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Diabetes Flashcards

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1
Q

How does the patient present?

A 
Polyuria 
Polydipsia
Not sleeping well
Wakes up during the night to use the bathroom
Drinks more than usual
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2
Q

What question does the GP ask?

A

How much water is he passing a day?

How much water is he drinking a day?

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3
Q

What is prediabetes?

A

Blood sugars are higher than usual, but not high enough for you to be diagnosed with Type 2 diabetes.
Means that you are at high risk of developing type 2 diabetes

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4
Q

What are other terms for prediabetes?

A

Borderline diabetes
Impaired glucose regulation
Non-diabetic hyperglycaemia

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5
Q

What are the risk factors for diabetes?

A

Over 25 for African-Caribbean, Black African or South Asian
Over 40 if you are white
6x more likely if you have a direct family member
4x more likely in above groups
High blood pressure
Overweight
Large around the middle

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6
Q

How can type 2 diabetes be prevented?

A

Manage weight
Eat healthy, balanced diet
Be more active

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7
Q

What constitutes a healthy diet?

A 
Mediterranean diet
Dietary approaches to stop hypertension (DASH)
Vegetarian and vegan diets
the Nordic Diet
Moderately cutting down on carbohydrates
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8
Q

What is the NHS Diabetes Prevention Programme?

A

Joint commitment from NHS England, Public Health England and Diabetes UK
Deliver at scan, evidence-based behavioural interventions for individuals identified as being high risk

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9
Q

Why has the programme been implemented?

A

Many cases of type 2 are preventable
Behavioural interventions can greatly reduce the risk
Treatment accounts for 10% of NHS’s budget

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10
Q

What are the aims of the programme?

A

Reduce incidence
To reduce incidence of associated complications with diabetes e.g. heart, stroke, kidney and eye problems
Reduce health inequalities associated with diabetes

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11
Q

How was the NHS DPP developed?

A

Review of the available evidence from existing programmes
Informed development of core components
Established a user involvement group
Demonstrator sites selected
Commissioned analysis of health survey for England data

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12
Q

What is the intervention?

A

Core goals:
Achieving healthy weight
Achievement of dietary recommendations
Achievement of physical activity recommendations

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13
Q

Who is eligible to go on the programme?

A

Prediabetics
HbA1c 42-48mmol/mol
Fasting plasma glucose 5.5-6.9mmol/l

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14
Q

What are the referral routes into the programme?

A

Identified as having an appropriately elevated risk level
NHS Health Check Programme
Identified through opportunistic assessment as part of routine clinical care

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15
Q

What are the core defects in type 2 diabetes mellitus?

A

Insulin resistance in muscle and the liver

Impaired insulin secretion by pancreatic beta cells

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16
Q

What are other defects in type 2 diabetes mellitus?

A

Resistance to glucagon-like peptide 1 (GLP1) contributes to failure in function of beta cells

Increased glucagon levels and enhanced hectic sensitivity to glucagon contribute to the excessive glucose production by the liver

Resistance in adipocytes results in accelerated lipolysis and increased plasma free fatty acid levels (also contribute to failure of beta cells)

Increased renal glucose reabsorption maintains hyperglycaemic levels

Resistance to appetite suppressive effects of a number of hormones contributes to weight gain

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17
Q

How does glucose enter cells?

A

Insulin binds to insulin receptor on cell membrane
Glucose enters via GLUT4 transporter (insulin dependent)
Found in muscle and adipose
Via facilitated diffusion

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18
Q

What happens to glucose after it enters the cell?

A

Glycolysis
Link reaction (oxidation of pyruvate)
TCA cycle

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19
Q

What are the main features of GLUT-1?

A

Found in: endothelium and erythrocytes

Function: Basal transport (insulin independent)

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20
Q

What are the main features of GLUT-2?

A

Found in: Kidney, small intestine, liver and pancreatic beta cells

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21
Q

Where is active transport used to transport glucose?

A

Kidney and Intestine

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22
Q

What are the main features of GLUT-3?

A

Found in: Neurones and placenta

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23
Q

What happens when someone is insulin insufficient?

A

Cells weight GLUT4 transporters will be relatively deplete of glucose
Others with other transporters will intake glucose down conc. gradient

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24
Q

Per molecule of glucose, how many ATP can be produced?

A

Roughly 30

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25
What actions are prompted by insulin in the liver?
``` Tells liver to take up and store glucose (glycogenesis) Decreased gluconeogenesis Decreased lipolysis Decreased glycogenolysis Increased lipogenesis ```
26
What actions are prompted by insulin in muscles?
Increased glucose uptkae Increased glycogenesis Increase protein synthesis Decreased protein catabolism
27
What actions are prompted by insulin in fat?
Lipogenesis Prevent lipolysis Increased glucose uptake
28
What occurs in type II diabetes?
Tissues are insulin resistant | Body produces insufficiently producing insulin
29
What can initially occurs in type II diabetes?
Hyper-production of insulin by beta cells Eventually they can no longer produce this amount This is when a patient become diabetic
30
What would you see in the bloods of a diabetic patient?
Increased free fatty acids | Increased blood glucose
31
How can being overweight contribute to diabetes?
Visceral fat is particularly resistant to insulin Diabetes susceptibility genes Adipokines come from fatty tissue have toxic action on beta cells Inflammation
32
In what order would the condition come in?
Normoglycaemia Impaired fasting glucose Impaired glucose tolerance Type 2 diabete mellitus
33
What is a normal fasting glucose?
<5.5mmol/l
34
What is a normal post prandial glucose?
<7.8mmol/l | To obtain result you give them a 75g oral glucose load and result taken 2 hours after
35
What is a normal random glucose?
<11.1mmol/l
36
What are the main features of impaired fasting glucose?
Abnormal fasting glucose but not diabetic levels | Normal post-prandial and random
37
What are the main features of impaired glucose tolerance?
Cannot manage glucose adequately after a meal Post-prandial always abnormal Fasting glucose <7mmol/l, can be normal Random always normal
38
What values define diabetes?
Fasting glucose >7mmol/l Post-prandial glucose >11.1mmol/l Random >11.1mmol/l
39
What else need to be considered before giving a diagnosis?
HbA1c | Do they have symptoms?
40
What is impaired fasting glucose?
Predominantly hepatic insulin resistance leads to continuous glucose output from the liver
41
What is impaired glucose tolerance?
Predominantly muscle insulin resistance plus impaired post-prandial insulin release results in poos cellular glucose uptake
42
Which test is the least useful in diagnosing T2DM?
Urine dip test Glucose may be present at a level below diabetes Other conditions can cause glucose to be present in urine
43
What is the renal urine threshold for glucose?
About 10mmol/l Varies from person to person And within a person
44
What is an HbA1c?
Haemoglobin that has become glycosylated | Occurs non-enzymatically
45
Advantages of HbA1c as a diagnostic tool?
Hb has a lifespan of 120 days a so show glucose levels over a three month period Patient doesn't need to fast No need to waste resource on sugary drinks Patient doesn't need to come in 2 hours beforehand
46
Disadvantages of HbA2c as a diagnostic tool?
Co-morbidities may affect result e.g. Anaemia, HIV, pregnancy Relies on normal red blood cell/ Hb levels to compare with reference range If RBCs die early will give a falsely low reading
47
What is a behavioural insight?
Uses knowledge of how and why people behave to encourager positive behaviour change Considers psychology, social anthropology and behavioural economics
48
How can you optimise uptake to a programme e.g. DPP?
Discussion with GP who can explain admission Infographic and leaflets with simple instructions Target high risk group by sending personalised letters
49
How can you make an infographic most effective?
Think about the audience and adjust content Language Pictures featuring people from different ethnicities and sizes When talking about food think about different cultures
50
How can you ensure maximum retention on the programme?
``` Local/ less travel Convenient times Cater with healthy foods Incentives e.g. discount for health food store Make them fun and engaging ```
51
How can the DPP help with behavioural changes?
``` Progress monitoring Social activities with groups of people with similar goals Motivate each other Forums for healthy recipes Prepare for shogun with a list ```
52
What is the EAST framework for behavioural change?
Easy Attractive Social Timely
53
What is the medication used for diabetes?
Metformin
54
Why is Metformin used as first line treatment of T2DM?
``` Few serious side effects Safe to take for a long time Well tolerated Oral tablet- easy to take Does not cause weight gain Reduces risk of cardiovascular events Cheap drug ```
55
Where does metformin act??
``` Liver Fat Muscle Wide mechanism of action In cells with GLUT4 it increases translocastion of GLUT4 to membrane ```
56
What are the symptoms of T2DM?
``` Nocturia Polydipsia Fatigue Weight loss Thrush Itching around penis/vagina Cuts and wounds taking longer to heal Blurred vision ```
57
What are the two types of complications that can arise from diabetes?
Microcvascular | Macrovascular
58
Give some examples of microvascular complications?
Retinopathy—> Blindness Nephropathy—> renal failure Neuropathy—> Impotence and diabetic foot disorders
59
Give some examples of macrovascular complications?
Cardiovascular diseases | E.g. heart attacks, strokes, insufficiency in blood flow to legs
60
What can be shown to delay onset and progression of complications?
Good metabolic control
61
How is retinopathy caused?
Small blood vessel damage to the back layer of the eye, the retina leading to progressive loss of vision
62
How can retinopathy be diagnosed?
Regular eye examinations
63
How can retinopathy be treated?
Good metabolic control Early detection Timely intervention
64
How can nephropathy be caused?
Damage to small blood vessels in the kidney
65
What can diabetic kidney disease lead to?
Kidney failure Death Leading cause of dialysis and kidney transplant
66
What are the symptoms of nephropathy?
``` Usually no symptoms early on Feelings of tiredness Anemia Not think clearly Electrolyte imbalances ```
67
How can diabetic kidney disease be diagnosed?
Simple urine test for protein | Blood test for kidney function
68
How can nephropathy be treated?
Controls of high blood glucose Control of high blood pressure Intervention with medication Restriction of dietary protein
69
How does diabetes cause neuropathy?
Direct damage by hyperglycaemia | Decreased blood flow to nerves by damaging small blood vessels
70
What are the symptoms of neuropathy?
Numbness in extremities Pain in extremities Impotence Not recognising cuts and developing foot infections
71
What is diabetic foot disease?
Ulceration and subsequent limb amputation Most costly complications of diabetes Results from both vascular and neurological disease processes Comprehensive foot programmes can reduce amputation rates by 45-85%
72
How does diabetes cause cardiovascular disease?
Hyperglycaemia causes atherosclerosis ‘clogging of arteries’ | Narrowing causes decreased blood flow to cardiac muscle (heart attack) or brain (stroke)
73
What are the symptoms of cardiovascular disease?
``` Chest pain Leg pain Confusion Paralysis Etc. ```
74
How can cardiovascular diseases be diagnosed?
``` Early detection of other risk factors e.g. Smoking High blood pressure High serum cholesterol Obesity ```
75
How can cardiovascular diseases be treated?
Controlling risk factors | Controlling blood glucose
76
What is T2DM?
Chronic metabolic disorder associated with hyperglycaemia caused by impaired insulin secretion and insulin resistance
77
How is impaired insulin secretion caused?
``` By pancreatic beta cells dysfunctioning As a result of Lipotoxicity Glucotoxicity Resistance to incretins (intestinal hormones that stimulate insulin secretion) ```
78
What results from peripheral organs (liver, muscle, kidneys etc.) becoming insulin resistant?
Reduced glucose uptake from blood Excessive glucose reabsorption by kidney Increased gluconeogenesis
79
What causes insulin resistance?
Impaired insulin receptor signalling as a result of Genetic abnormalities Ectopic lipid accumulation Mitochondrial dysfunction Inflammation and endoplasmic reticulum stress
80
What determines the risk of complications?
Severity and duration of hyperglycaemia
81
What is the action of diabetes drugs?
``` Target hepatic glucose production Promotes insulin secretion Increases sensitivity to insulin Act on the inverting axis Target intestinal and renal glucose absorption ```
82
What percentage of diabetes cases are T2DM?
>90%
83
Why might incidence of T2DM have increase in China and India where there is a low prevalence of obesity?
Fat vs. Muscle ratios | Different fat distribution and a greater severity of beta cell failure

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