Diabetes – Diagnosis and assessment M Nasim

Epidemiology Global prevelance 4.6 % Diabetic population has doubled up in last 13 years Cluster observational survey - the authors concluded that screening of patients with a BMI of >or=27 and aged >50 by fasting glucose identified a substantial prevalence of undetected type 2 diabetes and IFG

Classification of Diabetes IDDM NIDDM MODY Maturity onset diabetes of the young is a form of diabetes which is distinct from typical non-insulin dependent diabetes mellitus in that: onset is early in life autosomal dominant inheritance no requirement for insulin fairly asymptomatic, picked up often at pregnancy low disease related mortality Gestational diabetes Approximately 1 in 400 pregnancies are complicated by diabetes. 95% of diabetic mothers are insulin dependent.

Classification- secondary diabetes pancreatic diseases causing diabetes Pancreatitis Pancreatic tumour endocrine diseases causing diabetes Acromegally Cushing Glucagonoma Pheochromatosis drugs and chemicals causing diabetes Steroid induced Thiazide diuretics Phenytoin

Diagnosis random venous plasma glucose concentration >= 11.1 mmol/l OR a fasting plasma glucose concentration >= 7.0 mmol/l If symptomatic – one reading If asymptomatic – needs two readings IFG fasting plasma glucose >= 6.1 mmol/l but < 7.0 mmol/l IGT Fasting plasma glucose < 7.0 mmol/l and OGTT 2-hour value >= 7.8 mmol/l but < 11.1 mmol/l The risk of subsequent conversion to diabetes is about 4.7% per year in Caucasians and higher in some ethnic minority groups Increased mortality risk (1.5%) Double mortality rate from CV causes

Aims of assessment of diabetic patient To educate the patient - DESMONDS To set goals for glycaemic control To detect any complications of diabetes and treat them as appropriate. To assess the patient's overall health and to treat any associated or coincidental illness, physical or mental. To provide support and Advice how they can best alter their lifestyle

Symptoms Polydypsia, Polyuria, tiredness, weight loss, Unexplained fatigue Blurred vision Repeat episodes of genital itching or thrush Slow healing of wounds Symptoms tend to develop quite slowly, over weeks or months

Examination Weight, height, BMI Smoking status BP and pulse Carotid bruits Heart sounds Peripheral pulses Inspect footwear (for suitability) and the feet carefully for any deformity, ulceration, or peripheral vascular disease. Check peripheral limb sensation – vibration sense using 128 Hz tuning fork, pinprick sensation with 'neurotips' and/or nylon monofilament probe

Legs for evidence of amyotrophy Ankle and knee jerks Inspect eyes, looking for any evidence of xanthelasmata, cataract formation or ophthalmoplegia Visual acquity Ophthalmoscopy- later would be digital retinal photography programme Depression Erectile dysfunction

Investigations Lipid profile HbA1c U&Es Estimated creatinine clearance / eGFR

Assessing and addressing modifiable risk factors Glycaemic control and how to improve it Smoking status and how to stop smoking if needed Dietary patterns and how to modify them (can help with improving glycaemic control) Exercise and how to incorporate regular physical exertion into one's life Lipid status and any lifestyle modifications or medication required to improve it Blood pressure and how to improve its control with medication and lifestyle modification Avoiding weight gain or losing weight (pertinent to both type 1 and type 2 patients).

BP Target – British Hypertension Society if no evidence of nephropathy Optimal BP target – 130/80 Audit standard – 140/80 Threshold for intervention – 140/90 if nephropathy Target BP 130/80 125/75 when proteinuria 1g/24hr

HbA1c target – JBS2 Ideal - <6.5% Audit target – 7.5%