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Understanding Type 2 Diabetes 1 October .10.00am . Judy Downey RGN BSc hons Independent Diabetes Nurse Consultant AssociateLecturer New Bucks University Former Committee Member PrimaryCare Diabetes Society @DowneyJude2757 @Lwnurses #LWN #LearnWithNurses Using Medall To get slides To get certificateMedall.org Live chat for any problems getting certificates/slidesClosed FB group & Page What are we going to cover? • Classification of diabetes • Diagnosing type 2 diabetes • Non-diabetic hyperglycaemia • HbA1c targets • The annual review • The importance of lifestyle change • Assessing CVD risk Classification of diabetes • Type 1. An auto-immune condition in which beta cells produce no or very little insulin. Usually occurs in young people. Less than 10% of diabetes population • Type 2. Linked strongly to lifestyle issues such as obesity and consumption of large amounts of highly processed foods. Family history common. Insulin resistance stops insulin from doing it’s job! IR precedes T2D by many years. 90% of diabetes population. Can be diagnosed in teenagers!!! Less common types of Diabetes • LADA – Latent Auto-Immune Diabetes in Adults • MODY – Maturity Onset Diabetes of the Young • Gestational – strong link to obesity and type 2 diabetes • Type 3 – studies ongoing to establish possible link between type 2 diabetes and Alzheimers • Type 3c is linked to conditions, where pancreas is not producing sufficient insulin , such as – pancreatitis, pancreatic cancer, cystic fibrosis, haemachromatosisMODIFIABLE RISK FACTORS Some health habits and medical conditions related to lifestyle will increase risk of developing type 2 diabetes, including:  Being overweight, especially large waist circumference  Sedentary lifestyle  Smoking  Diet containing large amounts of carbohydrates and sugar  Dyslipidaemia  Non-diabetic hyperglycaemia NON MODIFIABLE RISK FACTORS  Race or ethnicity: Afro-Caribbean and South Asians have a higher incidence  Family history of diabetes  Risk increases with age  Women: Previous Gestational DiabetesLots of terms used to describe Pre- Diabetes •Borderline diabetes •Impaired Fasting Glucose (IFG) •Impaired Glucose T olerance (IGT) •Impaired Glucose Regulation (IGR) •Non-diabetic hyperglycaemiaCertain mental health conditions are also a risk factor for type 2 diabetes, these include: •Schizophrenia •Bipolar disorder •DepressionKeeping glucose levels steady • What does the liver produce? Glycogen • What does the pancreas produce? Insulin =HomeostasisIn type 2 diabetes, the cells can’t utilise glucose properly. The glucose builds up in the bloodstream. In insulin resistance, the beta cells still make insulin, but cells don’t use it or respond to it as they should. After a number of years, especially in poorly controlled diabetes, the beta cells eventually produce too little insulin Diagnosing Diabetes • Fasting >7.0mmol/l • Random >11.1mmol/l • HbA1c >48mmol/mol • OGTT 0hrs <7.0mmol/l - 2hrs >11.1mmol/l (7.8mmol/L in pregnancy) Report of a WHO/IDF Consultation. http://whqlibdoc.who.int/publications/2006/9241594934_eng.pdf Case History. Mike age 55 • Mike has come to see you because he is worried that he is at risk of diabetes • What would you want to know? • What would you need to do in this consultation?Blood glucose test results • Mike’s HbA1c is 44mmol/mmol • FBG: 6.8mmol/l HbA1c 42-47 mmol/mol indicative of Non diabetic Hyperglycaemia Other results from Mike • BP is 142/89 • BMI is 36.2 • Waist measurement is 44” (112cm) • He works as a sales rep with a large territory • He smokes 10 cigarettes a day • He drinks 6u/night Other results • Total cholesterol 6.3mmol/L; HDL-C 0.9mmol/L • Triglycerides 2.2mmol/L • Fbc, U&Es, LFTs, TFTs all normal • eGFR 73ml/min What is this pointing to? What might be plan of action? Introduction to the Metabolic Syndrome At least 3 of the 5 following criteria must be met to diagnose a person with metabolic syndrome: •Abdominal obesity: waist circumference of ≥102 cm in men and ≥88 cm in women •Hypertriglyceridemia: ≥150 mg/dl (1.695 mmol/L) •Low HDL-C:1.04 mmol/dL in men and < 1.30 mmol/dL) in women •High blood pressure (BP): >130/85 mmHg •High fasting glucose: >6mmol/L The Annual Review • HbA1c • B/P • Lipids • Retinal screening • EGfr and ACR • Foot check • Weight and waist circumference • Smoking status Annual review Surveillance for long term complications of type 2 diabetes • Cardiovascular Disease • Peripheral Vascular Disease • Retinopathy • Nephropathy • Neuropathy Landmark studies such as UKPDS (1998) and ADVANCE (2009) have shown that improving glycaemic control reduces risk of long term complications, particularly microvascular ones.QRisk score? 6 months later • Mike initially improved his diet, lost weight and became more active. • Had not wanted to take any therapies at that point. • As time went on, however, he became demotivated and the weight crept back; he finds it hard to fit in any exercise now • He has recently been feeling tired and an FBG was 7.8mmol/L • His latest HbA1c is 60mmol/mol. HbA1c 48mmol/l or above diagnostic of diabetes Glycaemic control • How important is it? • Is it as important for all patient groups? • What’s the legacy effect? • What is ‘good’ control? ADA/EASD position statement: Intensiveness of glucose lowering should be individualised Patient/disease features More stringent HbA 1c 7% Less stringent Risks potentially associated with hypoglycaemia Low High Disease duration Newly diagnosed Long-standing Usually not Life expectancy modifiable Long Short Important comorbidities Absent Few/mild Severe Established vascular complications Absent Few/mild Severe Patient attitude and Highly motivated, adherent, Less motivated, Potentially expected treatment efforts Excellent self-care capacitieson-adherent, poor self-care modifiable capacities Resources and support system Readily available Limited ADA=American Diabetes Association; EASD=European Association for the Study of Diabetes. Inzucchi SE et al (2015) Diabetes Care 38: 140–9 Mike 3 months after diagnosis • Diagnosed T2DM • Diet & lifestyle changes ongoing, he says • Latest HbA1C after anoth3/12 is 56mmol/mol • BP 146/92 TC 5.7, HDL 1.0, LDL 3.6 Mike • Reinforce lifestyle messages • Suggest he signs up for the low carb program • Commence Metformin, titrate to 1G bd. • Commence ACE or ARB for raised B/P (should be 130/80) • Commence Atorva 20 mg for raised cholesterol (should be below 4 mmol/L) • Review in 3 months NB If he truly adopts low carb lifestyle he may reverse his diabetes. Give hHOPE!SUGAR EQUIVALENT Resources • Phcuk.org – resources – sugar infographics • Trend-uk.org – resources • Diabetes.org.uk – professionals – information prescriptions • https://www.lowcarbprogram.com/ • https://diabetesonthenet.com/resources/ • www.gpnotebookeducation.com