Information provided relates to general trends

Lecture 5
Diabetes

Trend are identified from studying large groups of people with diabetes This information is not necessarily applicable to any specific individuals Many factors affect the course of illnesses Anyone with concerns following this lecture are welcome to discuss these with me

Food enters digestive system Sugar absorbed through intestines into blood

Pancreas
Blood carries sugar to cells

Insulin

Cells absorb sugar Sugar converted into useful energy

What is Diabetes?
Comprises a group of disorders characterised by raised levels of blood glucose Usually blood sugar levels: 3.5 to 6.5 mmol/l High blood sugar because pancreas cannot produce enough insulin (type 1) or is resistance to it (type 2) Insulin is the hormone responsible for the converting blood sugar into useful energy

History
References as early as 1552 BC to diabetes noted symptoms included: polyuria; weight loss, excessive thirst, sweet tasting urine, fatigue 1889 Mehring and Minkowski create diabetic dog by removing its pancreas 1921 Banting, Best, Collip & McLeod identify insulin & treat successfully depancreatised dog 1922 Leonard Thomson, 14 yo, weighing 65lb successfully treated

Type 1 Diabetes
Insulin Dependent Diabetes Mellitus Used to be called juvenile onset diabetes Most commonly begins during childhood Cells that produce insulin in the pancreas have been destroyed by the immune system Accounts for about 15% of people with diabetes Before & after insulin tx Best & Banting Need daily injections of insulin to survive

Type 2 Diabetes
Pancreas doesnt produce enough insulin or cells ignore it (insulin resistance)

Prevalence
About 3% of those UK have diabetes Type 2 rate = 0.4% in children & 10% in those over 65 Type 2 more common in those of African, Aboriginal & Hispanic descent in West About half undiagnosed Rates increasing - set to double over next 15 years Increasing incidence parallels that of obesity (e.g. Massachusetts: 1958 - 0.9%; 1995 - 3%)

Most people with diabetes have type 2 (85%)

Generally occurs in those over 40 years old Associated with obesity & runs in families to some extent Build-up of glucose more slow often unnoticed 30%-50% will require insulin injections Lifestyle issues prominent

Aetiology
Type 1 Genetics Environment Hypothesis ~30% risk in monozygots Virus, diet, stress Destruction of pancreatic cells Type 2 ~100% risk in monozygots Obesity, age, malnutrition in- utero Various

Only possible by good control of blood sugar

10

Aim is to prevent long-term complications

Treatments

Blood Sugar Levels

8 6 4

Insulin

Diet

Exercise

Typical Routine Type 1

1. Wake-up & test blood sugar levels 2. Adjust insulin & administer as required 3. Have breakfast 4. Test blood sugar levels before tea 5. Adjust insulin & administer as required 6. Test blood sugar levels before bed 7. Adjust insulin & administer as required have snack

Signs of Blood Sugar Levels

Hyperglycaemia Tiredness Nausea Hyperactivity Blurred vision Irritability Increased breathing Hypoglycaemia Headache Hunger Sweating Confusion Shaking Irritability Anxiety Blurred vision Drowsiness Confusion

Irreversible microvascular & macrovascualar damage Small Blood Vessel Damage

Eyes: Visual impairment Kidneys: renal dysfunction Nerves: foot ulcers

Chronic Poor Control - Health Implications

NHS Costs
5% of total costs & 10% of in-patient costs on diabetes care

Large Blood Vessel Damage

Brain blockages: Stroke Heart blockages: angina, MI Limb blockages: ulcers

Most costs are associated with complications Presence of complications = 5 times the cost, e.g., 5 times as likely to be admitted to hospital & stay twice as long

Scotland 2002/2003 = ~ 320 Million

Summary
Type 1 & 2 diabetes are chronic illnesses Those with diabetes need to keep blood sugar levels within certain ranges by manipulating insulin, diet and exercise continually If not the cost in human terms can be substantial The primary determinant of longer-term health is the self-care behaviour of people with diabetes

Psychological Issues
Barriers to self-care 1. Depression 2. Stress & Anxiety 3. Fear of Hypoglycaemia 4. Lifestyle change

Somatic symptoms include: change in appetite; sleep disturbances; fatigue

Consists of somatic & psychological sensations

Depression - Symptoms

Depression & Diabetes

Incidence rate of ~20% (5% of general public) Possibly because of imperfect relationship between self-care & health, or combination of acute & chronic stressors Clinic staff may not help Probably most significant correlate of poor control (r = 0.515, p < 0.001)

Psych. symptoms include: low mood; loss of interest; social withdrawal; worthlessness, guilt, low motivation Cognitive Triad Negative View of Self Negative View of World Negative View of Future

HADS depression scores by blood sugar control

8 6 4 2 0 Good Medium Poor

Anxiety / Stress & Diabetes

Blood sugar release is symptomatic of stress Lifetime prevalence rate of GAD is ~40% (~5% in adult population) Sig relationship with control (r=0.426, p=0.024) Symptom overlap problem often very important

HADS anxiety scores by blood sugar control

10 8 6 4 2 0 Good Medium Poor

Fear of Hypoglycaemia
Fear of unpleasant symptoms of very low blood sugars Typical stress reactions of hypervigilence & avoidance

Normal feelings re-set high

Often associated with high blood sugars

Symptom overlap a particular problem

Fear of Hypoglycaemia Worry scores by blood sugar control

42 40 38 36 34 32 30 Good Medium Poor

Trigger Bedtime blood sugar checks reading of 13% Thought (Illness Cognitions) What if something happens; Im all alone; Ill have some toast just in case Behaviour Has few slices of toast just in case Result High blood sugars next morning

Trigger Awaiting presenting @ work meeting Emotions Thoughts My blood sugars are low; I need to do something; I m going to faint Anxiety Fear Stress Symptoms Sweating Blurred vision Shaking

Lifestyle Change
Reflect culture, personal beliefs, choices & self-efficacy General finding is that periodic boosters are probably required for many Often not delivered effectively by diabetes services Other issues also influential (as mentioned) Exercise, diet, alcohol intake, smoking etc.

Behaviour Eat or drink sugary item

Summary
Diabetes is a chronic illness that impacts on all aspects of life

Treatments include insulin & adjusting lifestyle People with diabetes are responsible for this & thus are the primary determinant of longer-term health The costs in human & financial terms of poor control are great As self-care is paramount, psychological issues are fundamentally influential in current & long-term health Control improves by addressing barriers to self-care

The End