- Serum total cholesterol <4mmol/l
Improve quality of life
Individualised care each patient will have different goals which are achievable for them, depending on many factors such as stage of life
What is the limitation of using a self-monitoring blood glucose test?
Only gives a reading for BG in that moment, doesn’t give a larger picture of what is going on
HbA1c is more accurate as it gives an overview of BG levels on average from the past 3 months
What is the dietary advice for those with type 2 diabetes?
- Providing individualised and on-going nutritional advice dietary patterns to create the wanted outcome
- Healthy eating
- If overweight, set a target weight loss of 5-10% (80-90% of those with T2D are at least overweight)
- Advice should be sensitive to a person’s needs, culture, willingness to change and quality of life
- Encourage high fibre low GI sources of CHO
- Include low fat dairy products and oily fish
- Control intake of saturated fat and trans fatty acids
NICE
What is the dietary advice for glycaemic control for those with type 2 diabetes?
- Prioritise sustained weight loss of at least 5% in overweight people by reducing caloric intake and increasing energy expenditure
- Aim for Mediterranean diet or equivalent health eating pattern
- Offer individualised education to support people to identify and quantify their dietary carbohydrate intake, encourage low GI food and consider reducing total amount of carbohydrates
- Aim for at least 150 minutes of moderate to vigorous activity over at least 3 days
Dyson et al, 2018
What is the dietary advice for CVD risk reduction for those with type 2 diabetes?
- Dietary patterns specifically Mediterranean and DASH style diets are recommended
- Decrease salt intake <6g/day
- Eat 2 portions of oily fish each week
- Eat more wholegrains, fruit and vegetable, fish, nuts, legumes and pulses
- Consume less red and processed meat, refined carbohydrates and sugar-sweetened beverages
- Replace saturated fats with unsaturated fats, and limit intake of trans-fatty acids
- Limit alcohol intake to <14units/week
- Aim for modest weight loss of at least 5% in overweight individuals
- Aim for at least 150 minutes per week of moderate to vigorous physical activity, over at least 3 days
- Products containing 2-3g of plant stanols and sterols per day can be recommended
Dyson et al. 2018
What is the view around low carbohydrate diets?
What are the recommendations?
Recommendations:
- A low CHO diet can be recommended as an effective short-term option of up to 6 months for improving glycaemic control and triglycerides
- Should include wholegrain, high fibre, fruit and vegetables and limit saturated fats
- Weight management remains the primary goal for improving glycaemic control and reducing CVD risk
- People supported with changing medications along with changes with diet
- Less than 130g/day
SACN 2021
‘Lower carb diets for adults with type 2 diabetes’
- Benefits to HbA1c
- Beyond 6 months, no evidence any better than other diets
Views:
- People find it hard to commit to long term
- Carb intake usually higher than what is prescribed
- Too low can risk not getting enough fibre
- Being by cutting down sugary processed foods
What other factors may affect blood glucose levels?
Illness
- Causes metabolic stress and raise in blood glucose levels that can lead to ketoacidosis. Insulin or tablet must continue together with easily taken sources of carbohydrates
- If a patient is ill, more glucose is released into the bloodstream as part of their defence mechanism
- Vomiting and diarrhoea can affect food absorption which can alter BGLs
- Dehydration diabetic ketoacidosis
Alcohol
- Can raise BGLs short term
- If on insulin/ Gliclazide can cause hypos later may be advised to keep and eye on BGL and/or have a snack after
- Some alcohol high in sugar e.g. cocktails, liqueurs
Exercise
- Beneficial for health but can lower BGLs
What is diabetes remission?
Where a patient can reduce their HbA1c below 48mmol/mol and keep it there for 6 months without the need for medications.
Not cured just well-managed, much reduced risk of complications
Can relapse with weight gains and/or higher glucose diet
Still encouraged to attend relevant appointments
Can be achieved after bariatric surgery 70-85% of patients went into remission after 2 years
Benefits:
- Better quality of life
- Reduced need for diabetes medications
- Better blood glucose control
What was the diabetes remission clinical trial?
Low calorie, 850kcal, weight management programme
Type 2 diabetics with a diagnosis within the past 5 years, age between 20-65, all overweight or obese
Diabetes medication stopped
Meal replacements
Occurred for 12-20 weeks
Healthy foods gradually reintroduced
Advices on weight maintenance and healthy eating for the remainder of the 12 months period
Findings:
- 1 year 46% in remission
- 2 years 36% in remission
Remission closely linked to weight loss – 64% of those who lost more than 10kg were in remission after two years
High dropout rate 30%
A lot of variation
Going to run for 5 years, still on going.
Direct trial, funded by diabetes UK.
Sample size 280
What are the Dyson (2018) guidelines for weight management and remission of type 2 diabetes
For overweight or obese people with type 2 diabetes
- Aim for at least 15kg weight loss as soon as possible after diagnosis
- Improve glycaemic control and CVD risk. Aim for at least 5% weight loss achieved by reducing energy intake and increasing energy expenditure
Adopt an individualised approach which may include dietary, physical activity, surgical and medical strategies that are recommended for people without diabetes
What affect does bariatric surgery have on type 2 diabetes?
70-85% of patients went into diabetes remission after 2 years
Easy way to achieve weight loss
Causes the body to use insulin more efficiently and effectively
People feel full more quickly
Change gut hormone
Increase amount of bile acids which can increase insulin sensitivity
NICE criteria
- For those with T2D BMI >35kg/m2
What is structured diabetes education?
‘Offer structured education to adults with type 2 diabetes and their family members or carers at the time of diagnosis with annual reinforcement and review. Explain to people that structured education is an integral part of diabetes care’
NICE
Diabetes education courses:
- Significantly improve long-term glycaemic control
- Reduce the onset of complications
- Significantly improve the quality of life and self-management skills
- Are cost effective
Diabetes UK
Key messages:
- Self-management
- Lifestyle
- Knowing your numbers and targets
- Healthy eating
- Get moving
- Lose weight if needed
- Signpost to resources
What is the ‘Healthier You’ NHS diabetes prevention programme?
Free programme delivered in 13 sessions over 9 months
Designed for those identified at high risk
For those who have HbA1c between 42-47 mmol/mol
Face-to-face or digital delivery
National coverage
Average weight loss so far 3.3.kg
Highly cost effective
7% in reduction being diagnosed with diabetes
How can type 2 diabetes be prevented?
- Aim for 5% weight loss in those at risk
- Increase fibre
- Increase physical activity
- Healthy dietary patterns e.g. Mediterranean diet, dash diet, moderate carbohydrate
- Reduce total and saturated fat intake
- Restrict energy intake
What is the approach toward paediatric diabetes?
- General principles of good glycaemic control as the same with adults should be monitored by a paediatric diabetes dietitian
Need to consider - Growth (increasing energy and nutrient need with time)
- Variable levels of physical activity
- Changing food likes and fluctuating meals patterns
- The psychological welfare of child eating disorder risk
- Parenteral anxiety
What dietary changes may be required when starting insulin?
Carbohydrate counting
- Insulin dose will need to be adjusted according to the carbohydrate content of what you are planning to eat
- Only needed for basal-bolus insulin regime
- Carbohydrate contents can be found on nutritional labels, references books, websites, apps
Exchange system
- All foods are categorised as either CHO, meat (or substitute) or fat
- One serving of carbohydrate can be exchanged for any other carbohydrate as long as in same amount
Fibre content
- When a serving of food has more than 5g of fibre, subtract the grams of fibre from the grams of CHO to calculate insulin dose
- Fibre slows the body’s absorption of carbohydrate so less insulin is required to manage blood sugar levels
What is a hypo?
How can they be managed?
Hypoglycaemia is when blood sugar levels are below 4mmol/l
Causes
- Missing or delaying a meal or snack
- Not having enough carbohydrate at last meal
- Doing a lot of exercises without having extra carbohydrate or without reducing insulin dose
- Taking more insulin then needed
- Drinking alcohol on an empty stomach
Prevention
- Eat regular meals with starchy carbohydrate
- Plan ahead
- Eat an extra starchy carbohydrate snack or meal if more active
- Reduce insulin when exercising
- Check BG levels before and after activity or exercising
- Have a starchy snack before bed if drank alcohol
Treatment
- Oral administration of fast-acting glucose should be given with the blood glucose tested after 10-15 minutes
- Fasting acting glucose sources –> 5 dextrose tablets, 5 jelly babies, small glass of sugary drink, fruit juice, 2 tubes of glucose gel
