What Is Diabetes

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What Is Diabetes?

• Diabetes is a condition in which the level of
  glucose in the blood is PERSISTANTLY raised
  above normal range
• This can be due to a relative or absolute lack
  of insulin or because of impaired insulin
  utilization

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Diabetes

• Condition resulting from a breakdown in bodys
  ability to produce or utilise insulin.
• Type 1 Diabetes Beta-cell destruction
• Type 2 Diabetes Defective secretion of insulin
• insulin
  resistance

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Core Defects in Type 2 Diabetes
A progressive metabolic disorder characterised by
Type 2 diabetes
Insulin resistance
?-cell dysfunction
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Incidence rapidly increasing.
2 million in UK (2000) Estimates of 3 million
in UK by 2010 Amos AF et al. Diabetic
Medicine 1997 14 (Suppl 5) S1-S85
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The Missing Million
Significant numbers of people remain undiagnosed.
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Diabetes an Increasing Global Burden
Estimated number of people with diabetes
worldwide
Number of people (millions)
(Year)
Amos AF, et al.. Diabetic Medicine 199714 (Suppl
5)S1S85.
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UK Economic Costs

• Year 2000 projected NHS
• diabetes expenditure (9) 4,878,000,000
• Equivalent to
• per week 93,807,692
• per day 13,401,098
• per hour 558,379
• per minute 9,306
• per second 155

British Diabetic Association Fact Sheet. May 2000.
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New Diagnostic Criteria (WHO, 2000)
Diabetes symptoms PLUS - fasting lab plasma
glucose gt 7.0 mmols - random level gt 11.1
mmols - 2 hour post 75g anhydrous glucose
(OGTT) gt 11.1 mmols With NO symptoms - confirm
diagnosis with plasma venous measurement - 2
separate measurements required
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New Terminology (WHO, 2000)
Impaired Glucose Tolerance (IGT) - stage of
impaired glucose regulation - fasting plasma
glucose lt 7.0 mmol/l and 75g OGTT 2-hour value
gt 7.8 mmol/l but lt 11.1 mmol/l. Impaired
Fasting Glycaemia (IFG) - fasting plasma glucose
gt 6.1 mmol/l but lt 7.0 mmol/l. - OGTT to exclude
diagnosis of diabetes.
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IGT IFG

• Not clinical entities in own right, but risk
  categories for
• cardiovascular disease (IGT) and/or future
  diabetes (IFG
• IGT
• Early treatment may reduce progression diabetes
• 2-5 people with IGT per year progress to
  diabetes
• Healthy eating advice / weight management
• Annual check for diabetes

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CLASSIFICATION OF DIABETES

• Type 1 diabetes
• Type 2 diabetes
• Maturity onset diabetes of the young (MODY)
• Gestational diabetes
• Secondary diabetes

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Chronic Complications of Diabetes
Retinopathy Most common cause of blindness in
people of working age
Macrovascular and Cerebrovascular Disease 23
fold increased risk of coronary heart disease
and stroke
Nephropathy 16 of all new patients needing renal
replacement therapy have diabetes
Foot Problems 15 of people with diabetes
develop foot ulcers 515 of people with
diabetic foot ulcers need amputations
Erectile Dysfunction May affect up to 50 of men
with long-standing diabetes
The Audit Commission. Testing Times. A Review of
Diabetes Services in England and Wales, 2000.
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Life Expectancy and Diabetes
Adults with diabetes have an annual mortality of
about 5.4, double the rate for non-diabetic
adults. Life expectancy is decreased by 510
years.
Goodkin G. Journal of Occupational Medicine
197517(11) 716721. Donnelly R, et al. British
Medical Journal 2000 320 10621066.
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Type 1 Diabetes

• Generally occurs in people lt 40 yrs
• Sudden onset
• Beta cell destruction means the pancreas is no
  longer able to produce insulin
• Need insulin to survive
• Presence of ketones in large amounts indicates
  absence of insulin
• Ketoacidosis kills

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Genetic Susceptibility Environmental
Factors Auto-immune attack Beta cells
destroyed Type 1 Diabetes
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Signs Symptoms

• Sudden onset
• Weight loss
• Polydipsia
• Polyuria
• Lethargy
• General malaise

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Insulin

• Discovered in 1921 by Banting Best.
• Until the 1980s insulin was extracted and
• purified from the pancreas of cows pigs.
• Human insulin now routinely used
• Usually manufactured by recombinant DNA
• technology from E.coli bacteria or yeast cells.

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Diabetes Control Complications Trial (1993)

• Large scale prospective study
• Type 1 diabetes
• 1440 patients in 29 centres. N.America
• Randomised to two groups-
• conventional therapy vs intensive therapy

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Diabetes Control and Complications Trial (1993)
Clinically important retinopathy, neuropathy
nephropathy reduced by 35-75 in those with
strict glycaemic control but 3 fold greater
risk of hypos.
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Type 2 Diabetes

• Usually occurs in people gt 40 yrs
• Genetic predisposition / Environmental trigger
• Usually overweight
• Results from insufficient insulin secretion
  and/or insulin resistance
• Symptoms insidious vary in severity

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TYPE 2 DIABETES - PREVALENCE

• 3 in the UK
• Increases with age - gt10 of people gt 65yrs
• gt 6 in ethnic minority groups
• 25 of Asian origin gt 60 yrs

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Type 2 diabetes - an epidemic!
One new diagnosis every 5 minutes in the UK
(Gatling et al, Diabetic Medicine 1998)
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The 2 Key Causes of Type 2 Diabetes
?-cell dysfunction
Insulin resistance
Type 2 diabetes
Beck-Nielson H et al. J Clin Invest
19949417141721 Saltiel AR, Olefsky JM.
Diabetes 19964516611669
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Whats The Problem?
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Type 2 Diabetes A Complex Metabolic Disorder
Impaired insulin secretion
Insulin resistance
Macrovascular complications
Microvascular complications
INSULINRESISTANCESYNDROME
Central obesity
Hypertension
Dyslipidaemia
The Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus. Diabetes
Care 1997 20 (7) 11831203.
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Type 2 diabetes an end-point.
.. Look for early detection and
appropriate intervention
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Risk Factors for Type 2 Diabetes
GENETIC FACTORS - Ethnicity - Family history
(40)
GESTATIONAL DIABETES AND PARITY
CENTRAL OBESITY
INCREASING AGE
PHYSICAL INACTIVITY
Williams G, Pickup JC. Handbook of Diabetes. 2nd
Edition, Blackwell Science. 1999.
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Glycaemic Control

• 3 months diet is initial therapy
• Stepwise approach, if HbA1c gt 7 or FPG gt 6.0
  mmol/l
• make changes every 3 months.
• BMI 20-25 use Sulphonylurea
• BMI gt 25 use Metformin
• Use early combination therapy followed by
  insulin therapy.

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Current Treatment Regimens in Type 2 Diabetes
MUSCLE ADIPOSE TISSUE
PANCREAS
PERIPHERAL GLUCOSE UPTAKE UTILIZATION Metformin
INSULIN SECRETION Sulphonylureas,Non-sulphonylur
eas Meglitinide family
INSULIN REPLACEMENT Insulin
INSULIN SENSITISING Thiazolidinediones (PPAR?
agonists)
GLUCOSE ABSORPTION ?-glucosidase inhibitors
GLUCOSE PRODUCTION Biguanides
LIVER
INTESTINE
DeFronzo RA. Annals of Internal Medicine
1999131281303. International Diabetes
Federation (Europe). Diabetic Medicine
199916716730.
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UK Prospective Diabetes Study (1998)

• 5000 patients in 23 centres in UK
• 20 year study
• 3867 newly diagnosed with type 2 diabetes
  randomly allocated to conventional therapy (diet
  initially) or intensive therapy

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The Burden of Type 2 Diabetes Can Be Reduced

• The UKPDS showed that, when glucose levels are
  above normal, any reduction in HbA1c is
  beneficial

25 reduction in microvascular complications
0.9 reduction in HbA1c

UKPDS 33. Lancet 1998352837853 UKPDS 34.
Lancet 1998352854865
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Identification.
just the beginning
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Diagnosis Annual Review

• Metabolic control
• Lipid screen
• Creatinine
• Proteinuria / Microalbuminuria
• Eyes for visual acuity and dilated fundoscopy
• BP
• Feet inspection and education
• Injection sites Diet review

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Gestational Diabetes Mellitus

• Occurs during pregnancy
• Resolves after delivery but may recur in
  subsequent pregnancies
• Risk factors
• Obesity
• Family history of type 2 diabetes
• Previous gestational diabetes mellitus
• Increases risk of developing type 2 diabetes
• Increases risk of developing hypertension

Williams G, Pickup JC. Handbook of Diabetes. 2nd
Edition, Blackwell Science. 1999.
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MODY

• Different genetic background to T2D
• Strong family history of diabetes diabetes
  often develops at an early age (lt25 years)
• Its clinical heterogeneity can be explained by
  genetic heterogeneity (five genes identified)
• May be treated by diet or tablets

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Signs Symptoms of Hypoglycaemia

• Signs symptoms vary from
• person to person and at different
• plasma glucose levels
• Four should be the floor!

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Causes of Hypos

• Missed or delayed meals
• Insufficient carbohydrate
• Physical activity
• Alcohol
• Temperature change
• Lipohypertrophy
• Timing amount of treatment

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Levels of Hypoglycaemia

• Mild / Moderate
• Severe

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Treatment of Hypos

• MILD / MODERATE 3 dextrosol, 3 sugar lumps, 2
  teaspoons of
• sugar in
  water, 100mls lucozade followed
• with
  starch.
• SEVERE glucagon 0.5mg or 1mg I.v., I.m.,s.c./50
  mls 50
• dextrose I.v. followed with
  starch when able.

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The Diabetes Team

• Patient
• Diabetes Consultant
• DSN
• Dietitian
• Podiatrist
• Psychologist
• GP / Practice Nurse

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Diabetes National Service Framework (Diabetes
NSF).

• Standards, milestones targets for the
  prevention management of DM.
• 2 parts
• - Standards, rationales key interventions
• - Delivery Strategy -national deliverables to
  be met with milestones local targets for
  service delivery.

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www.doh.gov.uk/nsf/diabetes
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Resources
Publications available on the website - core
patient leaflets http//www.diabetes.org.uk/h
elp/cat/splash.htm - healthcare professional
reports http//www.diabetes.org.uk/info/c.htm
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Diet Lifestyle
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Perception of diet

• Traumatic
• Adherence difficult
• Change and confusion
• Conflicting advice

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Traditional Diet Therapy

• 1. The Egyptians
• Ground earth
• Water
• Bones
• Wheat
• Lead

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Traditional Diet Therapy

• 2. Rollo (1798)
• Breakfast 1 pint of milk
• 1 pint of lime water
• Bread and butter
• Lunch Black pudding
• Dinner Old meat
• Supper As breakfast

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Traditional Diet Therapy

• 3. Allen (1913)
• Waking Cocoa, 1 egg
• Breakfast Black coffee
• and whisky
• Lunch Green salad, 1 egg
• Tea Cup of tea
• Supper Green salad

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Diet in the past

• Carbohydrate restricted to 40 Recommended Daily
  Intake (RDI)
• Lines / exchanges
• High fat and protein intake

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Nutritional Guidelines for DM

• The implementation of nutritional advice for
  people with diabetes.
• Diabetic Medicine (2003)20786-807
• Nutrition subcommittee of DUK
• Take account of EASD ADA evidence-based
  guidelines
• www.diabetes.org.uk/infocentre

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2003 Diabetes UK (DUK) Guidelines
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Carbohydrate

• 45-60 Energy intake with fat CHO combined
  making 60-70 energy intake.
• Regular Intake
• Low glycaemic index foods
• Sucrose up to 10 daily energy, provided eaten in
  the context of a healthy diet and distributed
  throughout the day.

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Carbohydrate
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FIBRE

• No quantitative recommendation
• Insoluble fibre
• Soluble fibre
• - positive effect on BG
• levels and the lipid
• profile

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Fructose

• Space fruit out over the day
• Sweet fruits and fruit juice in moderation.
• Fructose has no proven advantage over sucrose.
  Not recommended as a tabletop sweetener.

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Glycaemic Index

• Idea emerged in the early 1980s with work done
  by Jenkins and colleagues
• Method of assessing the post-prandial glucose
  response to a food against a standard of white
  bread / glucose

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How GI Is Measured

• Glucose (reference food)

Spaghetti (test food)
BG
BG
100
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1 hour
2 hours
1 hour
2 hours
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Why do carbohydrate foods have different
glycaemic responses?

• Complex and not fully understood
• Appears to be related to the rate at which
  carbohydrate is digested and absorbed

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Why Is the GI So Important?

• Slow digestion and gradual rise in blood glucose
  response after a low GI food
• Slower digestion helps to delay hunger pangs and
  promote weight loss

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Factors That Affect the Glycaemic Index of a Food

• Protein and fat content of the food
• Physical form of the CHO
• Temperature of the food
• Water content
• Mixture of CHO fibre

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The GI Table of Foods
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Fat

• lt35 total daily energy intake
• Saturated
• Polyunsaturated
• Monounsaturated

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Saturated Fatty Acids

• lt10 RDI
• Avoid - can raise blood cholesterol level
• Found mainly in animal products such as red meat
  and dairy products
• Some may be of vegetable origin eg palm oil.

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Polyunsaturated Fatty Acids

• lt10 RDI
• Found in vegetable oils such as sunflower oil and
  in polyunsaturated margarines and in oily fish.

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Monounsaturated Fatty Acids

• 10-20 RDI
• Lower susceptibility to lipid peroxidation
  consequent lower atherogenic potential
• Found in oils such as olive oil and rape seed
  oil.

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Protein

• 1gm per Kg bodyweight
• 10-20 of total daily energy intake
• Eat small servings of protein
• (3-4 oz cooked weight)
• Eat more fish or chicken rather than pork, lamb
  or beef

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Protein

• Avoid any fat on meat and remove skin from
  poultry
• Choose low fat foods such as low fat yoghurts and
  cheese
• Have beans and lentils as the protein portion of
  meals, as these contain less fat and have high
  amounts of fibre

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Salt

• Use less salt in cooking
• Avoid use at the table
• It may take a little while to adjust to less
  salty food

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Salt

• Manufactured foods
• Salt
• Monosodium glutamate
• Sodium bicarbonate
• Sodium nitrate
• Ready-made meals
• Tinned vegetables
• Canned and packet soups
• Tinned, cured and smoked meats and fish

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Salt

• When using stock cubes, use only half the
  quantity and do not add extra salt to the recipe
• Alternative flavourings in cooking eg spices,
  pepper, garlic, herbs, lemon juice, vinegar
• Crisps, peanuts and other savoury snacks are high
  in salt

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Plate Model
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Exercise The Benefits

• Stamina

Improved BG Control
Blood Pressure
Weight Loss
Well Being
Cardiac Strength
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Types of Exercise

• Swimming with the family
• Walking the dog
• Join the local gym keep fit, exercise bike
• Gardening

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Exercise Points to Remember

• Insulin adjustment
• Regular monitoring
• Additional carbohydrate may be needed
• Injection sites

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Alcohol

• Health Education Guidelines
• Men - 21 units / week
• Women - 14 units / week
• REMEMBER
• Calorie content
• Diet mixers
• Low-sugar beers / lager higher in alcohol
• Dont drink on an empty stomach
• Diabetes ID

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Alcohol Hypoglycaemia

• Insulin Alcohol Fast
• How?
• Alcohol lowers BG levels
• Alcohol (ethanol) blocks gluconeogenesis, ?
  glycogen depletion
• insulin ? hypoglycaemia

HYPOGLYCAEMIA
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How to Avoid Hypoglycaemia

• Take food with alcohol

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Points to Remember

• Reduced awareness of hypo symptoms
• Hypo may be delayed (take extra snack after
  drinking alcohol)
• Carry Diabetes ID
• Sulphonylureas hypos