beas bhattacharya great western hospital. what is diabetes?
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Diabetes
Beas BhattacharyaGreat Western Hospital
What is Diabetes?
History“Diabetes”Mid 16th century: Greek, diabainein - 'go through‘ Latin 'siphon', meaning “to pass through”
= Increased Urination
Indian physician(Susruta & Charaka)-5th cent AD
Polyuria with “sweet tasting urine”
Was thought to be a kidney disease
Basic problem
“a serious disease in which the body cannot properly control the amount of sugar in your blood because it does not have enough insulin”
Webster Dictionary
In a nutshell
Diabetes mellitus (DM) is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both.
Diagnosis –blood test
HBA1C>6.5%
Fasting plasma glucose is ≥7.0 mmol/L
2-hour post glucose load is ≥11.1 mmol/L.
Broadly two type
Lacking or not making insulin(Type 1)
Resistance to the working of Insulin (Type 2)
Insulin Discovery
The breakthrough: Toronto 1921 – Banting & Best
© 2004, John Walsh, P.A., C.D.E.
Before Insulin
Before insulin was discovered in 1921, everyone with type 1 diabetes died within weeks to years of its onset
JL on 12/15/22 and 2 mos later
3 million by 2010
WHO estimation(Adults)
285 million in 2010336 million in 2011
552 million by 2030.
Diabetes in UK
• Over 2.5 million people diagnosed1
• Approx 4.9% of UK adult population1
• T2D accounts for 85-95% of all cases1,2
The total number of people with diabetes in the UK could increase to >5.5 million by 20303
1. IDF Diabetes Atlas. The Global Burden [last accessed http://www.idf.org/diabetesatlas/5e/diabetes April 2012]2. World Diabetes Foundation. Diabetes Facts [Last accessed http://www.worlddiabetesfoundation.org/composite-35.htm April 2012]
3. Diabetes UK, One million people in the UK are unaware they have T2D [last accessed http://www.diabetes.org.uk/About_us/News_Landing_Page/One-million-people-in-UK-unaware-they-have-Type-2-diabetes/ April 2012]
2.5 mil2010
5.5 mil2030
Prevalence of diabetes in the UK
1940 1950 1960 1970 1980 1990 2000 20100
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
Diabetes in Swindon
Population Swindon – 209,200 (2011 Census)
Approx Diabetic Population Swindon – 14,000
6% of population has diabetes(Estimated 7.3%in 2020, 8.3% 2030)
Europe :5-6%Asia :11-12%
Why is that a problem?
Diabetes & it’s complications
Quality of lifeMorbidityMortalityCost
COMPLICATIONS OF DIABETES
Small vessel(Microvascular)• Eye disease(Retinopathy)• Kidney disease(Nephropathy)• Nerve/Foot affection(Neuropathy/Diabetic Foot
disease)
Big vessel (Macrovascular)• Cardiac events,Heart attacks• Peripheral vascular disease• Cerebrovascular disease
Diabetes has serious implications
Blindness
Leading causeof blindnessin working ageadults1
Kidney failure
Leading cause of end-stage kidney disease2
Heart Disease
Stroke
2 to 4 fold increase in cardiovascular mortality and stroke3
Amputations
Leading cause of non-traumatic lower extremity amputations5
8/10 diabetic patients die from cardiovascular events4
1 Fong DS et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 2Molitch ME et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 3 Kannel WB et al. Am Heart J 1990; 120:672–676. 4Gray RP & Yudkin JS. In Textbook of Diabetes 1997 Chapter 57.
5Mayfield JA et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
Eye DiseaseRetinopathy
DIABETIC EYE DISEASE
Present in most diabetic people after 20 years >20% of patients develop sight threatening
retinopathy – improving with better careAbout 90% type 1 diabetes developed diabetic
retinopathy within 25 years of diagnosis. 12 % of new cases of blindness between the ages
of 45-74.
Diabetes Foot Disease
Microvascular Damage Leads to Neuropathy
Examination of tissues from patients with diabetes reveals capillary damage, including occlusion in the vasa nervorum Reduced blood supply to the neural tissue results in impairments in nerve signaling that affect both sensory and motor
function
Dyck PJ, Giannini C. J Neuropathol Exp Neurol. 1996;55:1181-1193.Sheetz MJ, King GL. JAMA. 2002;288:2579-2588.
Normal nerve Damaged nerve
Occluded vasa nervorum
Damage to myelinated and unmyelinated
nerve fibers
Effects of Diabetic Peripheral Neuropathy
Images: 1,4Edward J Bastyr, III, MD; 2,3Rayaz A Malik, MBChB, PhD, MRCP.
The factsFoot in Diabetes-20% of total
diabetes expenditure 6000-7000/year Amputations : 2009-
2012
5 yr Mortality: post amputation>40%
Hospital costs of amputation are £25 million per year. Even a modest 10% reduction will have significant cost savings
Cardiovascular Disease D.O.H. 2013
Kidney Disease
Diabetic kidney disease= the single most common cause of renal failure
Dia
gn
osi
s in
pati
en
ts w
ith
ES
RD
(%
)
Diabetes Uncertain
aetiology*
Other Glomerulo-
nephritis
Pyelonephritis
Polycystic kidney
Renal vascular disease
Hypertension
0
30
20
10
24.0
20.7
15.6
11.8
7.8 7.3 6.96.0
Adapted from: Nephron Clin Pract 2010;115(Suppl.1) The Renal Association. UK Renal Registry. Twelfth Annual Report 2009.
*Includes presumed glomerulonephritis not biopsy proven.† Figures shown are calculated excluding data not available. Data for primary renal diagnosis (PRD) missing in 10.8% of patients. In centres with >25% missing PRD data, percentages in the other diagnostic categories not calculated. Centres with very high rates of uncertain diagnosis also excluded.
Primary Renal Diagnosis†
30
CV event risk greatest when diabetes and CKD both present
Adapted from: Foley RN, et al. J Am Soc Nephrol 2005;16:489–95.
CHF=congestive heart failure; AMI=acute myocardial infarction; CVA/TIA=cerebrovascular accident/transient ischemic attack;PVD=peripheral vascular disease; ASVD=atherosclerotic vascular disease. *ASVD was defined as the first occurrence of AMI, CVD/TIA, or PVD.
CHF AMI CVA/TIA PVD ASVD* Death
CV
eve
nt
incid
en
ce
per
100 p
ati
en
t-ye
ars
No diabetes/no CKDDiabetes/no CKDNo diabetes/CKDDiabetes/CKD
60
50
40
30
20
10
0
32
England National Diabetes Audit 2009-10
Prevalance of End Stage Renal Disease
( dialysis or transplantation in type 2 diabetes)2003-4 = 0.26% 2009-10 = 0.56%
Kidney disease 'biggest threat' for diabeticsBBC News 2013
“An audit of 1.9 million people with Type 1 and Type 2 diabetes found more than 13,000 had a stroke in 2009-10,
a 57% rise from 2006-7.
And more than 7,000 had kidney failure, up 31% from 2006-7.”
What are the cause of mortality in patients with diabetes Nephropathy ?
Stroke MyocardialInfarction
HeartFailure
SuddenDeath
Is it all doom and gloom?
Positives
AwarenessCommunity based service advocatedEarly detectionNational bodies-Diabetes UKNSF 9 standardsFocused, specialised services-E.g. Foot
serviceNew drugs, insulin pumpsNew evidences
What can we do?
We all have a roleAs health professional, community, public
-Raise awarenessChange lifestyle
Diabetes is a Pandemic evolving
There won’t be many family unscathed or untouched
Responsibility is not just on health care professionals
-it’s on all of us!
Who are at risk?Overweight/BMI>25
WITH
Family History-1st degree relative
Ethnicity- e.g.South Asians
Gestational DiabetesPast Big babyCardiovascular diseaseHigh lipids
Symptoms
excessive hunger
headache
profuse sweatingExcessive thirst
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Cornerstones of treatment
Insulin/tablets
Physical activity
Diet
Lifestyle changes
Lifestyle modification• Diet• Exercise• Weight loss• Smoking
cessation
If a 1% reduction in HbA1c is achieved, you could expect
a reduction in risk of:
• 21% for any diabetes-related endpoint
• 37% for microvascular complications
• 14% for myocardial infarction
Stratton IM et al. BMJ 2000; 321: 405–412.
Dietary recommendations for diabetes
Eat starchy foods regularly
Eat more fruit and vegetables
Reduce animal or saturated fat
Cut down on sugarReduce salt
Exercise / activity
30 minutes moderate intensity most days preferably all
Helps to: Increased insulin sensitivityDecreased insulin requirementsWeight reductionLipid controlBlood pressure control
CHRONIC COMPLICATIONS OF DIABETES
1. Absolute prevention of complications-stop it!
2. Preventing the progression of complications to sight / life threatening disease- stop progress!
Evidence
Beneficial effects of good glycaemia control on complications
DCCT Kumamoto UKPDS
HBA1C 9→7% 9→7% 8→7%
Retinopathy 63% 69% ~20%
Nephropathy 54% 70% 25-30%
Neuropathy 60% --- ---
Glucose Control Study Summary
The intensive glucose control policy maintained a lower HbA1c by 0.9 % over a median follow up of 10 years from diagnosis of type 2 diabetes with reduction in risk of:
12% for any diabetes related endpoint p=0.02925% for microvascular endpoints p=0.0099
16% for myocardial infarction p=0.05224% for cataract extraction p=0.046
21% for retinopathy at twelve years p=0.01533% for albuminuria at twelve years p=0.000054
What can we do as community ?“Charity begins at home”- holds trueWe can’t change our genes but we can change
our habits.
If not for us, can we do it for the community, the future generation.
Maybe be set an example for others e.g. .as a proactive and responsible community
What can communities do?
Raise public awareness Create a sense of urgencyCommunicate the magnitude of the problemGet people involved in improving their healthRecognise those who are most at riskReduce risk to families, friends and wider communities
Open day regular discussion/public meets(like today!)
Break the barriers-GP-Hospital-”Community”
Council & Government bodies-cheaper exercise options (Town Garden
walks/Swindon Football ground cycle rides)-Healthy affordable food stalls at City centre etc
Measure Up: Tactics Roadshows ~20 UK towns/year
Simple 2-minute test to assess risk of diabetes
Advice about diabetes Advertising
Posters at strategic locations throughout the UK
Adverts in national newspapers and consumer magazines
Online targeting of at risk groups
Lobbying Extended poster campaign
and awareness day at UK Houses of Parliament
Campaigning at conferences of UK political parties
Diabetes UK. Measure Up – Are You At Risk of Diabetes. http://www.diabetes.org.uk/Measure_Up_-_are_you_at_risk_of_diabetes/.
NSF 9 standardsNSF
9 standards
NICE & NSF9 Key care process
Blood glucose level measurement
Blood pressure measurementCholesterol level
measurementRetinal ScreeningFoot and leg checkKidney function testing(Blood)Kidney function testing(urine)Weight checkSmoking status check
of NEWER DRUGS
ANTI-HYPERGLYCEMIC THERAPY
- Metformin
- Sulfonylureas
- Thiazolidinediones
- DPP-4 inhibitors
- GLP-1 receptor agonists
-Dapagliflozin
-
Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]
Treatment goals
Symptom freePrevent short term complicationsPrevent long term complicationsQuality of life = Lifestyle focus
Diabetes UK Careline
A support helpline for anyone with diabetes, their friends, family and carers.
How to contact Call: 0345 123 2399
Monday–Friday, 9am–5pm.
Email: careline@diabetes.org.uk
Website-http://www.diabetes.org.uk/
Diabetes UK Phone AppsLog and track a range
of levels: blood glucose, insulin, carbohydrates, calories, weight and ketones
View your data in day and week graphs to spot trends
See your daily average blood glucose level, total carbohydrates and total calories
Other websiteshttp://www.nhs.uk/
Conditions/diabetes-type2/Pages/living-with.aspx
DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) programme
Thank you!
Questions ?
www.plymouthdiabetes.org.uk/
Pathophysiology-biochemical and vascular factors
Background
Foot in Diabetes-20% of total diabetes expenditure Annual cost Diabetic Foot ulcer £600 million+ Annual cost of diabetes related amputation £119
million6000+ Amputations : 2009/20105% of diabetics develop a foot ulcer each yearRoughly 100,000 people with foot ulcers (per year)0.5% of these will go onto have an amputation
South west has a high amputation and admission rate
Abdominal obesity and increased risk of cardiovascular events
Dagenais GR et al, 2005
Ad
just
ed
rela
tive
ris
k
1 1 1
1.17 1.16 1.14
1.29 1.27
1.35
0.8
1
1.2
1.4
CVD death MI All-cause deaths
Tertile 1
Tertile 2Tertile 3
Men Women<95
95–103>103
<87
87–98>98
Waistcircumference (cm):
The HOPE study
Adjusted for BMI, age, smoking, sex, CVD disease, DM, HDL-cholesterol, total-C; CVD: cardiovascular disease; MI: myocardial infarction; BMI: body mass index; DM: diabetes mellitus; HDL: high-density lipoprotein cholesterol
Chronic kidney disease and cardiovascular (CV) risk
Adapted from: Go AS, et al. N Engl J Med 2004;351:1296-1305.
As eGFR decreases, risk of CV events increases
* Adults (1,120,295 ) within large US integrated healthcare system, with serum creatinine measured: 9.6% had been diagnosed with diabetes.
Age-standardised rates of CV events according to eGFR*
0
5
10
15
20
25
30
35
40
2.11
45 - 59 30 - 44 15 - 29 <15
Estimated GFR (ml/min/1.73m2)
73,108 34,690 18,580 8,809 3,824No. of events
Ag
e-s
tan
dard
ised
rate
s of
CV
eve
nts
(per
100 p
ers
on
-yrs
)
≥60
3.65
11.29
21.8
36.6
66
Impact of Intensive Therapy for Diabetes: Summary of Major Clinical Trials
Study Microvasc CVD Mortality
UKPDS DCCT / EDIC*
ACCORD ADVANCE
VADT
Long Term Follow-up
Initial Trial
* in T1DM
Kendall DM, Bergenstal RM. © International Diabetes Center 2009
UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:854.
Holman RR et al. N Engl J Med. 2008;359:1577. DCCT Research Group. N Engl J Med 1993;329;977.
Nathan DM et al. N Engl J Med. 2005;353:2643. Gerstein HC et al. N Engl J Med. 2008;358:2545.
Patel A et al. N Engl J Med 2008;358:2560. Duckworth W et al. N Engl J Med 2009;360:129. (erratum:
Moritz T. N Engl J Med 2009;361:1024)
Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (1)
•Physical inactivity
• First-degree relative with diabetes
• High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
• Women who delivered a baby weighing >9 lb or were diagnosed with GDM
• Hypertension (≥140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level<35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)
• Women with polycystic ovarian syndrome (PCOS)
• A1C ≥5.7%, IGT, or IFG on previous testing
• Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
• History of CVD
*At-risk BMI may be lower in some ethnic groups.
1. Testing should be considered in all adults who are overweight(BMI ≥25 kg/m2*) and who have one or more additional risk factors:
ADA. Testing in Asymptomatic Patients. Diabetes Care 2012;35(suppl 1):S14. Table 4.
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