Diabetes

Thousands of people in the uk have type 2 diabetes which remains undiagnosed. Millions of people are also at risk of diabetes, however, this can be reduced by exercise and diet.
Type 1 diabetes mostly impacts young people and children; it is commonly diagnosed at 10-14 years old. It is an autoimmune disease which destroys the insulin-producing beta cells in the pancreas.

Type 2 diabetes makes up 90% of those with diagnosed diabetes. It is more common in older people, and is a multifactorial disease caused by genetics and environment together, including obesity, excessive and unhealthy eating, a lack of exercise and stress. It is characterised by insulin resistance- the inability of insulin to move glucose into the cells for effective metabolism.  This results in overproduction of insulin, then a progressive decline in insulin production.

At- risk groups: type 2 diabetes
-The main modifiable risk factor is being overweight. Others include poor diet and lack of physical activity. Non-modifiable risk factors include factors such as ethnicity, and sex.
-Type 2 diabetes is 6 times more common in south Asian ethnicities, and 3 times more common in African / African-Caribbean ethnicities than general population. Women who have a history of gestational diabetes have 30% risk of developing type 2 diabetes.
-It is recommended that those with a glycated haemoglobin (HBAlc) of 42-47 mmol/mol (6.0-6.4%) should be considered as ‘high risk’.
-Patients with an impaired glucose tolerance or raised fasting glucose have an increased risk of progression to type 2 and other vascular complications.
-Some patients may have blood glucose levels above the normal defined range, but not high enough for a diagnosis of  type 2 diabetes. These are said to have ‘impaired glucose regulation’, or ‘prediabetes’.
-Prediabetes= greater risk of progressing to type 2 / developing CVD than the general population.

Type 1 diabetes
This condition has less clear risk factors than type 2. 85% of type 1 cases are in patients with no family history, however there is a genetic link. Those with variations in the HLA-DQA1, HLD-DQB1 and HLA-DRB1 genes have a higher risk of type 1 diabetes. Those with a family history with type 1 are 15X more likely to develop the condition.

Environmental factors: exposure to Coxsackie B4 virus, rotavirus, and cytomegalovirus may increase the risk of developing the condition

Signs and symptoms of diabetes
There is a great lack of awareness of what they are. Up to half of type 2 diabetic patients will already have complications of diabetes by the time they are diagnosed. As a result, the first presentation of type 2 may be a medical emergency, eg stroke, heart disease, blindness, renal disease, peripheral vascular disease which could require limb amputation. Some new cases of type 1 diabetes in children/ young people will present with diabetic ketoacidosis; a complication if diabetes characterised by v high blood glucose levels, presence of ketones in the blood/urine, and acidosis. This is a life-threatening condition; Those with diabetic ketoacidosis need emergency treatment with IV insulin and fluids, close monitoring in hospital and support.  People and parents need to raise awareness of signs of diabetes.

Signs of type 1 and type 2 diabetes can be spotted more easily by considering   the ‘4 T’s’: Toilet, Thirsty, Tired, Thinner. These signs occur more slowly in type 2 diabetes and they may be missed.
-Toilet: If a patient is developing diabetes, they pass more urine than normal (polyuria). They may need to use the toilet at night, wet the bed, or for babies have heavier nappies. This is because the glucose in the blood exceeds the renal glucose threshold, and is therefore excreted in the urine, causing water to also come out in the urine
Thirsty: As a result of polyuria, they will feel thirsty and drink more. Polyuria and polydipsia are osmotic symptoms.
Tired: The patient will lack ability to utilise glucose for energy, causing tiredness.
Thinner: The body attempts to compensate for a lack of glucose in cells by metabolising protein and fat, resulting in weight loss.
-Diabetics may get blurred vision, caused by a change in lens refraction because of hyperglycaemia. This normally improves once a patient’s glucose levels are normalised, and those recently diagnosed with diabetes shouldn’t buy new glasses for the first 3 months after diagnosis.
-Diabetics are also at risk of recurrent infections (particularly fungal infections and urinary tract infections) which can be causes by higher blood and urine glucose concentration, because it impairs phagocyte activity and causes poor wound healing.

Screening and diagnosis

-Population screening not recommended by UK National Screening Committee. Despite this, NICE recommends type 2 risk assessment is done in:
-Non-pregnant adults aged over 40
-Aged 25-39 if South Asian, Chinese African-Caribbean, black African, and other high risk black and minority ethnic groups
-Adults with conditions increasing the risk of type 2, eg: CVD, hypertension, obesity, stroke polycystic ovary syndrome, a history of gestational diabetes
-NICE states that community pharmacy staff should carry out these risk assessments and refer anyone with a high score to their GP for blood sugar tests. Staff in pharmacies that can’t carry them out should advise about using validated self-assessment tests.
-Those suspected to have type 2 should be assessed further to confirm the diagnosis

Those with diabetes normally have:
-raised HbA1c   (more likely to be higher in type 2)
-glucose present in urine
-type 1: ketones in urine and blood
-A diagnosis of diabetes is given if they have the symptoms, and one of the below…
-A random plasma glucose ≥ 11.1 mmol/ L
-A two-hour plasma glucose ≥ 11.1 mmol/L (taken 2 hours after a 75g glucose challenge in an oral, glucose tolerance test
-A fasting plasma glucose ≥ 7.0 mmol/ L
-HbA1c ≥ 6.5% (48 mmol/mol) on two separate occasions (usually taken 2-4 weeks apart)
-A diagnosis of prediabetes is given if they have one of:
-A fasting plasma glucose of 6.1-6.9 mmol/L
-A two-hour plasma glucose of 7.8-11.0 mmol/L
-HbA1c of 6.0-6.4% (42-47 mmol/mol) on one occasion
-Those with predibetes should be advised to improve their life-style, particularly diet and more exercise.

Pharmacists can play a vital role in preventing diabetes, by spotting the signs in patients, initiating tests and referring to appropriate professionals if needed. They should recommend anyone with 2 or more risk factors to undergo diabetes screening tests every 3 years.

Hackett, E and Crasto, W. (2014). Identifying patients with diabetes. The pharmaceutical journal, 293(7835), pp 494-496

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