Key practice points: Flashcards
Key practice points:
The incidence of II DM in younger adults and adolescents in NZ is increasing; people of Māori, Pacific and South-Asian ethnicities are particularly at risk
People with early onset II DM have increased morbidity and mortality compared to those with a later onset or to those of similar age with I DM
Preventing, or delaying, onset of II DM is paramount to reducing the burden of diabetes complications; this may be possible with careful management
Test HbA1c levels in pts at high risk, regardless of their age, so that patients and their whānau/family can be supported to make lifestyle changes before or soon after they develop diabetes
The management of II DM in younger people is essentially the same as for older people, i.e. lifestyle interventions and metformin first-line, but treatments need to be more assertive, e.g. pharmacological treatment escalated sooner
A high degree of pt and whānau/family engagement is crucial to maximise the benefits of lifestyle changes and ensure that medicines are taken as prescribed
Early onset II DM: increasingly common and associated with higher risks
Approximately 5% of the total population has II DM
The prevalence of diabetes is highest in older age groups, reaching approximately 15 – 20% in people aged over 65 years;
However, prevalence in people aged 30 – 39 years has nearly doubled between 2006 and 2018
The prevalence is approximately 2-3 x higher in adults aged 25 – 39 years of Māori and Pacific ethnicity compared to those of European ethnicity
Many young people are at high risk of developing II DM
People with HbA1c levels of 41 – 49 mmol/mol are classified as having “pre-diabetes”,
- which is associated with an increased risk of CVD
- and progression to II DM.
16% of the population aged under 45 years had pre-diabetes.
It is estimated that in the Auckland region, over 40% of people of Māori, Pacific or Indian ethnicity aged 35 – 39 years have pre-diabetes
Early onset results in worse health outcomes
Younger people diagnosed with II DM before the age of 40 years, have a higher risk of:
- early mortality,
- CVD
- CRD and
- retinopathy than older adults with II DM or people with I DM at a similar age.
This is largely because:
- people diagnosed younger have diabetes for longer and are therefore exposed to more risk
- glycaemic control tends to be worse
- younger people are more likely to have sporadic contact with healthcare services
Test people at high risk
HbA1c should be tested in people:
- at high risk of II DM
- of any age
to aid early detection and therefore reduce their risk of future CV and renal complications.
As II DM is not necessarily associated with any symptoms, patients may not even recognise that they are at risk.
Identifying people at elevated risk
MOH guidelines recommend HbA1c testing in adults (age > 18 years) with any of the following risk factors:
A BMI of ≥ 27 kg/m2 for people of Māori, Pacific or South Asian ethnicities,
or ≥ 30 kg/m2 for people of other ethnicities*
A first-degree relative who developed type 2 diabetes at an early age, e.g. < 40 years
Long-term use of oral corticosteroids
Females with a personal history of gestational diabetes
Females with polycystic ovary syndrome
Severe mental illness, particularly those on long-term antipsychotic treatment
Known IHD, cerebrovascular or PVD
A specific opportunity to incorporate HbA1c testing into routine practice is the cardiovascular risk assessment; the age at which to start assessments is now recommended as:
45 years for males and 55 years for females with no known risk factors
30 years for males and 40 years for females of Māori, Pacific or South-Asian ethnicity
35 years for males and 45 years for females with known cardiovascular risk factors or at high risk of developing diabetes
25 years for people with severe mental illness
