Module 1 Flashcards
Diabetes Prevention and Management
Requires engagement with:
policy makers politicians economists scientists the pharmaceutical industries
Type 1 Diabetes
previously known as Insulin Dependent Diabetes Mellitus or IDDM
autoimmune disease characterized by a lack of insulin production
commonly presents in children and young adults
requires insulin therapy to maintain life.
10% of the total burden
Scandinavian and Northern European countries having a relatively high incidence
Type 2 diabetes
Non-Insulin Dependent Diabetes or NIDDM
insulin resistance and a gradually decreasing amount of insulin from the pancreas
used to be thought of as a ‘late onset’, now children and many young people
benefit from insulin.
The number of people suffering from diabetes in 2016.
463 million
The global prevalence of diabetes among adults over 18 years in 2014
8.5%
WHO projects that diabetes will be the ____ leading cause of death in 2030.
7th
In 2016, an estimated______deaths globally were directly caused by diabetes.
1.6 million
Risk Factors for Type 2 Diabetes
Age over 45
Men , woman’s risk rises at menopause
Ethnicity (Native American
Australian Indigenous
African American
Hispanic
Pacific Islander
Asian )
Increased waist size in both men and women (80 cm for women and 94 cm for Caucasian men)
Babies exposed to intrauterine hyperglycemia
Family history
Physical inactivity
overweight (BMI 25-29 kg/m2) or obese (BMI 30+
History of gestational diabetes(7 times more likely)
Medication(steroids, some antipsychotic agents, thiazides, beta-blockers and statins)
Heavy cigarette smokers, (20+ a day)
BP = > 140/90 mmHg
History of cardiovascular disease
HDL-Cholesterol; <35 mg/dL (0.9 mmol/L) Triglycerides >250 mg/dL (2.8 mmol/L)
(PCOS)
Heavy drinking
a ‘Western diet’ that contains higher levels of sugar, saturated fats and red meat
The Basic Tests for Diabetes
Oral glucose tolerance test (OGTT)
Fasting plasma glucose test (FPG)
Glycated haemoglobin (HbA1c)> 6.5% (48 mmol/mol).
Random tests
Oral glucose tolerance test (OGTT)
2-hr PG ≥200 mg/dL (11.1 mmol/L) during OGTT (75-g)*anhydrous glucose
this test can be unpleasant
less accurate and harder to standardize
the patient needs to refrain from smoking
storage of samples over the two-hour period
Fasting plasma glucose test (FPG)
FPG ≥126 mg/dL (7.0 mmol/L)*
Fasting is defined as no caloric intake for ≥8 hours
Random tests
Random PG ≥200 mg/dL (11.1 mmol/L) In individuals with symptoms of hyperglycaemia or hyperglycemic crisis
In the absence of unequivocal hyperglycemia results
No clear clinical diagnosis?
repeat the same test on a different day
In the absence of unequivocal hyperglycemia results
Same test with same or similar results?
diagnosis confirmed
In the absence of unequivocal hyperglycemia results
Different tests above diagnostic threshold?
diagnosis confirmed
In the absence of unequivocal hyperglycemia results
*Discordant results from two separate tests?
Repeat the test with a result above diagnostic cut-point.
Diagnosing Type 1 Diabetes
polydipsia (excess thirst) polyuria (excessive urinating), fatigue, or weight loss due to an acute rise in glucose.
Diagnosis is by blood glucose testing rather than HbA1c
Diagnosing Gestational Diabetes
diagnosed in the 2nd or 3rd trimester, may or may not persist beyond her pregnancy
type 2 diabetes, persisting beyond her pregnancy.
no existing diagnosis of diabetes found to have diabetes in her first trimester of pregnancy (< 12 weeks gestation
Diagnosing Prediabetes
people with impaired fasting glucose (IFG) or glucose tolerance (IGT)
What is the difference between capillary and plasma glucose?
Fasting plasma glucose is higher than capillary plasma glucose by almost 12%
Impaired fasting glucose (IFG)/ prediabetic?
fasting glucose is between 108 and 126 mg/dl (6.0 and 6.9mmol/L)
impaired glucose tolerance (IGT)?
diagnostic criteria for IGT are that a blood test taken at the two-hour point of a glucose tolerance test is at least 140 mg/dL (7.8 mmol/L) and not more than 199 mg/dL (11 mmol/L).
The WHO defines screening as
process of identifying those individuals who are at sufficiently high risk of a specific disorder to warrant further investigation or direct action
Screening process
a screening strategy ( by risk factor, by criteria, by public place to promote self-refer
test sensitivity and specificity
sensitivity of the test
proportion of people with diabetes or prediabetes who test positive
A very sensitive test ( High sensitivity) is unlikely to miss someone who does have diabetes
specificity of a test
proportion of people who do not have diabetes and correctly test negative
A very specific test ( high specificity) is unlikely to suggest that someone who does not have diabetes tests positive
specificity Vs sensitivity
In reality, specificity is less important that sensitivity
all positive test followed up by full diagnostic testing
Principles and practice of screening for disease
10 screening criteria
1]important health problem
2]an accepted treatment for patients
3]Facilities should be available.
4]recognizable latent or early symptomatic stage
5]suitable test or examination
6]The test should be acceptable to the population
7]natural history adequately understood
8]agreed policy on whom to treat as patients
9]The cost of case-finding economically balanced
10]Case finding continuing process
The WHO says that diabetes is a major cause of
vision loss due to retinopathy
end-stage renal disease
cardiovascular events
lower extremity amputations
TEST2PREVENT
KNOW YOUR RISK OF TYPE 2 DIABETES
the test is based on the Finnish Diabetes Risk Score (FINDRISC)
Component
- age
- BMI
- waist circumference
- 30 mins of daily activity
- how often eat vege and fruits
- medication for BP
- Is blood glucose high?
- H/o family with DM?
A Diabetes Register
database or list of all the patients with diabetes in a practice or using a service
What type of information does A Diabetes Register collect?
patient history, address, date of DM diagnosis
vital signs
blood and other test results
prescribing decisions
notes on patient’s reactions to any changes
observations during screening
observations during treatment
Screening for Complications in People Living with Diabetes?
local practice - regional - national data - NHS Diabetic Eye Screening program
National Diabetic Registries
- to monitor the impact of policy decisions on the prevalence of diabetes or change in morbidity
- not used to manage care
- developed from information from health services
correct screening interval for those who test negative for type 2 diabetes?
Screening can be performed using?
ADA suggests three years
NICE says 5 years
HbA1c, fasting plasma glucose or 2-hour plasma glucose
intermediate hyperglycaemia?
glycaemic levels between normal glucose tolerance and diabetes (sometimes referred to as non-diabetic hyperglycemia
What is Impaired Fasting glucose?
Impaired Fasting Hyperglycemia or glucose (IFG) is a state of higher than normal fasting blood (or plasma) glucose concentration, but lower than the diagnostic cut-off for diabetes.
What is Impaired Glucose Tolerance?
Impaired Glucose Tolerance (IGT) is a state of higher than normal blood (or plasma) glucose concentration 2 hours after 75 gram oral glucose load but less than the diagnostic cut-off for diabetes.
What is Non-diabetic hyperglycaemia?
People can be diagnosed with non-diabetic hyperglycaemia when their HbA1c is between 5.7–6.4% (39 – 46 mmol/mol.
What is the WHO definition of IFG?
- IFG: fasting plasma glucose >= 110 mg/dL (6.1 mmol/L) and < 126 mg/dL (7 mmol/L) per WHO 1999 criteria.
- ADA has chosen a lower cutoff of 100 mg/dL (5.6mmol/L)
Recommendations for overweight individuals by ADA?
at least 150 minutes of moderate activity a week, or 30 minutes five days a week.
activities such as walking, bike riding, or swimming
NICE recommends a minimum of 150 minutes of moderate-intensity activity per week which can be taken in bouts of 10 minutes or more
minimum recommendation by doing 75 minutes of vigorous-intensity activity spread across the week or by combining bouts of moderate and vigorous-intensity activity.
recommended that individuals include activities to increase muscle strength twice a week
Benefits of exercising for diabetes
increasing insulin sensitivity blood pressure improve cholesterol lose weight energy and sleep joints and flexibility exercise releases endorphins reduce stress levels improve their HbA1c go into remission.
anxious about exercise
too tiring,
harder to manage
worried about their blood sugar levels.
Exercising if you have diabetes complications
neuropathy or foot ulcers- avoid weight-bearing activity like jogging- do Chair-based exercises
Classification of Diabetes
- type 1 : slowly evolving immune mediated diabetes (LADA) ,onset of symptoms can be slow in children with type 1 and in adults with LADA
- type 2:insulin resistance and insulin deficiency
- type 3:
- caused by diseases of the exocrine pancreas or other endocrine disorders
- monogenic diabetes
- treatment induced diabetes
- gestational diabetes and neonatal diabetes
Diabetes Definition
a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both
Slowly evolving immune-mediated diabetes of adults
formerly called latent autoimmune diabetes of adults (LADA),
similar to slowly evolving type 1 in adults
has features of the metabolic syndrome,
single GAD antibody
greater beta cell function.
do not require insulin therapy at diagnosis
can be controlled initially with lifestyle and oral agents.
Ketone-prone type 2 diabetes
hybrid form
present with ketosis and insulin deficient,
do not require insulin
not immune-mediated
characterized by common episodes of ketosis.
Three criteria for Slowly evolving immune-mediated diabetes of adults?
- positivity for glutamic acid decarboxylase (GAD) autoantibodies
- age older that 35 years at diagnosis
- no need for insulin therapy in the first 6-12 months after diagnosis
What are some of the more common causes of secondary diabetes?
- damage or defect to the beta cells : chronic pancreatitis, pancreatic cancer, pancreatectomy, cystic fibrosis or hemochromatosis
- endocrinopathies relating to thyroid, pituitary or adrenal disease: impaired glucose tolerance and acromegaly
- Cushing’s Syndrome
- polycystic ovary syndrome (PCOS)
Monogenic Diabetes
- 1-2%
- caused by a single gene (mono) mutation.
two main forms
1] Maturity Onset Diabetes of the Young (MODY)
= collection of nine different gene mutations,
=all inheritable
=suspected with a strong multi-generational history of diabetes.
2] Neonatal Diabetes
= much rarer
= only form of diabetes to affect babies under 6 months of age
key features of neonatal diabetes
- caused by a change in a gene which affects insulin production.
- levels of blood glucose (sugar) in the body rise very high.
- diagnosed with diabetes under the age of 6 months,
- type 1 doesn’t affect anyone under 6 months
- 20% with have some developmental delay (eg muscle weakness, learning difficulties) and epilepsy.
two types
1] transient : resolves before the age of 12 months - recurs later during the teenage years - 50–60%
2] permanent : lasts forever and accounts for 40–50%
Treating neonatal diabetes
- 50% don’t need insulin
- with a tablet called Glibenclamide [Sulfonylurea]
- change in the KCNJ11 or ABCC8 gene and need higher doses
- improve the symptoms of developmental delay
- molecular genetic testing is essential
Treatment Induced Diabetes
steroids, thiazide diuretics, beta-blocker, some anti-psychotic medication, statins
Gestational Diabetes Risk Factors?
screening test?
- 2% and 70% of those affected by gestational diabetes go on to develop type 2 diabetes within 10 years.
- BMI >30 kg/m2
- a previous baby with macrosomia > 4.5 kg
- gestational diabetes in a previous pregnancy
- history of diabetes in a first degree relative
- ethnic group with a high prevalence
screening test for diabetes is offered between 24-28 weeks,
GDM complication
Neonatal
- excessive birth weight= shoulder dystocia, increased rate of cesarean section
- early (preterm) birth, respiratory distress syndrome
- hypoglycemia
- type 2 diabetes later in life
Maternal
- high blood pressure and preeclampsia
- future diabetes
most people with diabetes
(90%) have type 2 diabetes 5% have type 1 diabetes 1% have monogenic diabetes 1% have secondary diabetes 1% have treatment induced diabetes the rest fall into ‘other’ category
successful patient-centred diabetes care should be a subtle blend of:
using communication skills to empower people with diabetes
using best science generated by evidence from important clinical trials to inform key prescribing decisions
respecting patients’ ideas and concerns
‘PICO’ method
P= patient or population or problem
I= intervention or indicator. [include the use of a specific diagnostic test, treatment, adjunctive therapy, medication or the recommendation ]
C= comparison
O=outcome
ACE inhibitor ACE inhibitor
Vs ARB
ACEI = reduced all-cause mortality, CV mortality, and major CV events ,ARBs had no benefits on these outcomes
ACEIs should be considered as first-line therapy
5 Steps of Evidence-Based Medicine
1] ask clinical question 2] accquire best evidence 3] appraise the evidence 4] apply the evidence 5] assess your performance
What do you understand by the term “hierarchy of evidence”?
the concept that some types of studies are more reliable than others
- due to the numbers of patients
more reliable than a case report
Can you represent the hierarchy of evidence in a diagram?
pyramidal shape qualitatively integrates
In each ascending level, the amount of available evidence generally declines
increased quality of evidence and reduced risk of bias.
Confidence in causal relations increases at the upper levels.
Hierarchy of evidence level of EBM pyramid
from top to bottom 1] RCT 2] Cohort 3] Case-control 4] Cross-sessiona;, survey 5] case report, case study 6] Mechanistic studies 7] ideas, editorials, expert opinion
why Rosiglitazone withdraw?
Increase risk of CVS event
Cardiovascular Outcome Studies (CVOTs) Current Limitations
CARDIOVASCULAR EXPERT
EPIDEMIOLOGIST
HEAD OF RESEARCH
issues associated with Placebo-Controlled Design
Glycaemic equipoise: two opposing arms maintain and achieve similar glycemic levels
Comparison: Some drugs used have an adverse effect on CV events.
Ethical issues:
a systematic review process
This involves five major steps: 1] write review protocol for guideline 2] select relevant studies 3] assess quality 4] interpret result 5] synthesizing result
two types of bias in medical research.
Selection bias results from the way in which the study population is selected.
Ascertainment or information bias occurs due to measurement error or misclassification of subjects according to one or more variables.
level of evidence
HIGH[true effect lies close to that of the estimate] - Cochrane reviews
MODERATE
LOW
VERY LOW
second level of evidence- provided by at least one randomised controlled trial
Typical Questions to Ask when Assessing a Study:
Was this the best design
minimise bias
What methods of analysing results
Are there systematic reviews
three broad considerations When reading any research
Validity: Has the research been conducted in such a way as to minimise bias?
Results: What does the study show?
Relevance: What do the results mean for the patient or context in which a decision is being made?
Critical Appraisal Criteria
Does the paper describe the background to the study and ask a clear research question?
Are the aims of the study clearly stated?
Is the method section sufficiently clear and detailed to allow the research to be repeated by others?
Are the results clearly presented, with good use of appropriate graphics and statistical tests?
Are the sampling and recruitment methods and inclusion/exclusion criteria clearly stated?
Are the results relevant to your own practice population/practice setting?
Is the comparison with existing literature adequate?
Are the strengths and weaknesses of the study candidly and fully described?
Is the referencing adequate, with inclusion of relevant previous work and other sources?
Are potential conflicts of interest stated by the authors?
Is the funding source identified?
Is there a statement of ethics committee approval?
