1. Members Seminar “An Overview of Diabetes Mellitus” Dr Abu Ahmed Clinical Endocrinologist Tuesday 15 th June 2010

2. An overview of diabetes mellitus Dr Abu AhmedConsultant Physician and EndocrinologistBlackpool Victoria Hospital

3. Why do we use the new Patient Information Leaflet system?  To provide a corporate image  Provide information in a clear and concise manner  To provide patients with a clear understanding of procedures undertaken by the Trust explaining risks, benefits and alternatives  To ensure that all patient information leaflets follow the Trust procedure for Creating a Patient Leaflet Corp/Proc/057

4. Definition and types of diabetesPresentation and risk factorsTreatment and prevention

5. Diabetes in the UK is increasing Adapted from: 1. Diabetes UK. Diabetes in the UK 2004. Diabetes UK, London, 2004. 2. Diabetes UK. State of the Nation 2005. Diabetes UK, London, 2005. 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 1940196019801996200420052010 Millions of people with diabetes

6. High blood glucose (sugar) levelNot enough insulin or inefficiency of insulinLong-term dysfunction of target organs What is diabetes?

7. Type 1 diabetes Type 2 diabetes Gestational DMSpecific causes

8. Amos AF et al. Diabet Med 1997; 14 (Suppl 5): S1–S85. The size of the problem Diabetes prevalence (thousands) 0 500 1000 1500 2000 2500 3000 1995 2000 2010 Type 1 Type 2 3 million by 2010

9. It is an auto-immune condition Usually appears before the age of 40 Acute or subacute presentation Patients are rarely obese

10. Causes of T1DM It results from destruction of B-cell It occurs in genetically susceptible individuals Environmental factors are also important

11. the body doesn’t produce enough insulin or the insulin that is produced doesn’t work properly. It develops when Usually it appears in people aged over 40 Most patients are obese

12. The prevalence of T2DM and BMI Adapted from Department of Health. Health Survey for England 2003. London: The Department of Health. 0 2 4 6 8 10 12 14 18.5 or under18.5 to 2525 to 3030 to 40Over 40 BMI (kg/m 2 ) Prevalence of T2DM (%) Male Female

13. Visceral obesity and insulin resistance  As body weight increases, insulin resistance increases 4  IR is closely linked to abdominal obesity 2,3  Reducing abdominal obesity improves insulin sensitivity 5 1. National Obesity Forum. How to measure your waist. www.nationalobesityforum.org.uk/apps/content/html/ViewContent.aspx?id=6463 (accessed 18.01.06). 2. Carey DG et al. Diabetes 1996; 45: 633–638. 3. Matsuzawa Y et al. J Diabetes Complications 2002; 16: 17–18. 4. Abate N. J Diabetes Complications 2000; 14: 154–174. 5. Williams KV et al. Diabetes Obes Metab 2000; 2: 121–129.

14. Initially the b-cells compensate for increasing insulin resistance NormalImpaired glucose tolerance Time Insulin resistance Insulin production

15. As b-cell function declines, blood glucose levels increase Adapted from Bailey CJ et al. Int J Clin Pract 2004; 58: 867–876. NormalIGTT2 diabetes Time Insulin resistance Insulin production Glucose level Beta-cell dysfunction

17. Type 2 diabetes Insulin resistance It is the best predictor of T2DM Factors contributing to IR: –Obesity –Polygenic familial trait –Physical inactivity –Pregnancy –Drugs –Chronic hyperglycaemia

18. Causes of type T2 diabetes Type 2 diabetes Insulin resistance B-cell dysfunction

19. Haffner SM et al. Diabetes Care 1999; 22: 562–568. Bloomgarden ZT. Clin Ther 1998; 20: 216–231. > 90% of T2DM are insulin resistant Genetic factors Environmental factors Family history Ethnicity Obesity Age Diet Lack of exercise Insulin resistance is a root cause of Type 2 diabetes

20. prevalence of IGT and diabetes according to age 0 10 20 30 40 35 -45 -55 -65 ->75 % of population Age (years) Diabetes IGT cos t

21. Insulin resistance is a core defect in patients with obesity and Type 2 diabetes 1. Haffner SM et al. Am J Med 1997; 103: 152–162. 2. Reaven GM. J Intern Med 1994; 236 (Suppl 736): 13–22. High BP 1 High glucose 1 Other CV risk factors 2 Insulin resistance CV risk High cholesterol Obesity

24. Risk factors for DM

25. Risk factors Family history of diabetesAge - cultureLack of physical activitySedentarismPoor dietExcessive weightSmoking, drugs and alcohol

26. Prevention of T2DM Control of risk factors Exercise, Life style changes and Diet Drugs Surgery Results in weight loss Improves insulin sensitivity Therapy that:

27. Prevention of T1DM Auto-immune disease, in genetically susceptible individual

28. Diabetes presentation T1DM usually develops over a few weeks, with severe symptoms In T2DM, the signs and symptoms will not be so obvious or even non-existent

29. Diabetes symptoms Causes of symptoms and signs  High blood glucose levels  Complications  Treatment  Cause of diabetes

30. Diabetes symptoms  Increased thirst  polyuria  Extreme tiredness  Weight loss  Blurred vision  Genital itching or thrush  Slow healing of wounds

31. Acute complications DKA HHNK syndrome Treatment complications

32. Insulin resistance is a core defect in patients with obesity and Type 2 diabetes 1. Haffner SM et al. Am J Med 1997; 103: 152–162. 2. Reaven GM. J Intern Med 1994; 236 (Suppl 736): 13–22. High BP 1 High glucose 1 Other CV risk factors 2 Insulin resistance CV risk High cholesterol

33. Stamler J., et al Diabetes Care: 16: 434-444

34. 0 10 20 30 40 50 No history of MIHistory of MI 7-year incidence of cardiovascular events (%) No history of MIHistory of MI Haffner SM et al. N Engl J Med 1998; 339: 229–234. Increased risk of MI in T2 diabetes Non-diabetic Type 2 diabetes Remember – look at a person with Type 2 diabetes as if they have already had an MI

36. MacrovascularMicrovascular Stroke Heart disease and hypertension 2-4 X increased risk Foot problems Diabetic eye disease (retinopathy and cataracts) Renal disease Peripheral Neuropathy Peripheral vascular disease Meltzer et al. CMAJ 1998;20(Suppl 8):S1-S29. Complications Erectile Dysfunction

37. Psychological issues DepressionStress and anxietyFear of complicationsLifestyle changes

38. Diagnosis of diabetes Clinical featuresUrine analysisBlood glucose levels

39. Goals of management Control of blood glucoseControl of risk factorsPrevention of end-organ damageDecrease morbidity

40. HbA 1c MV complications Heart attack * Deaths related to diabetes * 21 Stratton IM et al. UKPDS 35. BMJ 2000; 321: 405–412 Amputation or fatal PVD 37 14 12 43 Stroke ** 1% Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA 1c * p<0.0001 ** p=0.035 UKPDS: Tight Glycaemic Control Reduces Complications

41. Cardiovascular events 3 Microvascular complications 1 Macrovascular complications 2 Tight blood glucose control Tight blood pressure control Control of lipids 1.UKPDS Group. Lancet 1998; 352: 837–53. 2.UKPDS. BMJ 1998; 317: 703–13. 3.Colhoun HM et al. Lancet 2004; 364: 685–96. 4.BMA. Revisions to the GMS contract 2006/07. Delivering investment in general practice. London: BMA; 2006.

42. Monitoring Blood glucose controlWeightDietBlood pressureLipid profileFoot examinationKidney functionEye screening

43. Management of diabetes Multi-factorial approach: Optimal control of risk factors: Structured education Lifestyle management Optimal weight control Optimal blood glucose control Optimal blood pressure control Optimal control of cholesterol

44.  Life-style measures:  Weight management  Increased exercise  Dietary treatment  Smoking cessation  Treatment of depression Management of diabetes

45. Lifestyle measures Benefits: y Lowers glucose levels in blood y Contributes to weight loss y Improves physical and mental wellbeing y Improves insulin sensitivity

46. Drug therapy of T2DM Type 2 diabetes Insulin resistance B-cell dysfunction Metformin Glitazone Sulphonyluria Gliptins exenatide

47. Indication for Insulin Therapy in T2DM Tablet failure Severe intercurrent illness (MI, foot ulcer)Late diabetic complicationsPregnancy What insulin?

48. Insulin therapy For type 1 diabetes For type 2 diabetes

49. Leonard Thompson, 1922 In Jan, 1922, Banting and Best injected a 14-year-old "charity” patient His blood glucose had dropped Leonard lived a relatively healthy life for 13 years

50. Summary  Diabetes is common  Diabetes is associated with increased risk of CV complications and late organ damage  Good diabetes management reduces the risk of complications