Type 2 Diabetes Mellitus:



Type 2 Diabetes Mellitus:

Overview 2007

Background:

The Canadian Health Council 2007 report indicates that roughly 1 in 20 Canadians, around 5% have type 2 diabetes (T2DM). However, the DIASCAN Study out of St. Michael's Hospital in Toronto found that 16.4% of primary care patients 40 years old or older had known diabetes.

|[pic] |[pic] |

|Source: Health Canada Council Report 2007 | |

The incidence of type 2 diabetes is increasing at a dramatic rate with projection by the World Health Organization (WHO) that there will twice as many people with T2DM by 2025 as there were in 2000. Much of this can be attributed to increased obesity, which is secondary to increased consumption of energy dense foods and a more sedentary life style.

There are a number of factors that will contribute to an increasing prevalence of diabetes in Canada including:

• an aging population (diabetes is more prevalent at older ages)

• an increasing worldwide prevalence of obesity

• an increase in the aboriginal population,who are especially predisposed to developing diabetes

• a decrease in physical acyivity

Pathophysiology of Diabetes

The natural history and pathophysiology of diabetes is now becoming well understood. Beta cells in the pancreas detect fluctuations in blood glucose and other nutrients. When blood glucose rises, insulin is released. Insulin reduces blood glucose at three levels: muscle (takes up glucose and stores excess as glycogen), fat (takes up glucose and stores excess as fat) and liver (stops production of new glucose -gluconeogenesis, decreases the break-down of glycogen into dextrose-gluconeolysis, and promotes glycogen synthesis from glucose.

|Insulin and Glucose Disposal in the Non-diabetic |The following factors or steps appear to be involved in the development of|

| |type 2 diabetes. |

|[pic] | |

|Source IDF Diabetes education modules accessed May 2007 |Diabetes begins with a genetic predisposition to B-cell deficiency in |

| |secretion and action of insulin, and to excess energy efficiency, |

| |resulting from exposure to an excess of calories, both through increased |

| |intake (energy dense foods) and reduced output (a sedentary lifestyle). |

| |With the expansion of visceral fat stores comes the expansion of hormones |

| |(e.g. resistin, fasting-induced adipose factor (FIAF)) and intermediate |

| |metabolites (free fatty acids) which interfere with insulin action. |

| |Hyperinsulinemia, the insulin-resistant phase occurs as the demand for |

| |greater insulin grows and can be considered a prodromal phase for future |

| |diabetes. Data indicates that 92% of people affected by type 2 diabetes |

| |are insulin-resistant. |

| |Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) occur |

| |after insulin resistance and are considered to be prediabetic stages. |

| |These stages can occur for varying lengths of time in different |

| |individuals depending on their genetic makeup and environmental factors. |

| |Some individuals may progress rapidly to overt type 2 diabetes, whilst |

| |others may progress gradually. A small proportion may even recover from |

| |this intermediate stage. This recovery is called reversion to normal |

| |glucose tolerance. |

| | |

|[pic] | |

|Source IDF Diabetes education modules accessed May 2007 | |

| | |

| |[pic] |

|Insulin insensitivity or hyperinsulinemia occurs before the development of T2DM. During |Source IDF Diabetes education modules accessed May 2007 |

|this phase more insulin is required to lower blood glucose levels. In this phase there is | |

|less uptake of glucose into muscle tissue and the liver. The liver does not receive the |Insulin and Aging |

|signal to stop glucose production thus it continues to release stored glucose-glucolysis |Insulin requirements increase as part of the normal aging process, which also results in |

|and to make new glucose-gluconeogenesis. Excess glucose is taken up by the fat cells and |beta cell loss. Primary failure occurs when insulin requirements exceed insulin |

|by the liver where it is converted to triglycerides resulting in "fatty liver." |production. People with T2DM lose 7% of their beta-cell function each year resulting in |

| |increasing insulin deficiency. Lifestyle and diet can help control blood glucose levels in|

| |some individuals, although the success rate is low. However, if diet/lifestyle changes are|

| |not effective or as beta-cell loss increases oral blood-glucose lowering drugs are |

| |necessary to maintain near-normal blood glucose levels. Eventually, around 50% of people |

| |with T2DM will require insulin therapy in addition to their oral glucose lowering therapy,|

| |which is known as 'secondary failure.' |

Risk Factors for Progression

The primary risk factors for progression to T2DM are:

| |First-degree relative with diabetes |

| |Age 40 years and older |

| |Member of high-risk population (e.g. people of Aboriginal, Hispanic, Asian, South Asian or African descent) |

| |History of IGT or IFG |

| |Dyslipidemia |

| |Hypertension |

| |Overweight |

| |Abdominal obesity |

| |Vascular disease |

| |Presence of complications associated with diabetes |

| |History of gestational diabetes mellitus |

| |History of delivery of a macrosomic infant |

| |Polycystic ovary syndrome |

| |Acanthosis nigricans |

| |Schizophrenia |

Reduced physical activity and being overweight are the major precursors of, and the most modifiable risk factors for, diabetes.

Definitions

Diabetes mellitus is defined as a metabolic disorder which is characterized by the presence of hyperglycemia (> 7 mmol/l) due to defective insulin secretion and/or defective insulin action.

Prediabetes is a term that includes impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). Subjects with pre-diabetes are at risk of developing diabetes and its complications, though not all individuals with prediabetes will necessarily progress to diabetes. Clinical experience indicates that a significant proportion of people (~25-30%) who are diagnosed with IGT will revert to normoglycemia.

Diagnosing Diabetes

|According to the 2003 Canadian Diabetes Guidelines |Plasma Glucose levels for diagnosing IFG, IGT, and diabetes |

|the following gives a diagnosis of diabetes. | |

| |[pic] |

|[pic] | |

However, diagnosing people at risk of developing T2DM and focussing on preventing T2DM should also be a goal of diabetes educators. People with IGT or prediabetes (which used to be called chemical, latent, preclinical or subclinical diabetes), have an increased risk of developing T2DM. Identifying patients with IFG and/or IGT, particularly in the context of the [pic]metabolic syndrome, identifies people who would benefit from nutrition and life-style education in the hopes of preventing progression to T2DM.

|Metabolic syndrome |

|Metabolic syndrome is a health condition defined by a clustering of independent risk factors that increase a patient's chance of developing heart disease, stroke and|

|diabetes. |

| |

|Risk factors include: |

|abdominal obesity |

|insulin resistance |

|elevated triglycerides |

|abnormal cholesterol profile |

|high blood pressure. |

| |

|When two or more individual risk factors appear in a single patient, the patient is deemed as having metabolic syndrome. Metabolic syndrome may sometimes be referred|

|to as insulin resistance, Syndrome X, glucose intolerance or Reaven's syndrome. |

|According to the International Diabetes Federation |

| |

|A diagnosis of the metabolic syndrome requires: |

| |

|Central obesity (defined as waist circumference 94cm for Europid men and 80cm for Europid women, with ethnicity specific values for other groups) - plus any two of |

|the following four factors: |

|raised TG level: 150 mg/dL (1.7 mmol/L), or specific treatment for this lipid abnormality |

|reduced HDL cholesterol: < 40 mg/dL (1.03 mmol/L) in males and < 50 mg/dL (1.29 mmol/L) in females, or specific treatment for this lipid abnormality |

|raised blood pressure: systolic BP 130 or diastolic BP 85 mm Hg, or treatment of previously diagnosed hypertension |

|raised fasting plasma glucose (FPG) 100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetes. If above 5.6 mmol/L or 100 mg/dL, OGTT is strongly recommended |

|but is not necessary to define presence of the syndrome. |

| |

|[pic] |

|References |

|Anderson PJ, Critchley JAJH, Chan JCN et al. Factor analysis of the metabolic syndrome: obesity vs insulin resistance as the central abnormality. International |

|Journal of Obesity 2001;25:1782 |

|Carr DB, Utzschneider KM, Hull RL et al. Intra-abdominal fat is a major determinant of the National Cholesterol Education Program Adult Treatment Panel III criteria |

|for the metabolic syndrome. Diabetes 2004;53(8):2087-94 |

|Nakamura T, Tokunga K, Shimomura I et al. Contribution of visceral fat accumulation to the development of coronary artery disease in non-obese men.Atherosclerosis |

|1994;107:239-46 |

|Bonora E, Kiechl S, Willeit J et al. Prevalence of insulin resistance in metabolic disorders: the Bruneck Study. Diabetes 1998;47(10):1643-9 |

|Nesto RW. The relation of insulin resistance syndromes to risk of cardiovascular disease. Rev Cardiovasc Med 2003;4(6):S11-S18 |

| |

Stages of Disease Acceptance: Staging Your Diabetes Patient

Diabetes is a condition that needs to be managed by the person on a day-to-day basis. People with diabetes want information on their disease and want to be in control of their condition.

Diabetes educators, including the primary care provider, expect that people will assume personal responsibility for their disease including the role of decision-maker. It is important that this assumption be made explicit and that the patient understand that their outcomes largely depend on their own efforts. People with diabetes need to become the experts in their own lives, which means that they need knowledge about the disease and their therapeutic options, including benefits and limitations.

People diagnosed with a disease do not view the psychosocial and behavioral aspects of their care as separate from the therapeutic aspect. They view their disease in its totality.

• Will this kill me?

• How will this affect my working? Could I lose my job?

• How will this affect my family?

• Can I still drink, smoke, scuba dive, jog, etc?

• How will I pay for the medication?

• Will I get better?

Before education on their disease can begin to help them become experts the educator must understand that the patient may not immediately accept the diagnosis of T2DM.

Diabetes patients often go through several stages of acceptance after being diagnosed. Understanding these stages will help in counselling the patient and educating them about their disease. Diabetes education is not likely to be effective before a person reaches acceptance of their disease as they will be preoccupied and unable to understand the importance of what you are teaching.

Stages of Acceptance:

Denial. The person is not ready to deal with the change in their health status, therefore they deny the illness. The person may deny the seriousness or existence of the condition and "won't let it concern" them. This denial can be very dangerous. Statements like, "I'm going to eat what I want," "Exercise isn't important to me," or "My diabetes isn't bad enough to require medication" are all common signs of denial. Diabetes not only incurs a loss of physical and/or emotional wellness but may also result in the loss of personal independence.

At this stage the DE need to be a compassionate listener. The DE is at risk of losing the patient if they are too forceful with a detailed explanation of the disease and how they have to manage it. With careful observations one can find an opening to start the patient on the path of acceptance. Questions like "who in your life has diabetes? How do they manage it?" That answer could allow the fears of the disease to be examined. Denial could be from the perceived loss of personal integrity. Inquire about the patient's attitude about illness. "What kind of illnesses have you or your family had in the past?" What effect did it have on you? How did it change your life?

Anger. The person becomes angry at everything and everyone. "I've paid my dues, had my yearly checkups, and gone to church on Sundays. Why did I get diabetes? It isn't fair!" The person may feel that people around them act as if the problem doesn't exist or the opposite extreme that those they love are now telling them how to live their lives, ultimately creating anger. People who stay in this stage can become very bitter, and others will begin to avoid them.

The DE has to be very careful at this stage to help the patient work out their anger and vent. A show of support will go a long way in creating trust. Traditional questions like "you seem angry" "That friend's comment seemed to strike a sore spot" can open dialog.

Depression. The problem really hits. The patient with diabetes may cry, feel sorry for themselves, or generally give up. More subtle signs include not taking an interest in anything, not sleeping well, and not performing necessary daily tasks related to managing the disease. They find no joy in anything, and things may seem hopeless. These feelings can become self-destructive.

With patients at this stage the DE has a responsibility to assess the patient's depression to ensure it is not life threatening. Appropriate referrals, starting with the family doctor and social worker would be necessary. Commonly used depression screening tools include the Beck Depression Inventory, the Zung Self-Depression Scale, the General Health Questionnaire, the 2-Whooley Questions could be used to help determine the status of depression. This test could be administered in the waiting room before the appointment. People may not recognize emotional symptoms as health related. They may instead see them as "personal issues" and feel that they should be capable of handling them on their own, without the involvement of the health care team. Asking patients questions like: are you nervous? Empty? Very tired ? Sad? , can help explore the depression the patient is feeling.

One good reference on Depression is National Institute of Mental Health: The Invisible Disease: Depression.

Normal Grief Reactions Versus Symptoms of Clinical Depression

|Normal Grief |Clinical Depression |

|Self-esteem intact |Self-esteem disturbed |

|May express anger openly |Usually does not directly express anger |

|Experiences a mixture of "good dysphoria|Persistent state of dysphoria |

|and bad days" | |

|Able to experience moments of prevalent |Anhedonia prevalent |

|pleasure | |

|Accepts comfort and support from others |Does not respond to social interaction |

| |and support from others |

|Maintains feeling of hope |Feelings of hopelessness prevail |

|May express guilt feelings over some |Has generalized feelings of guilt |

|aspect of the loss | |

|Relates feelings of depression to |Does not relate feelings to a particular|

|specific loss experienced |experience |

|May experience transient physical |Expresses chronic physical complaints |

|symptoms | |

Bargaining. A last ditch attempt is made at reaching a compromise with reality. "If I only overeat on weekends, that won't be too bad." "If I exercise more, I won't have to take insulin." "If I give more to charity, I won't have another heart attack." The danger of this stage lies in the fact that you can't bargain with a chronic illness like diabetes; there is no compromise with reality. In this stage, a person with diabetes may really be hurting their body.

The DE can take advantage of the positive aspects of bargaining. "It is wonderful how you can follow the healthy meal plan on weekends, can you try to chose a few healthy food choices on the weekdays?" Encourage small steps of progress. Don't overwhelm the patient.

Acceptance. Having gone through the previous four stages, people with diabetes finally accept the illness as a part of them - a reality that they must live with, a reality that they cannot escape. They recognize that their best chance for future happiness lies in both understanding diabetes and in a disciplined commitment to controlling the condition. They are now ready to become their own disease experts and are open to learning.

This is an exciting phase for all involved. However, we know that our patients can slide up and down this scale. The stage of acceptance can be short lived. Praise and support is essential. Acknowledgement that the patient may not be able to consistently maintain their goal but to encourage them to get back on track as soon a possible. "Congratulations on walking every day last week. You have missed several days this week, what can you do to get back to walking?" Creating a contract can be effective in maintaining focus and commitment and ensure that the patient has set realistic goals.

Optimal Management of Disease

Reducing the symptoms of hyperglycemia is the most important aim of T2DM management. Secondary aims include limiting adverse effects of treatment, maintaining and even improving the patient's quality of life and psychological well-being, and preventing or delaying microvascular complications.

The UKPDS study was a pivotal study that clearly demonstrated the benefits of intensive glucose lowering therapy compared to conventional glucose lowering therapy. However, when intensive combination therapy was used to control blood glucose levels, the mean HbA1C was 11% lower in the intensive than in the conventional group.

|[pic] |[pic] |

|Source IDF Diabetes education modules accessed May 2007 |Source IDF Diabetes education modules accessed May 2007 |

What is now clear is that due to the destruction of beta cells, regardless of the use of medications, over time blood glucose control deteriorates. This deterioration begins with increasing insulin resistance which leads to increased glucose levels, usually due to age or lifestyle choices, this is called impaired glucose tolerance (IGT). As the body attempts to compensate it increases circulating insulin levels, eventually leading to a maximal output of beta cell capacity or outright beta-cell failure. With this beta-cell dysfunction, less and less insulin is produced and while fasting glucose levels may remain normal, post-meal or postprandial levels become abnormal. Insulin resistance and beta cell failure are the underlying cause of T2DM.

Early Intervention

A recent report from the Health Council of Canada strongly urges a shift from managing patients with diabetes to prevention-focussed health care. The report concluded that "the way we now provide primary health care leaves too many people with diabetes vulnerable to serious health complications that could be avoided. A redesign of the traditional family doctor's practice - to introduce teams, technology and other tools for change - will help achieve better care and help keep Canadians healthier."

Key findings from this report include:

• People at high risk for developing diabetes can prevent or delay the onset of disease with the right care.

• People with diabetes can often prevent or delay complications with the right care.

• When people with diabetes receive care focused on preventing complications, they are healthier and spend less time in hospital, with lower public health care costs.

• Canadians with diabetes appear to have poor control of key risk conditions that can lead to complications.

• Too many Canadians with diabetes are left vulnerable to serious but avoidable complications because they don't get the help they need to manage their conditions.

|[pic] |With our aging and more sedentary population disease |

|Source: Health Canada Council Report 2007 |prevention equals intervention; external motivation/ support|

| |is generally required to make lifestyle changes or to begin |

| |medication. |

| | |

| |The primary goal for intervention in patients with T2DM is |

| |to normalize both the fasting blood glucose as well as the |

| |post-meal blood glucose level. Meeting and maintaining |

| |near-normal glycemia reduces the risks of long-term |

| |complications that occur with diabetes and improves the |

| |quality of life of the patient overall. Ideally, |

| |interventions in diabetes need to decrease insulin |

| |resistance and increase insulin to normal levels. Early |

| |interventions may make glucose normalization easier as the |

| |changes required will be smaller and many of the |

| |complications of diabetes will not yet have occurred. |

| | |

| |Recommended targets for glycemic control |

| | |

| | |

| |A1C |

| |FPG\preprandial PG (mmol\L) |

| |2 hour postprandial PG (mmol\L) |

| | |

| |Target for most patients |

| | ................
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