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That's brilliant. Hi, everybody. Um, that's me, Judy Downey. Um, and you can see that I'm a diabetes nurse consultant. I also do a lot of teaching at universities. So welcome tonight, we're going to try and try and do what we can. It's maybe take notes. Normally, you don't need to when you've got slides to look at. But you are going to be getting these slides and there is a recording. So it's It's, uh, it's It's not the end of the world, but I'm trying to today just set the scene. I don't know how much diabetes work you've done or any training, but I'm basically starting at the beginning, um, to set the scene, um, and then we can hopefully in the future, build on it because it's a very, um, complex, uh, topic. So we're in less than are. We can't cover that much. So, um, so this is what we're what we're going to do is obviously discuss what everyone knows about insulin to do with diabetes. We're going to talk about what actually the hormone insulin actually does and how it works. Um, and speaking about, like, Jen and glucagon as well, um and talk about. Why do people get diabetes in the first place? What's what's the mechanisms? Why, why does it happen in particular thinking of Type two diabetes? And then, obviously you can tell from the title that I've got a very strong interest in getting the right diagnosis because sometimes people are misdiagnosed. Um, and if they are misdiagnosed, then then diabetes management is not correct, and this could affect their future health. Their risk of getting long term complications of diabetes. So getting this correct diagnosis and to start off with I just had a quick look at what's going on, um, briefly in your country in the Ukraine regarding diabetes. So, um, I just wanted to set the scene. So of course, you've got all this trouble going on a social and humanitarian crisis, Um, and so that people who have chronic diseases and, of course, diabetes, is a long term chronic illness. I like to call it in illness rather than the disease, Um, and and it's it's affecting your health resources. I know that. I know that, um, you know, and one of the problems is that diabetes medications, including insulin, which is necessary for people with Type one diabetes in order to live. They can't live without insulin injections, and and there is actually getting to be a big shortage. So, um, it's essential, especially for people with type one diabetes to have daily ins and injections. And I had a look at the International Diabetes Federation there Atlas, and it said that in, um in in the Ukraine, there were 2,000,325 people who had Type two diabetes in 2021. So this is quite recent. So that's how many people are actually diagnosed with Type two diabetes already, and there could be more. And of course, there's going to be an equal number, if not even more than that, who have this, what we call prediabetes or non uh, non non diabetic hyper glycemia. In other words, those people are on their way to going to develop Type two diabetes unless action is taken. And so that actually gives a prevalence. You know, across the country of over 7% of people have type two diabetes. Now that used to be quite a lot lower, and and, um, you probably know one of the big causes of this, don't you? And it's actually the rise in obesity across across all cut all countries, Really, Um, which is that which is strongly linked with the with the increase in the number of people developing Type two diabetes with Type one diabetes, which generally happens in much younger people. But not always. That's another where place we can go wrong with the diagnosis. We can't automatically say that's because someone is 55 or 60. They can't possibly have Type one diabetes. They actually can. But mostly it's Children and young people that develop Type one diabetes, which is the autoimmune version of diabetes. So it's so it's some. It's not linked to lifestyle as such, unlike Type two diabetes. But in the Ukraine for Type one diabetes, there's around 6700 Children. Um, I don't know what happened there. My screen just went minute Lee small. I can hardly see it. Oh, your screen is sharing now, is it? Yes, it's sharing now. Oh, okay. It's just for me. It's gone. Absolutely minute. Minute, Lee Small. I can hardly read it. Uh, no, I'll be all right if I get very close to the screen. you know why? Because it's so small. So, um, let's move on. Um, just get rid of that high. Judy, it's Sharon. Doctor Raymond here. I'm sharing the slides, as Hannah was unable to. And you too. Can you tell me which slide you want to be on? Please? I've moved on from this. Um, yeah, it's just It's just Yeah, that's That's it. It's just gone extremely small. Okay, there's a slide here. Says what is diabetes? Do you want that one or do you want? Yes. Yeah. What is diabetes? Okay, that's what's showing. Now when I'm on the sixth of 42. So when you're ready, tell me to move to the next one, okay? All right. So So, actually, if you can go back to the previous slide because that's thrown me a bit because it's changed, it's looks and and and the previous one to that if you don't mind Sharon, that's it. So So we're just talking about what's happening in the Ukraine, and obviously it's not only medicines, but it's some deliveries. Pharmacy services. It's all been disruptive, and and it's resulting in these huge shortages not only of incident but also other supplies, like I said, and also where people want to measure their blood sugars. For example, blood glucose meters. They're in short supply. Um, and as as we've already said, without insulin, people with type one diabetes may not survive and may may get diabetic Keto acidosis. So if you'd like to next slide, please. So, um, because there's a disruption food distribution. A lot of people with diabetes need to eat regular meals three times a day because of the way the instant works and because of the way the therapies work. If they don't eat regularly, then they may be at serious risk of very low blood sugar, which is hypoglycemia. So obviously there's a bigger risk of that with at the moment, and we can't we we always have to mention people's mental health, because did you know that people diabetes have up to four times higher incidence of depression and anxiety compared to people who don't have diabetes and they have a high risk of suicide? So all of this stuff that's going on at the moment is all going to be contributing to that next one, please. So it you know, it's a serious what once someone is diagnosed with diabetes. Generally speaking, they do have diabetes for the rest of their lives, although in another session that I'm going to do, I will mention that some people with Type two diabetes can actually go into remission or reverse their diabetes. But on the whole, once you're diagnosed, you have diabetes for the rest of your life, and you certainly do. If you have Type one diabetes, that is, that is something. If you're diagnosed at the age of 10 and you live to be 80 you'll have had type one diabetes for 70 years of your life. So, um so So it's a chronic disease. Um, and obviously people always think it must be lack of insulin. I'm not going to read every word on these slides. They they think, Oh, there can't be enough insulin, but actually often in type two diabetes, especially in the early days. There's actually a lot of insulin being secreted by the beta cells in the pancreas, often a lot more than is normal, and the reason for that is that the people in 10 15 years before they are diagnosed, this is before they're diagnosed. They developed this thing called insulin resistance, which means that the insulin that is produced by the beta cells, whose job is to get the glucose out of the bloodstream into every cell in the body. That's what that hormone does like, unlocks the door to the cell. It's a simple way of putting it. It's how I describe it, a patient's. But it enables the glucose that's in your bloodstream, which is there as a result of digesting food carbohydrates. The incident enables the glucose to get into the bloodstream. But when you've got insulin resistance, which nearly everybody would type two diabetes has, then the then the the insulin doesn't work so well, and so the glucose builds up in the bloodstream to very high levels. So what next one, please? So we call it a modern pandemic, which might sound a bit rich compared to Covid. But actually it is a very serious long term condition, and it's a cardiovascular condition as well. So it's not all about blood sugars. It's about, um, take take managing lipids and managing BP, which are equal importance as managing blood glucose. And it is very strongly linked to the rise in in obesity. Um, it cross most countries. So it's And of course, it costs a lot of money. What cost the most money, though, is actually the long term complications of diabetes, which can affect people's lives in a in a very serious manner. So, ideally, getting those the the diagnosis, especially in type two diabetes, as soon as as possible rather than waiting, um to someone has had, which has happened a lot. People are diagnosed with type two diabetes, and they probably have already had it for several years. And they have already got a complication of their diabetes, such as, uh, retinopathy, which which is the which is the eye condition, which is actually, um, one of the, uh, often a way that people find out they have diabetes because they're optician, looks into their eyes and can see the first signs of retinopathy. And that's when someone goes to their doctrine. Says, Can you check my You know, this is, um so, yeah, we want to avoid people being diagnosed and already having complications. So it's a it's screening. Um, Type two diabetes. It it is progressive, not can be. It is. It is progressive. Um these days in the UK I don't know about with you guys, But these days in the UK, we don't see so many people with complications already at diagnosis. And that's what we need to avoid and very worryingly. And this this lady wrote this in 2014. So this is eight years ago that the prevalence of obesity and type two diabetes was increasing in Children. So I expect you always imagined people who got Type two diabetes were older people and and we used to call it maturity onset diabetes. We used to call it that. But now that the boundaries of blurred so some older people can develop type one diabetes and sometimes you can get young teenagers 15 16 year olds who actually develop type two diabetes, not type one diabetes so they don't need to have insulin injections. Next one, please. So, yeah, these hormones, um, the islets of Langerhans, you have all heard of it of that within the pancreas, you and you've got the beta cells which produce insulin, and everyone knows about that. But you also very importantly, have the alpha cells producing glucagon Next one, please. And this is A. This is a schematic visual aid just to to Oh, that's that's come up bigger again. That's better. Is it still, Is it still still share ing Sharon? Or did it stop for a minute? Yes, OK, brilliant, Brilliant. So but basically in in order where you don't have diabetes, your blood sugar in in in units we use in the UK is very tightly controlled by by this system that's going on within the the body. So between four and seven millimoles millimoles per liter, that's very tight. So if someone ate a high carbohydrate containing meal, that's that would create a lot more glucose in the bloodstream because carbohydrate raises the blood sugar, and that would require more insulin to deal with that with the raised glucose is but that normally in normal situations, the beta cells produce exactly the right amount of insulin to go with whatever level your blood glucose may raise, too. So it stops the, uh, the blood glucose is raising too high, even if you've had a great big pizza or you've had a huge bowl of pasta. If you don't have diabetes and you don't have insulin resistance, the beta cells in the pancreas produce exactly the right amount of insulin to keep. Your blood glucose is in that in that range. Um, at the same time, if you don't eat anything, so you so you could have a fast you don't eat overnight. Or maybe you decide to fast for 24 hours. You you, actually, uh, the glucose it comes comes from the liver, and so that keeps changing on my screen. And that's as a result of the alpha cells producing glucagon. And the liver itself produces exactly the, uh, non diabetes. Okay, this is non diabetes, the liver. I find it fascinating producing exactly the right amount of glycogen in order to stop the blood sugar going too low. So even if you didn't eat for two days, your blood sugar wouldn't go so low that you become hypo. And this is such a finely tuned system. And it all goes out of kilter, especially in type two diabetes. And a lot of it is linked to high carbohydrate intake and and abdominal fat abdominal adiposity. So there's a lot of fat around your organs, including the pancreas and the liver, which actually, um prevents them from working so efficiently. Next one, please. And and it's this system, it's it's you've heard the term homeostasis. It's perfect. You know, the two things working in tandem in non diabetes, Um, to keep the blood glucose is regulated between four and seven. No matter how much or how little you you have to eat, it's in. It's fascinating, actually. Really? Next one, please keeping on the time. So, obviously, um, the glucose does need to enter every cell in the body, not just fat muscle and liver cells, um, to give them energy. Um, but every single cell in the body, and especially actually the brain, so the brain actually requires quite a lot of glucose. Um, but if there's excess glucose, um, it's stored in the liver as glycogen, and this is chains of glucose molecules, and this process is known as glyco Genesis. So, you know, Genesis means that the birth of something, doesn't it? Next one, please. And I think I've just said that if your blood glucose levels are falling, so some people choose to fast intentionally you know, uh, two days a week and you think, Well, how can they keep walking around and Why Why don't their blood sugars go too low? It's because the alpha cells produce this hormone glucagon and that stimulates the liver cells to release glucose from the store chains. And that's so you're low blood glucose stimulates glucagon to be produced, which stimulates glycogen to be produced in the liver. And that raises your blood glucose into that lovely, tight little area. And this is what we're trying to achieve with all the management in in Type one and type two diabetes to have blood glucose in in a very, um, possibly not as tight as 4 to 7. But we don't what we don't want and what's no good for anyone is for blood. Glucose is in response to insulin or or in response to some of the medications. What isn't good is for blood. Glucose is to be dropping down and then shooting up and then dropping down and then shooting up. That's nothing like what is happening in non diabetes, as you can see. Next one, please. Yeah, and I I just I just said that, didn't I sort of in a ahead of this slide. Um, So So you can read that for yourself But it's just fascinating to think how finely tuned that the whole system is. And also it makes us realize why it is quite difficult for people with with diabetes to achieve this sort of blood glucose control. Next one, please. And this is a This is one I've used over the years, Um, a lot. But it's another way of showing what I've just said. Um, so, um, basically, at the bottom of it, it's controlled blood glucose. So exactly the right amount of glucose, as is required, enters all the cells, including the brain. Thank you, everyone, for putting things into chat. I'll have a look later on. And obviously, um, the excess glucose does for not, let's say, form adipose tissue. But it increases the amount that amount of fat that's in the adipose tissue. And I keep getting back to this thing in Type two diabetes, Um, which is linked to obesity and in particular to central obesity. So that's some large waist circumference. And, of course, if you've got a large waist circumference, the fat is not only on the surface. It's around all your organs, all of your organs, including your heart, actually, and And remember, I said, diabetes, diabetes is linked to cardiovascular disease. And in fact, some people do say diabetes is a cardiovascular disease. And when we come on another session to talk about the new therapies that new therapies for Type two diabetes you you'll see that some of them are actually, um, cardio protective and renal renal protective as well. So when you think that most people with diabetes, especially Type two diabetes, do eventually unfortunately die of cardiovascular events or stroke, which is why we have to look after lipids and BP as well, you know, if we can use therapies that are going to protect the heart and protect the kidneys, a lot of people also succumb to renal failure, then that that's going to be an interesting session. Next one, please. In type one diabetes. Of course, there isn't any insulin, So this is talking about if there's no incidence so that the Type one person does not have insulin resistance and type one diabetes is an autoimmune disease. So the body terms on itself, if you like, and you do have things called I Let's sell antibodies and and other antibodies, which are actually um, destroying eventually the beta cells. The beta cells in the pancreas are the ones that make the incident, aren't they, Um, when we still don't know for sure why this happens? Um, sometimes it's very young Children, even babies, you know. And even babies need to have instant injections, so you so you don't so in. In Type one, which is less than 10% of our diabetes population has Type one diabetes. But that's why they require insulin injections. Unfortunately, insulin cannot be given in in any other way at the moment, Hopefully in the future. It would be nice if it didn't have to be injected at the moment. It has to be injected and where you have the shortage of insulin in due to the situation in your country. Obviously, this is really worrying for people with Type one diabetes, isn't it, because their lives depend on it. So, um and yeah, it's it's necessary for the complete metabolism of fats. And when the carbohydrate metabolism is disordered, fat metabolism is incomplete and intermediate products known as ketone bodies. You've heard of them, haven't you can accumulate in the blood as seen in Type one diabetes leading on two diabetic ketoacidosis, which is what will happen for someone with Type one diabetes if they cannot or will not. Occasionally, they will not do their injections. I will say that does happen sometimes, but on the whole, if there's a lack of insulin available for them to use, so they start giving themselves smaller doses, for example, or injecting every other day instead of every day, the sort of things you do. If you were running out, wouldn't you? Then they will will be at risk of DKA, as we call it the next one. Please. Yeah, this is the summary I've just said, you know? So So So remember, in Type two diabetes, which is 90% of our of our people, um, they often to begin with, have loads and loads and loads of insulin being produced by the beta cells in order to try and combat. It's in resistance, but the but the glucose still not enough glucose can get into the cells because of insulin resistance, whereas in type one diabetes there's a complete lack of insulin because of this autoimmune condition. So, um um, next one, please. Some of these saying very similar things. And we've talked about Glucagon, haven't we? How it works? How it enables the liver to to produce glycogen in order to actually raise our blood glucose is because that is needed sometimes next one, please. There we go. That's just something we we've talked about before. Um, note that the third line down breaks down stored fats triglycerides in fatty acids for use as fuel by cells. A lot of times, people's type two diabetes have very disordered lipid profiles and often do have quite high triglycerides. Actually, which is something when we're managing people with Type two diabetes, we do. We want to keep a handle on that. We want to keep an eye on that. Try try, and often people do eventually take statin therapy. For that reason, next one, please. So it's an interesting in non diabetes, Um, Glucagon. So I said earlier, you may have decide you're going to do fast for a couple of days, and this is where the Glucagon really comes into its own. So it keeps the blood glucose levels high enough, basically for the body, especially the brain, to function optimally. And when the glucose level is low, That's when your glucagon is released in response from the Alpha cells. And it's so it's just a circle of two things going on that keep the blood glucose under control. So when your carbohydrate is eaten, um, so carbohydrate is in. In in, basically, is a form of sugar. And when it's digested, it raises the blood sugars. Many of our patient's have no idea. By the way, if you ever talk to anyone with Type two diabetes that can't understand why their blood sugars are still high and they think they've given up all their sweets usually what they say, um, it's They are often very shocked to realize how much, for example, rice eating a bowl of rice, eating a bowl of pasta, eating, eating a load of chips, how much that raises their their blood sugars. And it's something to bear in mind when you're talking to people with Type two diabetes. Because a lot of people have got no idea. They think it's all about cutting out obvious sugar like sweets and cakes and things. So bear that one in mind, because if someone can cut down on the amount of those types of carbohydrates that they're eating their blood sugars are going to improve a lot, awful lot. So, um, so obviously, um, when carbohydrate is eaten, glucagon levels in the blood should reduce to prevent glucose rising too high. So again, we're back to our homeostasis. Next one, please. Next one, please. Sharon, can you hear me? Thank you very much. And we've talked about it. I I will say I'm not 100%. Can someone fill me in? How do you measure blood glucose? Is it milligrams per deciliter in the in the Ukraine? I think it probably isn't it? Yeah, I think it probably is. Um, it's certainly you measure. So you do minimal per liter. Ok, that's brilliant. Because, you know, in the USA, they measure in milligrams for per deciliter. So, um, it does vary from country to country. So this makes sense then, um, the normal range is 4 to 8. It says here, um, so it would be four fasting first thing in the morning, for example, um, And then after a meal no higher than eight million miles per liter, and again, that's getting back to this amazing, uh, system. The body's got to keep the blood sugar so tightly controlled, but where? Where someone's got diabetes and you don't necessarily aim for blood sugars quite as tight as that. So if anyone's at risk of hypoglycemia so often, these are older, frailer people who who maybe don't eat regularly. And remember in the previous slide we were saying, Actually, sometimes people can't eat regularly at the moment, can they? So we need to be so careful if they're taking any therapies, which could cause hypoglycemia, and you wouldn't want to aim for very low blood sugars as low as for, for example, if there was a real risk that someone was going to have, um, bad hypoglycemia. I'm afraid today I haven't got time to go into the high post, but honestly, that there's, uh, it can be dreadfully serious. So so individual targets. So it's so although I say 428 in a perfect world, this is really where you don't have diabetes at all. Although I have known people and have patient's who who do keep their blood sugars with their medications or their insulin in that range of around 4 to 8, we now call it time in range, so the latest meters. Um, if you could get hold of them, that is, um, where people can look at their results on their phones, right, and that they could set their time in range. They could set it, uh, like a graph between four bottom and eight top, and then it shows it shows their blood sugars. Um, how many of them are within that? Those two, Those two areas And these are particularly useful for people that use those continuous because meters, where where you can actually, uh, measure 20 or 30 blood sugars a day because you're not having to prick your finger every time. So this thing called time in range is now that one of the latest buzz words, we you know what we don't want, as I said earlier, is for someone's blood sugars to be going like this up and down, up and down. We want to see a line that's just somewhere. Normally, most of it say 80% of it. If we choose 4 to 8 to be our upper and lower parameters than than 80% of the readings. If 80% of the readings were in in that in that area. That would be excellent. Next one, please. So, yeah, we've talked about that. We've got beta cell destruction. Lack of insulin for type one. Um, it's in resistance is a huge thing for Type two diabetes and without, without saying it all over again. Just just remember that the beginnings of that these metabolic changes because it is metabolic changes maybe 15 years before the person can be diagnosed and they can be diagnosed when they're HBA. One c reaches 48 Um, and just bear in mind that in in person who is not who has not got diabetes, who has not got metabolic syndrome, who who is probably quite young, they're Excellency is only 30 or 32. I I always stress that because by the time it gets to 48 it's already quite a lot higher than it was, and that's taken 10 to 15 years to do that. Gestational diabetes is where ladies develop diabetes during their pregnancy, usually requiring in some injections during the pregnancy. But as soon as the child is born, then they then they because basically there that I always say they're on on their way to to getting type two diabetes anyway, which means they're beta cells can't cope with the added stress of the pregnancy and the fetus. But then, when the foetuses born and the baby is born, um, they're beta cells can then cope again. And that's called gestational diabetes. But it's a huge red flag for someone going on to develop Type two diabetes. Probably not too far away. Two years or something. Next one, please. This types three people often ask him about This is basically where you're you're you develop diabetes because of some damage of of some sort to the pancreas. Um, you know it pancreatitis. Obviously, if you had had your pancreas removed, that goes that saying, Um so So it's it's it's still diabetes. Um, but it's it's classified slightly different, but at the end of the day, the actual management would be very, very, very similar. Next one, please. These are other types, and I'm conscious of the time, so but you'll get these slides, but these are very rare, and you may never see any of these. I have rarely seen them either, but there there are other types, um, ketosis prone. Type two diabetes is pretty rare pretty rare because they often say, Oh, in type two diabetes, they don't have ketones. And that's used as a way to say whether you've got Type two Type one, because in type one you have ketones in type two. You don't well, that's true most of the time. But there are some people with Type two diabetes that are ketosis prone and that those just to say those are usually older people that are much much who are not overweight. They were really slim. And that is so unusual in type two diabetes that if I see someone diagnosed with Type two diabetes, that is slim. I do wonder. Is this actually really type two diabetes, or is it ketosis prone type or some people call it type 1.5 so you can see all those things there? Um, next one, please, um, maturity onset diabetes of the young, which we shorten to Modi in this country. But, um, but it it runs in families. Basically, it runs in families. Um, and it's it's different. Um, it's it's There is a change in a single gene. If a parent has this gene, um, mutation, any child that they have as a 50% chance of inheriting from them. And if they have the mutation, they generally go on to develop it by the age. By the time they're 25. Um, I think they're going to change the name of this because, um, of course, type two diets, not type two diabetes? Exactly. It's actually very easy to manage normally, but saying that when they coined the phrase maturity onset diabetes of the young, we didn't see Type two diabetes in young people. Like I said earlier, did we? It was it was virtually heard of when I started doing diabetes. You never saw it in teenagers or even people in their twenties. But things have really changed. So you've got Modi next one. Please. I'm not going to to read this. It's for interest. And if any of you ever go into in in into pediatrics, you probably be very interested in that. But again, you. When I started doing diabetes, you you just didn't see Type one diabetes in babies. They always used to say, Oh, age three and above. But again, even that's changing a bit, and you do sometimes have babies that are virtually born with diabetes. Um, it's it's and you're starting to see more than you did in the past. And I don't think there's a clear answer as to why this is. And those other two syndromes are actually linked with all those other you know, uh, life, life limiting conditions, really, And I personally haven't seen them, but it's worth knowing about the next one. Please. So there you go. Um, I you can read that for yourself because I've already said all of that one. Next one, please. Um, and again, I think we've just about covered all of that, that, generally speaking, nearly always type two patient's are overweight, and often they're older, but not always, Um, and often they don't have symptoms. So that's that's worth pointing out because I've seen people diagnosed who must have had their Type two diabetes for some years, and they've had HBA one c of over 100. Okay, if you remember that the HBO and see for diagnosis is about 48 or above many moles per mole, and yet I've seen people not very often, but I've seen people, usually men weirdly, I think, because men deny symptoms and they've come in and been diagnosed with an HBO and C of over 100. And you think and they're saying they haven't got any symptoms? It's in credible. Really? You think they would? Wouldn't, wouldn't you? All those osmotic symptoms that you get and you certainly see the osmotic symptoms very markedly in type one diabetes and also the the presentation of Type one Diabetes is happens within a matter of weeks. Um, because there's no incident on board and they very prone to develop diabetic ketoacidosis is which is, which is life threatening. It's life threatening. Um, and usually in type one diabetes, they don't have a family history, whereas in type two diabetes, they nearly always have a family history. And I've talked about insulin resistance, haven't I? Next next one, please. Those are the signs and symptoms. Um, again, you think to yourself How could someone with an HBA one C type to remember This is a type two with an HBA one c of over 100 Say they haven't got any of these symptoms. The only one that they sometimes do say and they're pleased about is they've lost some weight. Not surprising is it is it that they've lost weight and they're pleased about that because they've been trying for years to lose weight. So those are all the symptoms. Um, and, uh, you know, you've probably all seen seen this, Um, but, uh, one that people often complain about a lot is having to pass urine very frequently, having to get up five or six times in the night or even more. Um, because of that, they become really, really thirsty, Really, really thirsty because they're losing so much fluid. Um, and sadly, a lot of times they'll say they're drinking orange juice, for example, because they're so thirsty and they think orange juice is healthy. And of course, it's full of sugar. And of course, they feel tired because they're not getting the energy they need and wounds. You know, people often say, I I I cut myself and it used to heal so quick. And now all day it goes on for months. Next one. Please, Judy, we have a question. What do you mean by ketone prone? So I put keto acidosis prone, but you may want to expand on that or just keep going. Um, yes. Yeah, It's some. If some, If someone does is ketone prone. It doesn't necessarily mean they'll get Keto acidosis, but it would increase their risk substantially. Obviously, if it wasn't controlled. So, um yeah, yeah, that's really what that means. So it's called. It's not called Keto acidosis prone. I don't know why. Because in a way, it is, isn't it? But it's just semantics, Really. Does that make sense? Yeah, yeah, yeah. So, um, I'm I'll let you read this one yourselves, guys, because this is just the sort of things patient's might, how they might think and how how they might talk to you. So if we could move on, please. Sharon can. Thank you. Thank you so much. Um, and then I've mentioned we call it now. We people think of pre diabetes. This is this period before you're diagnosed with type two diabetes. Yeah, um, but it's official term in, in in the UK at least is non diabetic hyperglycemia. And you can see that the the blood test the HBA one C where you can give that diagnosis. It is a diagnosis is between 42 48. So don't forget that normal is 32. So 42 is already quite a lot higher. And and, of course, as all die, all diabetes is in is associated with increased risk of cardiovascular disease. Of course, so is prediabetes. I call it prediabetes. And if I'm talking to patient's that they understand that term. What that means is you're you're very, very likely to go on to develop full blown type two diabetes unless you do something about it under the the main things to do to do our lifestyle change losing weight in particular. So, um, it says here because I always dispute this even though I wrote this slide. But only 2 to 5% of people, um, who have prediabetes go on to develop diabetes every every year. I I think it's more than that. I think in my experience, it's more than 2 to 5% of people, Um, and for this reason they should be screened annually, So annual screening. In other words, repeat that HBA one C at least once a year. Check their lipids once a year. Check their BP once a year as you would if they already had been diagnosed, because out very, very high risk. Um, remember, we're trying to thinking of cardiovascular risk at all times. So next one, please. So yet, um, I haven't mentioned that there's a higher incidence of type two diabetes and certain ethnic, um, not necessarily. Minorities, even. But ethnic groups. So So in the UK, as a lot of South Asian people and you do see a much higher incidence of type two diabetes, and also you tend to see it at a younger age. Um, some people associate, um, you know, talk about B m my body mass index and where we're looking at, um, South Caucasian people being overweight if their b m I is 25 or more where, where we're looking at South Asian people, The cut off point for B. M I is less than 25 per personally, I don't get rely on on B m. I very much. I'm certainly very interested in waist circumference. That's really important. So next one, please. Yeah, so? So the that. That's just to say the youngest child I ever looked after with Taiwan diabetes was three months old. Can you imagine? Three months old And can you imagine doing blood sugars on a baby that small. We had to obviously prick a heel and and it was, you know, and she she actually nearly died because they she crashed. And, uh, you know, they didn't know what was wrong with her three months old, but actually, there was a good ending to that one. You'll be pleased to know next one. Pleased. So? So there's not normally a family history, but in type One, but saying that I did used to look after diabetic Children, as you can tell, and hardly ever was there a family member. But if there was, it was in This is anecdotal guys. But if there was a family member, it was in my experience, it was always the father. The father had Type one diabetes. I'd never known it. Where, where? Um, it was the mother. I'm not saying that can't happen, but I remember that the the ones I knew that had had a parent with Type one diabetes. It was always the father, and that's to do with these susceptibility genes. And they do say that the risk among first time degree relatives is is higher than in the general population. Next one, please So this screening got to come back to this because, ideally, where people find out that they're susceptible, they're prediabetic, for example, or they they that's ideal to to find out then and not wait until you start to get complications. And obviously that's done in primary care. So it's not. It doesn't require hospital visits, obviously, and I guess that's probably something that's not easy to to keep on top of the way things are at the moment. Is it guys you know, to get to to get people in for a health check where, where their BP, blood sugar, blood sugar would be done if there was a family history? Certainly, BP would be done. Certainly, lipids would be done. Weight's done, Um, and ideally, you know, in in the UK is I'm not sure how often it's supposed to be in. In the UK, it's supposed to be every five years, but in my experience, my own experience as a as a patient, it isn't it's not. It's hardly ever done, and I think that's such a shame, because these health checks actually pick up long term conditions right at the start so people don't end up in trouble. So that's that's what it's all about. And obviously, if you've got family history, obviously, if you've got this metabolic syndrome, so most people with Type two diabetes it's very, very unusual to meet someone who has Type two diabetes. That doesn't have some problem with their lipids or their BP. It's really unusual. So, um, and again, if it makes me wonder about the diagnosis, if they don't, um yes, and watch out for that huge increased risk of cardiovascular disease. If someone's already got cardiovascular disease, obviously that increases their risk. Next one, please. I'm very conscious of the time here. So, guys, So, um, so that's something I'll let you read at your leisure. Um, but that's that's if you were going to do fasting blood glucose. You could use it for diagnosis. But we generally these days, um, use HBA one C for for a diagnosis, although there are some exclusions. Um, and we we don't use HBA one c, for example, where anyone's got any problem any hemoglobinopathy or, in the case of gestational diabetes, hemo dilution. Because HBA one c, um, shows us the amount of glucose that has attached to a red blood cell during its life, which is about three months. So if you've got problems with your red blood cells sickle cell thalassemia if you're pregnant because you've got him a dilution if you're very anemic, then your HBA one C is not reliable. And then you might then the next one. Please. I think we've got all the glucose tolerance test coming up. Um, move on from for that one. That's that's that's of interest to have a proper look at when you get the slides. Um, it comes actually from an area I used to work in, as does that. And they're both talking about the different different ways of diagnosing that the H b o N c. Values the fasting blood glucose. If you did use fasting, blood glucose or to those values and they're all they're all on these 22 slides. Um, so So if you wanted to look at that whole guideline and I I haven't put it on resources, but if you want to look at it, if you if you write down Hounslow Hey, so So I have I know you're putting things into chat. I'll have a look in a minute. But if you want to look at all of these guidelines if you if you put Hounslow H O U s how h o Hounslow, Anyway, I've forgotten how to h o u N s L0 diabetes guidelines. You can see all of these there in the public domain, so I'll come to your questions in a minute. Next one, please. And that that this is what I've just been talking about this lab test, so I don't need to read that one next one. We're near the end. Actually, we can look at the questions this and I've said when it's not accurate. But for most people, it is accurate. And it's so much easier than back in the day. Um, where we, um, you know, used, uh, oral glucose tolerance test. So, um, but there are certain people that, you know it's not accurate, and these are they Next one. Please. Obviously, you look at other other things as well. You don't You don't just go on a blood test without thinking of other things. Such as their age, their family history. Are they overweight? Have they got metabolic syndrome? Um, you know Sometimes people get other diagnostic tests done, especially if there's a query. Could it be type one? Or is it type two? If you've got a query, you need to do other diagnostic tests if they're available. Guys. So you've got your beta cell antibodies. I mentioned you've got your C peptide, which shows, um, the presence of insulin in the bloodstream. But, um, if someone has got no symptoms, it's generally recommended. For example, with the HBA one C that you do two tests, not you Don't just do one. You do two. If they've got no symptoms and a lot of them don't have symptoms. Next one, please. I think that's the O G T. T. So you're pregnant, ladies? Well, well. We used to do on everyone once upon a time, but it's basically where someone takes in a known amount of glucose orally and then their blood glucose their blood venous samples are taken fasting, Um, and two hours an hour after and two hours after so it can be used as a diagnosis. If HBA one c, he's not accurate for this pet person, such as in pregnancy. Next one, please. There you go. That's some references, Um, that you may find you. So I'm now going to come on to the questions. Um, I do apologize if I miss anyone. Oh, thank you for writing hands. Look, Sharon, I just had a mental block there, didn't I? But they're They're they're they're guidelines are really interesting. And there's loads to read in there. So do have a look at that if you're interested in the public domain. Um, Judy, there's one question. Go on. Yeah, please. Yeah. Um, it's so glucose level in UK is up to eight. I m o l where it says Hi. There is. I see. I see it. Yeah. Yeah. Good. That's so that's Tetiana. Thank you very much. And you're you're just saying hi. You're just saying what? Why is that? Why? Why did it mention on one of those slides that the that the higher end was eight, um, which is higher than is recommended by the World Health Organization. So, um, that's a good question. And that you and if you look at other people's guidelines, such as if you look at the a d a d A. Which is the American Diabetes Association. Um, this is a good one to to write down, Um, if you're interested in diabetes because I know not everybody is. But if you are, if you look at the this, it's some. I haven't got it on a slide yet, but a D A. That stands for American Diabetes Association slash e a S D. That stands for European Association for the Study of Diabetes Consensus guidelines, and they they're really, really good. And I think they talk about seven. Uh, that's one of the things about different guidelines. Um, because to be frank, seven or eight, you know if it was seven or 12 or something, but it's there you could you could do a glue. You could do a glucose two minutes apart, and they would give you a different reading. You don't know that, don't you? So So I'm I can't. There's I don't think there is any, particularly and I Tetiana, I know lots of people who do check their blood sugars who aren't diabetic, including I do it sometimes, and sometimes you do get that one's after a heavy carb carbohydrate meal. Though I've been talking about you, do you do get it up to eight or even 8.5. And you don't you You don't have diabetes. If you measured your HBA one c, it will be normal because HBA one C is an averaging out, obviously, but you don't have diabetes. But if you have enough carbohydrate, if your blood sugar is going to Even though I talked about homie Stasis and how wonderful it was, I guess sometimes there's a bit of a strain put on it. Yeah. Yeah, that's what I think. Does that answer your question? Yeah. Anyone. I'm very sorry, but we've got a lecture coming up. I know, I know. Well, that's why I was going to say thank you all so much for joining me, and, uh, I hope it was helpful. Thank you very much. Thanks. I hope it was helpful. It was just a start, you know? Just try