1. Diabetes – Diagnosis and assessment
M Nasim

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

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

11. 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).

12. 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

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