What is the criteria for persistent hyperglycaemia
HbA1c of 48 mmol/mol (6.5%) or more
Fasting plasma glucose level of 7.0 mmol/L or more
Random plasma glucose of 11 mmol/L or more in the presence of symptoms or signs of diabetes
Describe some common signs of type 1 diabetes
Ketosis - metabolic state where your body burns fat for energy instead of glucose
rapid weight loss
age of onset under 50 years
BMI below 25
personal and / or family history of autoimmune disease
do not use BMI alone to exclude or diagnose type 1 diabetes in adults
What are some risk factors of Type 2 diabetes
Overweight
Inactive
Family history
Ethnicity
Diet
History of gestational diabetes
Describe how blood glucose is controlled
Carbohydrate in food is broken down by the body into glucose
However in order for the cells to open up and let glucose in, they need insulin which acts as a key to open the doors of the cell
What does glucagon do
Acts in an opposite manner to insulin; switches body’s metabolism so that it uses fatty acids instead of glucose as its energy source and it signals body to increase glucose production
Liver cells break down glycogen and release glucose into the bloodstream
Glucagon signals the fat tissues to break down triglycerides and release glycerol and fatty acids into the blood
What is the function of the pancreas?
Gland - has exocrine and endocrine functions
Acinar cells (exocrine): enzyme rich juice used for digestion
Islets of Langerhans (endocrine)
What is the function of alpha cells
produce glucagon
INCREASE GLUCOSE
What is the function of beta cells
secrete insulin
LOWERS GLUCOSE
How is insulin secreted?
See diagram
How does insulin reduce blood glucose?
Insulin binds at receptor -> binding promotes autophosphorylation of beta subunits. This autophosphorylation enables protein IRS-1 -> IRS protein interact with signaling molecules such -> activate MAP kinase
-> causes GLUT4 glucose transporters to be placed in cell membrane to promote glucose transport into cell
What is insulin resistance
Insulin levels are high over a prolonged period of time causing body’s own sensitivity to hormone to be reduced
One of earliest and most noticeable symptoms of insulin resistance is weight gain
Other symptoms
lethargy
hunger
difficulty concentrating
high blood pressure
What are some acute emergencies in diabetes
Ketoacidosis
Hyperosmosis
Hypoglycaemia
What are some chronic effects of diabetes?
Eye problems (retinopathy)
Foot problems
Foot problems
Heart attack and stroke
Kidney problems (nephropathy)
Nerve damage
What are some long term complications of diabetes
Diabetes to a two fold excess risk for cardiovascular disease
Diabetic retinopathy is the leading cause of preventable sight loss
Up to 100 people have a limb amputated in UK as a result of diabetes
Depression nearly 2x as high among people w diabetes v those without
Numbness on skin
weakened muscles
incontinence of bladder
erectile dysfunction
What is Retinopathy?
Blood vessels block retina
What is nephropathy?
Kidney disease
What are the early abnormalities of diabetes
Hyperglycaemia
leads to increased capillary flow = increased pressure
this causes damage to the vessel wall + stimulates basement membrane thickening
vessel closure = decrease O2 a
vessel permeability = leak water, fat and blood
Describe obesity as a risk factor of diabetes
90% of adults with type 2 diabetes aged 19-54 are overweight or obese
Describe genetic background as a risk factor
150polymorphisms associated with altered T2DM susceptibility
exact site unclear - most likely in islets
Type 1diabetes treatment overview
Insulin replacement - since type 1 diabetics’ bodies no longer produce insulin
diet and lifestyle
What are the aims of the treatment
Labratoryparametertargets
Blood glucose controlled
4-7mmol/l before meals
5-9mmol/l, 90 minutes post meals
HbA1c <48mmol/l (6.5% or lower)
Prevent/reduce acute and long term complications
Encourage self management as it is a lifelong condition
How do we monitor diabetes treatment?
Self testingfinger prick (capillary); blood glucose by patient
Continuous glucose monitoring devices to be made available to all adults (type 1)
HbA1C in clinic, every 3-6 months in adults
What is HbA1c?
Some of the glucose in your blood binds to haemoglobin - this combination of glucose to haemoglobin is called haemoglobin A1c
Amount of HbA1c formed is directly related to avg concentration of glucose in your bloodstream. Red blood cells live for 2-3 months - therefore HbA1c in blood reflects average level of glucose in your blood during last 2-3 months
If your diabetes is not well controlled, your blood glucose levels will be high causing higher HbA1c levels.
What are the targets from NICE guidelines?
Support adults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower to minimise the risk of long-term vascular complications
Agree an individualised HbA1c target with each adult with type 1 diabetes. Take into account factors such as their daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia
Ensure that aiming for an HbA1c target is not accompanied by problematic hypoglycaemia in adults with type 1 diabetes
What are the blood glucose targets
The optimal targets for glucose self-monitoring in adult type 1s is
FASTING PLASMA GLUCOSE LEVEL OF 5-7 mmol / L on waking
PLASMA GLUCOSE LEVEL OF 4-7 mmol / L
(for adults who choose to test after meals) PLASMA GLUCOSE LEVEL of 5-9 mmol / L at least 90 minutes after eating
Remind patient to be particularly careful to avoid hypoglycaemia when driving
Pharmacological management for Type 1 diabetes
Insulin
Different types
How/why
Pumps
Islet Transplantation
Insulin Regime
Goal is to have an insulin release profile most similar to a physiological state
Choosing a regime depends on
level of daily activities
diet
stability of blood glucose
monitoring of blood glucose
CONSIDER LIFESTYLE AFE AND ABILITY TO SELF BLOOD-TEST GLUCOSE
Species of insulin
Human
genetically engineered; either yeast or e.coli
Animal
Beef - increased incidence of allergic problems
Pork - less antigenic than beef
available as purified insulin
Type 1 treatment overview
Insulin replacement - since type 1 diabetics’ bodies no longer produce insulin