Diabetes Tut

• Define the pathophysiology of T2DM making links to VAT?

  • chronic metabolic disorder characterized by insulin resistance and progressive beta-cell dysfunction, leading to hyperglycaemia
  • VAT (Visceral Adipose Tissue) releases pro-inflammatory cytokines (TNF-α, IL-6) and free fatty acids, which impair insulin signalling
• First-Line Medical Therapy for T2DM:

  • Metformin is the first-line treatment due to its ability to:
  • Reduce hepatic glucose production
  • Increase insulin sensitivity
  • Promote mild weight loss
  • Lower cardiovascular risk
• Actions of Key T2DM Medications:

  • Gliclazide (Sulfonylurea)
  • Stimulates insulin release from pancreatic beta-cells by blocking K-ATP channels, leading to calcium influx and insulin secretion.
  • Risk: Hypoglycemia & weight gain due to continuous insulin secretion, even when glucose is low
  • Metformin (Biguanide)
  • Reduces hepatic glucose production (inhibits gluconeogenesis).
  • Increases insulin sensitivity in muscle and liver, so increases use of glucose
  • Weight-neutral or slight weight loss.
  • Low risk of hypoglycemia.
  • Dapagliflozin (SGLT-2 Inhibitor)
  • Blocks glucose reabsorption in the kidneys, causing glucose to be excreted in urine.
  • Reduces blood sugar, blood pressure, and weight.
  • Cardioprotective & nephroprotective.
  • Risk: Increased risk of genital infections & dehydration.
• Actions of ACE Inhibitors & Calcium Channel Blockers:

  • ACE Inhibitors (e.g., Ramipril, Lisinopril)
  • Block the conversion of angiotensin I to angiotensin II, reducing vasoconstriction & aldosterone secretion.
  • Lowers blood pressure, reduces kidney damage, and protects against cardiovascular disease.
  • lowers arterial resistance
  • First-line for Type 2 DM patients with hypertension.
  • Risk: Dry cough, hyperkalemia, angioedema.
  • Calcium Channel Blockers (CCBs) (e.g., Amlodipine, Diltiazem)
  • Block calcium influx into vascular smooth muscle, leading to vasodilation and lower blood pressure.
  • decreased myocardial workload
  • Preferred in older patients or those with isolated systolic hypertension.
  • Risk: Peripheral oedema, dizziness.
• Leptin:

  • hormone produced by adipose tissue in proportion to the amount of stored body fat - signals brain to reduce hunger and increase energy expenditure
  • travels to the brain, increasing affect of the SNS, increasing vasoconstriction, increasing total peripheral resistance, increasing blood pressure
  • this is a link between hypertension and diabetes
• BP target for being with diabetes:

  • 120 - 129/70 - 79 mmHg
  • Lower the better if asymptomatic
• Balwinder is a 62-year-old gentleman who was diagnosed with T2DM 12 years ago. His current BMI is 30.9, waist circumference 104cm and his most recent HbA1c is 79mmol/mol. Balwinder is treated with 3 anti-hyperglycaemic medications: gliclazide (sulfonylurea), metformin and dapagliflozin (SGLT-2 inhibitor). He is also taking a lipid lowering medication and 2 anti-hypertensive medications: lisinopril (ACE inhibitor) amlodipine (calcium channel blocker). His blood pressure is 152/90 mmHg. Balwinder has a sedentary occupation and spends most of his leisure-time being inactive (walks on average 10 mins at a light intensity daily)
• What type of assessments/questions would you carry out or ask Balwinder before he starts an exercise programme?

  • complications/symptoms e.g. chest pain, shortness of breath, neuropathy
  • how he manages his diabetes e.g. medication, blood sugar levels
  • is blood pressure controlled
  • diet
  • current mobility
• What type of exercise can safely be prescribed to Balwinder?

  • 150 mins moderate (40 to 59%) intensity exercise per week
  • flexibility/balance - tai chi
  • moderate strength (50 to 69%) - bodyweight exercises