Author: Christopher Saudek, M.D and Rita Rastogi Kalyani, M.D., M.H.S
Trinidad and Tobago Information Author: Claude Khan, BSc, MBBS, MRCGP, MSc and Nancyellen Brennan FNP, CDE
- In T&T, diabetes is commonly known as having "sugar "
- Newly diagnosed patients often present with HbA1c >9%; in other words, diabetes was likely present for some time before diagnosis.
- Persons of East Indian and African descent tend to have higher prevalence of diabetes (see Epidemiology of Type 2 Diabetes module)
- Currently, diabetes in T&T is managed primarily by general practioners.
- In T&T, there is only 1 board certified endocrinologist in the country and 1 diabetologist.
- In the public sector, physicians may have less time available to spend with each patient and limited resource availability (i.e. lab reagants), which can impact diabetes care.
- The Chronic Disease Assistance Programme (CDAP) provides T&T citizens with free prescription drugs for diabetes
- Current medications offered through CDAP for diabetes include: Glibenclamide (5 mg), Gliclazide (80 mg), Metformin (500 mg), Biphasic insulin (70% NPH, 30% Regular), NPH Insulin [link basal insulin], Regular Insulin.
- Current supplies offered through CDAP for diabetes include: insulin syringes and needles, glucometer test strips (Accuchek and Freestyle)
- Glucometer test strips have been available for any person taking insulin since 2008 through CDAP.
- Other medications offered through CDAP for hypertension, hyperlipidemia, and cardiovascular disease.
- Not infrequently, patients with diabetes have a fatalistic view of the disease (i.e. no matter what the patient does, the disease will not improve).
Diabetes education are imperative for effective diabetes management.
Diabetes mellitus is a common, chronic disease defined by hyperglycemia (high blood glucose), with multiple other metabolic abnormalities (i.e. acidosis) often present.
- The pathophysiology of diabetes is characterized by relative or absolute insulin insufficiency, due to either decreased insulin sensitivity and/or insulin secretory insufficiency.
- Insulin is the key hormone regulating uptake of glucose from the blood into most cells (primarily muscle and fat cells, but not central nervous system cells). Insulin is released into the blood by beta cells found in pancreatic Islets of Langerhans, in response to rising levels of blood glucose, typically after eating. Insulin also controls conversion of glucose to glycogen for storage in liver and muscle cells. Higher insulin levels increase anabolic processes such as cell growth, protein synthesis, and fat storage. Lower insulin levels result in catabolism and, in particular, can trigger ketosis or breakdown of fat.
- Diabetes mellitus ("sugar diabetes") is unrelated to diabetes insipidus except that they can both cause polyuria.
- About 23.6 million people, or 7.8% of the U.S. population had diabetes in 2007 (CDC), over 40% of those >40 years old with either diabetes or pre-diabetes (Cowie). Of these, approximately a quarter of individuals had undiagnosed diabetes. (See EPIDEMIOLOGY OF TYPE 1 DIABETES and EPIDEMIOLOGY OF TYPE 2 DIABETES
- The number of people with diabetes in the U.S. will almost double to 44.1 million in the next 25 years (Huang).
- Diabetes is the 7th leading cause of death in the U.S., responsible for about 1/3 of expenditures in Medicare, and the leading cause of: blindness among working age adults (due to diabetic retinopathy and macular edema), non-traumatic amputations, endstage renal disease and dialysis, and peripheral neuropathy.
Diagnosis and classification: type 2 diabetes (insulin resistance and relative insulin secretory defect) constitutes 90-95% of cases; type 1 diabetes (absolute insulin deficiency) constitutes 5-10% of cases; and other types (i.e. unusual genetic forms) constitute 1-5% of cases. Gestational diabetes is diabetes that is first diagnosed during pregnancy.
- Type 2 diabetes is highly associated with increased adiposity, particularly central (abdominal) (See ENVIRONMENTAL RISK FACTORS IN TYPE 2 DIABETES), and positive family history
- Type 1 diabetes is highly associated with specific genetic markers and is more prevalent in people of northern European ancestry (See RISK FACTORS IN TYPE 1 DIABETES).
- Acute complications: a direct, immediate consequence of hyperglycemia and other metabolic abnormalities, which resolve upon correction of these abnormalities. Examples: excessive thirst (polydipsia), frequent urination (polyuria), blurry vision, fatigue, ketoacidoisis.
- Polyuria and polydipsia usually occurs when blood glucose increases above urinary filtering threshold of 180 mg/dL. Blurry vision occurs due to osmolar shifts from hyperglycemia within the lens.
- Chronic complications: occur over years or decades of diabetes, and are difficult or impossible to reverse. Examples include microvascular complications (i.e. small vessel disease) such as retinopathy, neuropathy, and nephropathy or macrovascular complications (i.e. large vessel disease) such as coronary heart disease, peripheral vascular disease, or stroke.
- Pathophysiology for both microvascular and macrovascular complications are similar; both occur due to oxidative damage from long-term, uncontrolled hyperglycemia, resulting in plaque formation and narrowing of small- and large-sized blood vessels and ischemic damage to end organ tissues.
- Cardiovascular disease can be fatal. The risk of cardiovascular disease is increased 2-4 times by diabetes.
- Other common complications include poor wound healing, increased susceptibility to infections, erectile dysfunction, and gastroparesis.
- Many comorbidities associated with diabetes may influence management including: HIV, cystic-fibrosis, PCOS, post-pancreatectomy diabetes and Cushing's syndrome. Sleep apnea and depression are also common.
- Diabetes during pregnancy may be associated with neonatal and maternal complications if not optimally managed (See gestational diabetes).
- Prevention of diabetes, or the progression from "pre-diabetes" to diabetes, particularly by healthy lifestyle and obesity management, would be the ideal.
- Once the diagnosis of diabetes is established, treatment includes a Medical Nutrition plan, pharmacologic therapy as indicated with oral agents or non-insulin injectables (sulfonylureas and secretagogues, alpha-glucosidase inhibitors, thiazolidinediones, metformin, DPP-IV inhibitors, incretin mimetics) or insulin (basal insulins and bolus insulins), regular monitoring by the health care professional, and, most importantly, education of the patient about living with diabetes. In 2004-2006, 57% of people with diabetes took oral medications only, 16% insulin only, and 13% combined insulin and oral agents, and 14% no medication (CDC). Bariatric surgery may be offered to individuals with severe obesity and lead to improvement of diabetes.
- Medications used to treat complications and comorbidities of diabetes may exacerbate hyperglycemia including: antipsychotics, thiazide diuretics, beta-blockers, niacin and several antibiotics.
- Chronic microvascular complications of diabetes can be delayed or prevented by optimal glycemic control (i.e. A1c <7%) as demonstrated in several key studies including the Diabetes Complications and Control Trial (DCCT) in type 1 diabetes and the UK Prospective Diabetes Study (UKPDS) in type 2 diabetes.
- Both elevated blood glucose and other cardiovascular risk factors should be treated. A1c targets may be higher in children and the elderly.
- To reduce cardiovascular disease, address tobacco abuse, obesity, hypertension(goal <130/80 mmHg) and dyslipidemia (i.e. LDL<100 mg/dl). Glycemic control is also important as demonstrated in recent studies.
- To reduce retinopathy, neuropathy and nephropathy, blood glucose control is most important.
- Management of acute complications such as ketoacidosis, severe hyperglycemia, diabetic foot, or myocardial infarction, should include follow-up to establish good outpatient care.
- Optimally, a team is available to address the needs of the patient, including a nurse educator, nutritionist, primary care physician, podiatry, ophthalmology, and other specialties as indicated.
- An informed, involved patient is the essential center of every successful diabetes care plan.
- Diabetes is manageable. Its complications are not inevitable with optimal glycemic control and cardiovascular risk factor management, and can be treated if they occur.
- Diabetes nevertheless is a serious disease which can and does cause devastating complications and premature death, particularly if not well treated.
- Diabetes is a major and growing burden to society, due primarily to its long term complications, but also to its longitudinal care and the growing population of elderly individuals.
- Societal issues surrounding diabetes remain important to address, include driving with diabetes and employment discrimination.
- Cowie CC, Rust KF, Ford ES, et al.;
Full accounting of diabetes and pre-diabetes in the U.S. population in 1988-1994 and 2005-2006.;
Comments:A recent publication from NIDDK reporting an alarming 40% of people age > 20 years in the U.S. with either diabetes or pre-diabetes.
- Huang ES, Basu A, O'Grady M, et al.;
Projecting the future diabetes population size and related costs for the U.S.;
Comments:Modelled projection of rates of diabetes in the U.S. over the next 25 years.
- No Author Listed;
Diabetes Data and Trends;
Comments:Centers for Disease Control and Prevention (CDC), excellent source of reliable data on diabetes in the U.S.
- No Author Listed;
Diabetes Facts and Figures;
Comments:International Diabetes Federation (IDF), excellent source of reliable data on diabetes worldwide, as well as educational programs.
- No Author Listed;
National Diabetes Education Program;
Comments:The National Diabetes Education Program has useful, multicultural education information and resources.
- No Author Listed;
National Diabetes Information Clearinghouse (NDIC);
Comments:The National Institute of Diabetes, Digestive and Kidney Diseases has reliable diabetes information
- No Author Listed;
American Diabetes Association;
Comments:The American Diabetes Association is a reliable source of diabetes information, and has multi-faceted programs for people with diabetes.
- No Author Listed;
Juvenile Diabetes Research Foundation International;
Comments:The Juvenile Diabetes Research Foundation is an important funder of diabetes research as well as source of reliable diabetes information.