Endocrinology

Question 1

What is risk factors for type 2 diabetes

Answer 1

age over 45
family history (first-degree relatives)
overweight ( BMI >27)
RACE (australia aboriginals, VMI>22, pacific islander)
previous ABNORMAL fasting glucose
gestational diabetes
hypertension
polycystic ovaries

Question 2

METABOLIC SYNDROME

Answer 2

Elevated waist circumference
Generally >80cm for women(88cm for European/morth American women), >90 cm for men ( >102 for wuropean/north American men)
Elevated triglyceride levels (or drug treatment for elevated triglycerides)
≥1.7 mmol/L
Reduced HDL-C (or drug treatment for reduced HDL-C) 5.5 mmol/L
The MetSy is important because it identifies patients at increased risk of cardiovascular disease (CVD), diabetes and chronic kidney disease (CKD). The risk of having CVD, diabetes and CKD among people with the MetSy is 2–3 times that of people without the condition.5 It also increases the risk of complications in those with CVD and diabetes. Overall meta-analysis of studies suggests that there is a 1.6–fold increase in mortality in patients with the MetSy compared to those without it.

Question 3

management of metabolic syndrome

Answer 3

Management of metabolic syndrome
• The mainstays of treatment are lifestyle interventions to address central obesity and insulin resistance.
• Weight loss interventions based on caloric restriction, increased physical activity and behaviour modification
• These may include general advice such as reducing portion size and high energy foods, as well as a dietary program to create a 2 500 kilojoule energy deficit – usually designed by a dietician. The goal is to achieve a 5–10% reduction in weight.
• In the presence of the MetSy, increased emphasis should be placed on at least 30 minutes of aerobic activity and resistance training, especially in the elderly and in those who have comorbid depression.
• The next step is to consider medications and other conditions that may contribute to the risk of central obesity and insulin resistance. Foremost among the medications are psychotropic medications, notably the newer antipsychotic agents. Long term use of antidepressants, including selective serotonin reuptake inhibitors has also been associated with increased risk of the MetSy. Other medications that may contribute to weight gain include some anticonvulsants and beta-blockers (notably propranolol).
• Polycystic ovary syndrome (PCOS) and sleep apnoea require appropriate management if these are present.
• There are unfortunately no medications currently licensed for use in Australia to specifically reduce insulin resistance in patients with the MetSy. Metformin and the thiazolidinediones (or ‘glitazones’) may reduce glucose and triglyceride levels. However, their role in treating the MetSy is still controversial and neither is approved for this purpose in Australia (except in the treatment of PCOS). Furthermore, metformin was found to be inferior to lifestyle interventions in the United States Diabetes Prevention Program Outcome trial and its long term follow up
• Thus, drug therapy needs to currently focus on medications to address each of the physiological factors separately – blood pressure, lipids and glycaemia. Careful monitoring is required, however, as there is a risk that use of statins may reduce physical activity (through reduced exercise tolerance and muscle pain) and contribute to weight gain and insulin resistance
• Bariatric surgery may need to be considered to achieve sufficient weight loss, especially in patients with a body mass index greater than 35.

Question 4

BSL control

Answer 4

BEFORE MEALS 2 HOURS AFTER MEALS
IDEAL 4 – 6 mmol/l up to 8 mmol/l
FAIR 6 -8 mmol/l up to 10 mmol/l
POOR 8 or more 10 or more