UNDERSTANDING DIABETES

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What is Diabetes?

Diabetes is a common and chronic condition affecting approximately 4.4% of the population. There are at least 228,004 people in Scotland with diabetes and approximately 13,250 people with a recorded diagnosis in NHS Highland. The condition is largely self-managed by the person with diabetes and requires support from multidisciplinary teams in both general practice and hospital settings.
Therefore, providing good quality care for people with diabetes requires co-ordination and co-operation of the person with diabetes and the health care professionals working across a range of professions and organisations.
A diagnosis of diabetes can only be confirmed by tests which are carried out by a doctor or nurse.  See also Diabetes UK.

What are the Aims and Objectives of Diabetes Care?

The aims of diabetes care are to ensure effective detection, management and treatment for people with diabetes and to provide equity of care in a co-ordinated manner across Primary, Secondary and Tertiary care throughout the region.

Aims

• To promote high standards of care in NHS Highland
• To facilitate integration of care of people with diabetes in general practice
• To improve quality of life of people with diabetes by early detection and treatment of the disease
• To minimise the morbidity and mortality associated with diabetes

Objectives

• The identification and registration of all people with diabetes
• The maintenance of a  diabetes register for NHS Highland
• To offer all people with diabetes a high standard of care, including annual review, in a primary or secondary care clinic
• To consider referral of appropriate people for specialist assessment
• To audit the care of people with diabetes by following well defined and agreed protocols.

What are the main types of diabetes?

Type 1 Diabetes

• Usually presents as children/young adults BUT can present at any age
• Autoimmune destruction of pancreatic beta cells
• Associated with immune markers eg GAD antibodies
• Insulin deficiency is main problem
• Results in weight loss and ketonuria
• Risk of ketoacidosis high
• Requires urgent treatment with insulin.

See also Diabetes UK - WHAT IS TYPE 1 DIABETES?

Type 2 Diabetes

• Usually presents in middle and older age BUT younger people becoming more common
• Many are obese (see Dietary Advice)
• Combination of peripheral insulin resistance and relative insulin deficiency
• Usually no ketonuria
• Risk of ketoacidosis low.

See also Diabetes UK -  WHAT IS Type 2 DIABETES?

LADA – Latent Autoimmune Diabetes in Adulthood

How does LADA differ from type 2 diabetes?

• Patients with LADA may lack some of the features of  type 2 Diabetes eg age, obesity, lack of response to oral hypoglycaemic agents
• Individuals with LADA may not require insulin therapy in the early stages
• There may be no evidence of ketoacidosis at presentation however there is an underlying state of insulin deficiency therefore a risk of ketoacidosis with time or during intercurrent illness.
•  Individuals with LADA  share features common to people with both type 1 and type 2 diabetes.
• This condition is also associated with immune markers eg anti glutamic acid decarboxylase antibodies (GAD antibodies)

How common is LADA?

• The UK Prospective Diabetes Study found that antibodies specific to LADA cases are found in  6-10 % of type 2 diabetes cases. Amongst younger patients, the incidence is more common.

How is LADA diagnosed?

• Diagnosis is based on clinical features and presence of GAD antibodies
• These antibodies can identify LADA, and also can predict the rate of progression towards insulin dependency.

Are some people more prone to LADA?

• Suspect LADA if there is:
• An absence of metabolic syndrome features
• Uncontrolled hyperglycaemia despite using oral agents
• Evidence of autoimmune diseases (including thyroid disease and Pernicious Anaemia).

How is LADA managed?

• Treatment is focussed on controlling hyperglycaemia
• Preservation of beta cell function with Metformin and thiazolidinediones may be appropriate however sulphonylurea therapy or insulin may be required if ongoing hyperglycaemia and/or symptoms.

Other types

• Recognised genetic syndromes e.g MODY (Maturity Onset Diabetes of the Young)

Secondary Diabetes

• Pancreatic destruction e.g. pancreatitis, haemochromatosis, cystic fibrosis
• Syndromes associated with insulin resistance e.g Acromegaly, Cushing’s syndrome.

 Gestational diabetes

• Glucose intolerance of variable severity with first onset during pregnancy (see Oral Glucose Tolerance Test (OGTT)) please note that this link points to a page on the NHS Highland intranet and so will not work if you are accessing this information by a connection outside of NHS Highland
• 60% increased risk of type 2 diabetes within 20 years particularly if the person is obese (see Lifestyle Factors)
• Small proportion represent coincidental development of Type 1 diabetes in pregnancy

What is HbA1c?

The blood sugars checked at home do not always tell the whole story - so in clinic we measure HbA1c (short for "Haemoglobin A1c". You will sometimes hear this referred to as "glycosylated haemoglobin"). If the blood sugar has been high a lot of the time, the HbA1c level will be high too.

Haemoglobin is found on red blood cells, and it carries oxygen around the body. Over time, some of the haemoglobin becomes attached to glucose, to form glycosylated haemoglobin. When the blood sugar is high, glycosylated haemoglobin (HbA1c) is formed more quickly – and higher levels are found in the blood. Blood cells are gradually replaced over time, so the HbA1c reflects average blood sugar over the previous 12 weeks or so.

For further information in a printable format click here