Introduction To Patients With Diabetes

Question 1

What is diabetes mellitus

Answer 1

• “Diabetes is when blood glucose is too high (hyperglycaemia) and over years leads to damage of the small and large blood vessels causing premature death from cardiovascular diseases”

Question 2

What are the 2 types of diabetes

Answer 2

Type 1 and Type 2 Different aetiologies Similar complications

Question 3

Y is diabetes a major health concern

Answer 3

• 10% of the NHS budget 2014
• 1 in 4 develops kidney disease and is the single most common cause of ESRD in UK
• Leading cause of blindness of working age
• Most common cause of non traumatic lower limb amputation
• 15% life time risk of amputation
• 70% deaths due to cardiovascular disease (CAD and stroke)
• Life expectancy is reduced on average by 5 to 15 years in people with T1DM and 5 to 10 years with T2DM

Question 4

What has caused the type 2 diabetes epidemic.

Answer 4

Environment eg obesity not genetics

Question 5

Describe the pathophysioogy of diabetes

Answer 5

As blood glucose rises, the body sends a signal to the pancreas, which releases insulin
Acting as a key, insulin binds to a place on the cell wall (an insulin receptor), unlocking the cell so glucose can pass into it. There, most of the glucose is used for energy right away
So why does blood glucose rise?
Simply put….
•Inability to produce insulin due to beta cell failure and / or
•Insulin production adequate but insulin resistance prevents insulin working effectively and invariably linked to obesity
•Knowing that these are the 2 principle mechanisms helps understand how diabetes is treated

Question 6

What s the cause of type 1 diabetes

Answer 6

Beta Cells: secrete insulin… Autoantibodies made are directed against the beta cells and insulin producing cells destroyed
Often genetic - antibodies attack beta cell 0 gradually knock it out

Question 7

Type 2 diabetes

Answer 7

Your pancreas may not produce enough insulin (insulin deficiency)
Or your cells do not use insulin properly. The insulin cannot fully “unlock” the cells to allow glucose to enter (insulin resistance).

Question 8

How does diabetes mellitus present

Answer 8

• Typical symptoms of hyperglycaemia
• Symptoms of inadequate energy utilisation
• Polyuria, polydipsia, blurring of vision, urogenital infections - thrush
• Tiredness, weakness, lethargy, weight loss (If you haven’t got glucose - breakdown of fat )
• The severity of these symptoms will depend upon the rate of rise of blood glucose as well as the absolute levels of glucose achieved

Question 9

How is diabetes diagnosed

Answer 9

• You need laboratory confirmation
• Fasting glucose
• Oral Glucose tolerance test
• HbA1c - assessment of how much glucose in circulation attaches to RBCs- >6.5% 1 (or 2 if asyptomatic) most commonly used test
• You need symptoms and 1 abnormal test or 2 if asymptomatic
All acceptable but need to recognise that patients may be positive on 1 or 2 tests but not all three

Question 10

What is type 1 diabetes

Answer 10

• Absolute insulin lack secondary to autoimmune
destruction of β cells
• 250 000 people in UK (0.4% of population)
• 90% diagnosed under 30 years of age
• But can occur at any age
• Prevalence doubled every 20 years since 1945
• Aetiology not fully understood
• Twin studies

Question 11

Describe the presentation of type 1 diabetes

Answer 11

Symptoms
• Rapid onset (usually weeks) weight loss, polyuria and polydipsia
• Late presentation there may be vomiting due to ketoacidosis
• Patient
• Usually, but not always, young < 30 years
• Elevated venous plasma glucose
• Presence of ketones (breakdown products of fats)
- check blood glucose, also check blood ketone or urine ketone, if this high, likely to be diabetes
If type1 diagnosed as type 2 - given oral prep - they die (other way round does not cause as harm)

Question 12

Describe the treatment of type 1 diabetes

Answer 12

Treatment of type 1 diabetes is exogenous insulin – this cannot
wait
• Given by subcutaneous injection several times per day
Specialist field as the amounts and type of insulin required are dependent upon many factors

Question 13

What is type 2 diabetes

Answer 13

• 4-5 million people in UK (~4% of population)
• 90% are overweight or obese
• Prevalence increasing dramatically
• Many asymptomatic and diagnosis made at routine health checks
• Most are over 40 years of age
• Often managed by diet and tablets
• However, increasing seen in younger people and children

Question 14

Why does typ 2 diabetes develop

Answer 14

Many theories but difficult to ignore obesity epidemic

Question 15

What causes insulin resistance to develop

Answer 15

• Obesity – in particular central obesity
• Accounts for 85% of the risk for developing diabetes
• Muscle and liver fat deposition
• Elevated circulating Free fatty acids
• Physical inactivity
• Genetic influences
Itraabdominal fat interferes with sensitivity of cells to insulin and also insulin release

Question 16

What happens post variation surges or very low calorie diets

Answer 16

• Within 7 days fasting blood glucose normalises in Type 2 diabetes BEFORE any weight loss
• There is a massive fall in liver fat content and return of NORMAL insulin sensitivity
• This change is in step with decreasing pancreatic fat content NORMALISING β cell function
• Over 8 weeks first phase insulin release and maximal rates of insulin release return to NORMAL
• Type 2 diabetes can be considered as a potential reversible metabolic disorder precipitated CHRONIC intraorgan fat

Question 17

What are the symptoms of type 2 diabetes

Answer 17

Symptoms
Very variable as slower rise in blood glucose
May have polyuria, polydipsia, weight loss
Can be difficult to elicit from patient
No urinary ketones May be asymptomatic
Diagnosis made by routine screen

• Patient
Usually, though not universally, older
Most are over 40 years of age Increasing seen in younger people and children
90% are overweight or obese

Question 18

How to manage type 2 diabetes

Answer 18

Weight loss
Drugs to promote weight loss
Programs to give lifestyle coaching
Excercise - what type, how much

Question 19

How is type 2 diabetes treated?

Answer 19

• Type 2
• Lifestyle • Non-insulin therapies
Biguanides, sulphonylureas, thiazolidinediones, GLP1 analogues. DPP4 inhibitors, α-Glucosidase inhibitors, SGLT2s
• Insulin

• Require patient education and ability to monitor
results of therapy
• Look for other vascular risk factors – BP, lipids, smoking, exercise, diet
• Surveillance for chronic complications

Question 20

What are the acute complications of diabetes

Answer 20

Acute complications of hyperglycaemia 
• Massive metabolic decompensation 
Diabetic ketoacidosis in type 1 Hyperosmolar non-ketotic syndrome in type 2
Multiple causes of the above complications
• Acute complications of hypoglycaemia 
• Coma 
Brain needs glucose
Caused by hypoglycaemic therapy

Question 21

What are the chronic complications of diabetes

Answer 21

• Chronic complications
• Macrovascular or large vessel disease
Cerebrovascular, cardiovascular, peripheral vascular disease
Stroke, heart attack, intermittent claudication,gangrene

• Microvascular or capillary disease Retinopathy, nephropathy, neuropathy
Blindness, need for renal replacement therapy, erectile dysfunction, foot ulceration, diarrhoea, constipation, painful peripheral neuropathy

Question 22

What is metabolic syndrome

Answer 22

• Metabolic syndrome is a cluster of the most dangerous risk factors associated with cardiovascular disease: diabetes and raised fasting plasma glucose, abdominal obesity, high cholesterol and BP
• Together they confer a marked increase in cardiovascular risk
• For a person to have the metabolic syndrome:
• Waist measurement > 94cm for men and > 80 cm for women
• Plus any 2 of the following:
• Raised triglyceride > 1.7mmol/l or t treatment
• Reduced HDL cholesterol <1.0 for men and 1.2mmol/l for women
• Raised blood blood > 135/85 or treatment
• Or raised fasting blood glucose > 5.6mmol/l or treated diabetes

Question 23

What causes metabolic syndrome

Answer 23

Insulin resistance and central obesity, genetics, physical inactivity, ageing