Members Seminar “An Overview of Diabetes Mellitus”

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

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. Diabetes Mellitus

5. 3.5 3.0 2.5 2.0 Millions of people with diabetes 1.5 1.0 0.5 0.0 1940 1960 1980 1996 2004 2005 2010 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.

7. Types of diabetes

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

9. Type 1 diabetes

11. Type 2 diabetes

12. 14 12 10 8 Male Prevalence of T2DM (%) Female 6 4 2 0 18.5 or under 18.5 to 25 25 to 30 30 to 40 Over 40 BMI (kg/m 2 ) Adapted from Department of Health. Health Survey for England 2003.London: The Department of Health.

13. 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 ObesMetab 2000; 2: 121–129.

14. Insulin resistance Insulin production Time Normal Impaired glucosetolerance

15. Insulin resistance Beta-cell Glucose level dysfunction Insulin production Time Normal IGT T2 diabetes Adapted from Bailey CJ et al. Int J Clin Pract 2004; 58: 867–876.

17. 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. Environmental factors Genetic factors > 90% of T2DM are insulin resistant • Family history • Ethnicity • Obesity • Age • Diet • Lack of exercise Haffner SM et al. Diabetes Care 1999; 22: 562–568. Bloomgarden ZT. Clin Ther 1998; 20: 216–231.

20. % of population Diabetes IGT 40 30 20 10 0 35 - 45 - 55 - 65 - >75 Age (years) cost

21. Obesity CV risk Insulin resistance High glucose1 High BP1 High cholesterol Other CV risk factors2 1. Haffner SM et al. Am J Med 1997; 103: 152–162. 2. Reaven GM. J Intern Med 1994; 236 (Suppl 736): 13–22.

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

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

32. CV risk Insulin resistance High glucose1 High BP1 High cholesterol Other CV risk factors2 1. Haffner SM et al. Am J Med 1997; 103: 152–162. 2. Reaven GM. J Intern Med 1994; 236 (Suppl 736): 13–22.

33. Cardiovascular Death Rates: MRFIT data Stamler J., et al Diabetes Care: 16: 434-444

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

35. Diabetes complications

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

40. 21 UKPDS: Tight Glycaemic Control Reduces Complications Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA1c Deaths related to diabetes * MV complications 37 HbA1c 1% 14 Heart attack * Amputation or fatal PVD 43 * p<0.0001 ** p=0.035 Stroke ** 12 Stratton IM et al. UKPDS 35. BMJ 2000; 321: 405–412

41. Treatment Targets in Type 2 Diabetes Provide a Basis for Improved Outcomes Microvascular complications1 Tight blood glucose control Tight blood pressure control Macrovascular complications2 Control of lipids Cardiovascular events3 • 1. UKPDS Group. Lancet 1998; 352: 837–53. • 2. UKPDS. BMJ 1998; 317: 703–13. • Colhoun HM et al. Lancet 2004; 364: 685–96. • BMA. Revisions to the GMS contract 2006/07. Delivering investment in general practice. London: BMA; 2006.

43. 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

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

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

49. Leonard Thompson, 1922 • In Jan, 1922, Banting and Best injected a14-year-old "charity” patient • His blood glucose had dropped • Leonard lived a relatively healthy life for 13 years

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