Members Seminar “An Overview of Diabetes Mellitus”

Dr Abu Ahmed

Clinical EndocrinologistTuesday 15th June 2010

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

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

1940 1960 1980 1996 2004 2005 2010

Mil

lio

ns

of

peo

ple

w

ith

dia

bet

es

Amos AF et al. Diabet Med 1997; 14 (Suppl 5): S1–S85.

Dia

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tes

pre

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ce (

tho

us

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ds

)

0

500

1000

1500

2000

2500

3000

1995 2000 2010

Type 1 Type 2

3 million by 20103 million by 2010

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 under 18.5 to 25 25 to 30 30 to 40 Over 40

BMI (kg/m2)

Pre

vale

nce

of

T2D

M (

%)

MaleFemale

As body weight increases, insulin resistance increases4

IR is closely linked to abdominal obesity2,3

Reducing abdominal obesity improves insulin sensitivity5

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.

Normal Impaired glucosetolerance

Time

Insulin resistance

Insulinproduction

Adapted from Bailey CJ et al. Int J Clin Pract 2004; 58: 867–876.

Normal IGT T2 diabetes Time

Insulin resistance

Insulin production

Glucose level

Beta-celldysfunction

Insulin resistance• It is the best predictor of T2DM• Factors contributing to IR:

– Obesity– Polygenic familial trait– Physical inactivity– Pregnancy– Drugs– Chronic hyperglycaemia

Causes of type T2 diabetes

Type 2 diabetesInsulin resistance

B-cell dysfunction

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

0

10

20

30

40

35 - 45 - 55 - 65 - >75

% of population

Age (years)

DiabetesIGT

cost

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 BP1

High glucose1

Other CV risk factors2

Insulin resistance CV risk

High cholesterol

Obesity

Causes of symptoms and signs High blood glucose levels Complications Treatment Cause of diabetes

Increased thirst polyuria Extreme tiredness Weight loss Blurred vision Genital itching or thrush Slow healing of wounds

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 BP1

High glucose1

Other CV risk factors2

Insulin resistance CV risk

High cholesterol

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

0

10

20

30

40

50

No history of MI History of MI7-ye

ar i

nci

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ce o

f ca

rdio

vasc

ula

r ev

ents

(%

)

No history of MI History of MI

Haffner SM et al. N Engl J Med 1998; 339: 229–234.

Non-diabetic

Type 2 diabetes

Remember – look at a person with Type 2 Remember – look at a person with Type 2 diabetes as if they have already had an MIdiabetes as if they have already had an MI

Macrovascular Microvascular

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

HbA1c

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 HbA1c

* p<0.0001

** p=0.035

UKPDS: Tight Glycaemic Control Reduces Complications

Cardiovascular events3

Microvascular complications1

Macrovascular complications2

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.

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

Life-style measures:

Weight management

Increased exercise

Dietary treatment

Smoking cessation

Treatment of depression

Benefits:Benefits: Lowers glucose levels in blood Contributes to weight loss Improves physical and mental

wellbeing Improves insulin sensitivity

Type 2 diabetesInsulin resistance

B-cell dysfunction

MetforminGlitazone

SulphonyluriaGliptinsexenatide

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

Diabetes is common Diabetes is associated with increased

risk of CV complications and late organ damage

Good diabetes management reduces the risk of complications