Type 2 diabetes mellitus

Question 1

What is diabetes mellitus?

Answer 1

A condition where the blood glucose is above an internationally accepted level

Question 2

Usual clinical diagnosis of DM: blood

Answer 2

Blood

• glucose = or > 11.1 mmol/l + symptoms
• glucose = or > 11.1 mmol/l x 2
• HbA1c = or . 48 mmol/mol (6.5%)

Question 3

Reasons for using HbA1c test

Answer 3

Does not require the patient to fast before the test

Does not require multiple blood draws

Does not require a time commitment of several hours

Question 4

75g glucose tolerance test

Answer 4

Diabetes mellitus

• fasting plasma glucose =/ > 7mmol/L
• 2 hour plasma glucose =/ > 11.1 mmol/l

Impaired glucose tolerance
- 2 hour glucose between 7-11 mmol/L

Impaired fasting glucose
- fasting glucose between 6-6.9 mmol/L

Question 5

What is type 2 diabetes?

Answer 5

A common condition

Insulin resistance

Beta cells which cannot produce enough insulin to keep the blood glucose normal

Question 6

Islets in T2DM

Answer 6

A deficit in B-cells

Increased B-cell apoptosis

Extracellular amyloid deposits derived from IAPP

Question 7

Aetiology

Answer 7

Genetic
- polygenic

Fetal programming (epigenetic)

• maternal hyperglycaemia
• intrauterine growth retardation

Question 8

Other possible aetiological factors

Answer 8

Beta cell regression

Old age

Other pancreatic pathology

Change in the gut microbia

Glucotoxicity and lipotoxicity

Question 9

Epicardial fat

Answer 9

A strong risk factor for vascular disease

Between the heart and pericardium

Question 10

Ectopic fat produces

Answer 10

Free fatty acids

• insulin resistance
• atherogenic lipids

Cytokines

• insulin resistance
• inflammation

Procoagulant factors

Question 11

Prevalence of T2DM

Answer 11

UK prevalence 2017

• 4.6 million persons
• 12.3 million at risk

Question 12

Adult obesity in England

Answer 12

Risen from 15% in 1993 to 26% in 2016

Age group most likely yo be overweight or obese is 55-64

Prevalence of overweight and obesity
- above 70% among 45 upwards

Question 13

Prevention of diabetes

Answer 13

96% T2DM attributed to

• BMI > 23
• lack of exercise
• unhealthy diet

Question 14

Serious side effects/ morbidity

Answer 14

Hyperglycaemia

Dysregulation of lipid metabolism

High levels of proinflammatory cytokines

High levels of free radicals

Increased susceptibility to infections

Question 15

Maculopathy

Answer 15

Damage to the macula, often from fluid build up

Blood glucose too high for too long

Question 16

Cataract

Answer 16

Increased generation of polyols from glucose

1% reduction in HbA1c reduces cataract risk by 19%

Question 17

Glycolysation of connective tissue

Answer 17

Blood glucose too high for too long

e.g. cheiroarthropathy

Question 18

Bone in type 2 diabetes

Answer 18

Mechanically weaker

Increased fractures x2
- in spite of normal bone density

Question 19

Lipoprotein classes and inflammation

Answer 19

All the major classes impact inflammatory process that leads to atherosclerosis

Question 20

What to do with type 2 diabetes?

Answer 20

Prevent diabetes

Improve hyperglycaemia

Reduce the CV risk factors

Screen for complication and treat early

Question 21

Prevention/ treatment of type 2 diabetes

Answer 21

Lifestyle manouvres
- diet/ exercise/ smoking

Treatment of

• dyslipidaemias (statins)
• hypertension

Use of aspirin

Question 22

Screening to enable early treatment

Answer 22

Eyes

• retinal photography
• laser treatment when required

Kidneys

• measure urine albumin (EMU)
• control blood pressure
• ACE inhibitors and ARBs

Feet
- screen for neuropathy and vascular disease

Question 23

Pharmacological interventions

Answer 23

Reduce insulin resistance

Increase insulin production/ secretion

Provide insulin replacement

Question 24

Metabolic/ obesity surgery

Answer 24

Sleeve gastrectomy

Roux en Y bypass

Gastric band