T2DM

• Diabetes is a group of metabolic disorders characterised by hyperglycaemia resulting from defects in insulin secretion, insulin action or both
• Chronic hyperglycaemia can lead to damage of nerves, eyes, blood vessels, heart and kidneys
• Types of Diabetes


  • Type 1 – cell-mediated autoimmune destruction of pancreatic beta cells causing absolute deficiency of endogenous insulin
  • Type 2 - relative insulin insufficiency. Insulin is secreted but not enough to overcome the insulin resistance
  • Others: Genetic defects in beta cells or insulin action, Drug-induced (e.g. steroids, thiazides), Endocrinopathies (e.g. Cushings, acromegaly), Disease of exocrine pancreas (e.g. pancreatic cancer, CF), Infection (e.g. cytomegalovirus), Immune-mediated diabetes that are uncommon (e.g. Stiff-man syndrome), Genetic syndromes (e.g. Downs syndrome, Turner syndrome, Wolfram syndrome)
• Approximately 5 million people have diabetes in the UK, with 90% of these having type 2 diabetes
• Global Prevalence of diabetes
• Financial Burden of diabetes
• Risk factors for Diabetes

  • Obesity, Age, Family History, Gestational diabetes, PCOS, Ethnicity, Metabolic Syndrome, Dyslipidaemia (high TC and low HDL), Hypertension, Dietary factors, Sedentary lifestyle
• Diabetes Prevention Programme includes Structured education, Exercise, Diet which are highly cost-effective and maintained over a long duration
• China Da Quing diabetes prevention study

  51% lower incidence of diabetes during the 6-year active intervention, 43% over 20 years, At 23 years – 41% reduction of CV mortality and 29% reduction in all-cause mortality
• Diagnosis of Diabetes


  Incidental, HHS, Presenting Features, Not usually weight loss, No ketonuria, Onset over months, Not usually marked onset - usually more insidious, Typically presents after the age of 20 years however childhood type 2 is now emerging
• Diagnosis methods for Diabetes

  • HbA1c, Fasting plasma glucose, OGTT (Oral Glucose Tolerance Test)
• Diagnosis criteria for Diabetes

  • Fasting plasma glucose <5.6 mmol/L, 6.1-6.9mmol/L, ≥7mmol/L, 2 hours postprandial 7.8mmol/L, 7.8-11mmol/L, ≥11mmol/L, HbA1c < 42mmol/mol (6%), 42-47mmol/mol (6-6.4%), ≥48mmol/mol (6.5%)
• Diet in Diabetes
• Alcohol, Calories, Delayed hypoglycaemia in Diabetes
• Exercise in Diabetes
• Structured Education in Diabetes includes DESMOND/XPERT courses to prepare individuals with diabetes to cope with a complex chronic disease, make informed decisions about their care, make behavioural changes that will support self-management
• Traditional knowledge-based diabetes education is essential but not sufficient for sustained behaviour change
• Interventions that incorporate behavioural and affective components are more effective
• Type 2 Diabetes – Natural History

  • Years from Diagnosis: -10, -5, 0, 5, 10, 15
  • Beta Cell Function
  • Insulin Resistance
  • Insulin Secretion
  • Post Prandial Glucose
  • Fasting Glucose
  • Macrovascular Complications
  • Microvascular Complications
  • Pre-Diabetes
  • Type 2 Diabetes
  • Weight Gain
• Weight Loss: 17
• Type 2 Diabetes Becomes More Complex Over Time
• Treatment review


  Older patients receive clear guidance, diet and exercise plan, metformin given, avoiding diabetes complications, complications arise, complications such as CVD or renal impairment may become more frequent, more individualised approach to treatment required, quality of life becomes one of the most important considerations, disease progression, practitioner time, increasing complexity, awareness and culture of de-escalation, self-care/motivation/titration and education, education, education/understanding
• Glycaemic Control can deteriorate over time
• The progressive nature of type 2 diabetes involves the decline of β-cell function in the context of poor insulin sensitivity
• NNT for 5 years in order to prevent 1 CVD event: 0.9% reduction in HbA1c, 1 mmol/L reduction in cholesterol, 10/5 mmHg reduction in BP
• Three Treatment Targets


  • Lipids
  • Blood Pressure
  • Blood Glucose
• Complications of Diabetes


  • Sexual dysfunction
  • Peripheral sensory dysfunction
  • Skin infection
  • Atherosclerosis
  • Gastro-intestinal and bladder dysfunction
  • Diabetic foot
  • Diabetic retinopathy
  • Diabetic nephropathy
  • Diabetic neuropathy
  • Cerebrovascular disease
  • Peripheral vascular disease
  • Coronary heart disease
  • Cognitive impairment
  • Cardiac autonomic neuropathy
  • Microvascular
  • Macrovascular
  • Coronary heart disease
• Lipids- ESC/EAC


  • Treatment targets and goals for cardiovascular disease prevention
• Where it all started: DCCT, UKPDS – ‘legacy effect’ of tighter glycaemic control, ACCORD – increased CV mortality in those with tight control, VADT – no CV
• Types of diseases


  • Brovascular disease
  • Peripheral vascular disease
  • Coronary heart disease
  • Cognitive impairment
  • Cardiac autonomic neuropathy
  • Microvascular
  • Macrovascular
• Lipids- ESC/EAC Treatment targets and goals for cardiovascular disease prevention
• Blood Pressure- NICE Guidelines
• Legacy effect of tighter glycaemic control
• Increased CV mortality in those with tight control
• No CV mortality reduction
• Rosiglitazone - 43% increased risk of MI and a statistically nonsignificant 64% increased risk of CV death versus comparators
• December 2008 FDA (Food and Drug Administration) – Guidance Focus on CV safety
• Cardiovascular Outcome Trials
• Scottish Intercollegiate Guidelines Network. SIGN 154. November 2017. [Accessed Feb 2024]
• Management of hyperglycaemia in type 2 diabetes. Diabetologia 2018;61:2461-98