High blood sugar levels if untreated will cause shortterm effects and longterm complications. High blood sugar levels over the short term do not cause any damage to the organs of your body, however they will cause you to feel tired and weak, be thirsty and urinate a lot, be susceptible to infections and have blurry vision. In fact in the elderly, high blood sugar levels can lead to dehydration, electrolyte imbalance and lead to falls and of course we know getting a broken hip as an elderly individual can be pretty devastating.
Now high blood sugar levels over the long term, lets just say years, that can lead to the classic chronic complications of diabetes, eye disease or what we call retinopathy that leads to blindness, kidney disease or nephropathy leading to kidney failure necessitating either dialysis or transplantation and nerve disease or neuropathy which commonly leads to amputations. In addition, poorly controlled diabetes over the long term can also contribute to heart disease, along with inadequately controlled cholesterol and blood pressure levels. Doctors recommended Omega 3 is the single most important supplement you can take to.
Neuropathy Solution Program by Randall Labrum Review
Neuropathy Solution Program by Randall Labrum Review Neuropathy Solution Program by Randall Labrum Review is a safe and simple treatment program for permanently and effectively getting rid of neuropathy, stopping chronic peripheral neuropathy and diabetic nerve pain without having surgeries. The easy to implement techniques taught in the course use an instant relief from the agonizing pain, prickling and numbness and focus on the root causes of the neuropathy pain. They work on the microscopic level to cure nerve endings as well as macroscopic needs like lifestyle changes which can resolve many diseases like heart disease, diabetes and arthritis.
The stepbystep, doneforyou program inside Randall Labrum’s Neuropathy Solution Program guide works regardless of your age, ethnicity, gender, background, no matter your peripheral neuropathy results from chemotherapy, diabetes, hypertensions, without any costly drugs or pills or supplements. Examples Of Techniques And Concepts Taught In The Course Little known technique for relieving pain in most neuropathy sufferers Ways to start eradicating not only numbness, but also various kinds of pain popularly associated with peripheral neuropathy, such as prickling, tingling, stabbing, burning,. General understanding about peripheral neuropathy, why you have that problem.
And how to execute the selftreatment procedures. Why the sensory nerves become unhealthy and why they send abnormal signals to the sufferers’ brain. The thing associated with diabetes condition which often leads to the growth of peripheral neuropathy and what sufferers should do to prevent it. The link between circulatory health and the onset of peripheral neuropathy, how to make use of this connection to reverse the effects of neuropathy. The reason why a lot of middleaged people suffer from peripheral neuropathy, even when they do not suffer from diabetes or chemo at all.
Why those sufferers could expect a rapid, full recovery if they properly follow the steps introduced in Neuropathy Solution program. The reason why aging usually increase the degeneration of the sensory nerves and what you should do to prevent this process, reducing the risk of peripheral neuropathy. The littleknown link between the common ailment of lower back pain and the condition of peripheral neuropathy and what people could do to lessen the pain in lower back and impacts caused by two conditions. The simple routine that supplies you with dramatic results than your imagination.
Social Security Disability and Type II Diabetes
Hi. This is Jonathan Ginsberg. I would like to talk to you today about how I approach Social Security disability cases involving Type II diabetes. Type II is the typically adult onset diabetes. It is not juvenile or Type I diabetes. That’s really a separate type of category but Type II diabetes. Of course, we’re seeing a lot of that because of diet, obesity, that type of thing, and so a lot of people have it. Of course, since diabetes is fairly common judges see it a lot. So in turn they expect more from.
Claimants with diabetes. So really what I’m looking for in a diabetes case or what I think helps win would be several things. One is you should definitely be compliant with your medication. Ideally, you’d be on insulin. It’s much more difficult to win a case when you’re on the blood sugar pills without something else. So typically for a diabetes only case I’m looking for an insulin dependent diabetic. Someone who is compliant with taking the insulin. It’s not good enough to say anymore I can’t afford my medication and so I don’t take it.
All the time or I don’t like the way I feel. You’ve got to take the medications on time. You’ve got to be compliant with who put the diet. Typically in a Type II diabetes case, your doctor will give you a diabetic diet. American Diabetes Association Diet will restrict your calories and limit your sugar and simple carbohydrate intake. Very important to be compliant with that. If I see in a medical record that my client is not compliant, that he or she is drinking alcohol or is not compliant with the.
Diet, that makes it much more difficult to win. I think judges are looking for cases where there is neuropathy which is pain in the nerve. Typically, that is that numbness and tingling you’ll feel in your hands or your feet andor blurred vision which is the retinopathy where the vision is being affected. The capillaries in the eye are being damaged by the blood sugar fluctuations. We’re also looking for situations where diabetes has been longlasting. 10 years, 15 years because as you know diabetes is a progressive disease and.
The damage from the blood sugar fluctuations tends to accumulate. So if you’ve been diabetic for four or five years unless you really didn’t know, you were not compliant, didn’t have medications and had a lot of damage very quickly, judges typically are looking for cases where somebody had diabetes for a number of years. I think some of the other things that judges look for and I’ve won cases with, people who need to take frequent bathroom breaks. Obviously, diabetes causes a frequent need to urinate, having a lot of bathroom breaks in excess of what is normal which might be.
Twice a day. That can be a real problem in a work environment, especially in an unskilled work environment. So that’s one of the things that I ask my clients to keep track of. Variations and wild swings in blood sugar. I’ve had people tell me that low blood sugar is actually more debilitating than high blood sugar because it causes confusion and it’s more difficult to recover from. So if your blood sugar fluctuates and you cannot keep it at a certain level, that’s probably a stronger argument than one where the level is a little bit high. It’s may.
Be a 150 blood sugar 125, but it’s worse when it goes from 40 or 60 to 300 and back and forth and so forth. So that’s what I look for. Realize that judges see diabetes as sort of a longterm controllable illness that if you take your medications and watch your diet, it’s something you should be able to live with and it doesn’t necessarily mean you’re disabled. So what we’re really looking for are cases where there has been organ damage especially liver, kidney, that type of thing. There is.
Retinopathy, blurred vision that is not really correctable with glasses, neuropathy that you can’t feel your feet. Maybe you have situations where you’ve broken a toe because you can’t feel your feet. Things like that. So despite everything you’re doing to help yourself, the symptoms are just becoming too intrusive. It makes it difficult to perform work because of the constant pain or because of difficulty in mobility and that sort of thing. So that’s what judges are looking for in diabetes cases currently. So again I would urge you to keep good records of your symptoms. Keep a.
Ep. 4 Blood Sugar And The Body
When blood sugar levels rise, all that excess blood sugar doesn’t just affect the blood. In fact, its other effects are what gave diabetes its name. Welcome to The Diabetes Download, brought to you by Cornerstones4Care. Michael Stevens here. Breaking down diabetes. The fancy medical term for diabetes is diabetes mellitus. Why Well, a thousand years ago, people didn’t have supercool meters to easily measure blood sugar levels. But they did have dogs. Ancient Chinese and Japanese physicians noticed that some people’s urine was particularly enjoyedby dogs. And sure enough, when they examined it themselves, they found that it tastedwell, like urine, but sweeter than usual.
Later, this strange symptom, surprisingly sweet urine, became part of the namemellitus meaning pleasant tasting, like honey. What made the urine sweet Well, if the body’s normal way of dealing with glucose isn’t working because of diabetes, and it isn’t being managed by other means, some of that extra sugar has no other choice but to get urinated out. Glucose is filtered out by the kidneys, pulling a lot of water with it. If your blood sugar is too high for too long, glucose and all that water can start to build up in the bladder. Your urine becomes sweeter, and more FREQUENT.
Excuse me Which is where the word diabetes comes from. In ancient Greek it meant, PASSING THROUGH a large discharge of urine. More frequent urination than usual can be a symptom of diabetes. The same goes for excess glucose expelled in the urine. But even though glucose is literally sweet, high glucose levels aren’t sweet’ in the figurative sense of good’ or pleasant’they’re seriousand important to monitor and understand. Now let’s separate diabetes myth from fact with some help from WebMD MYTH If you have diabetes, you can’t eat any sweets.
FACT Actually, it’s OK to have a sweet treat once in a while. Just make sure to work it into your meal plan for that day, and adjust your medications if you need to. And make it a treat, not an everyday habit! Sugar. Seems harmless enough when it’s on our plate. But when too much of it from the food you eat stays in your blood for long periods of time, it can affect your nerves, your kidneys, and even your eyes. People with diabetes also have an increased risk for heart disease and stroke.
Scientists believe that having high blood sugar for too long has an effect that can damage your nerves, something called diabetic neuropathy. Nerves send signals to places all over your body. So if they get damaged, a variety of things can happen. You may feel either pain or numbness. Why numbness Well, if damaged nerves aren’t able to send messages to your hands and feet, it can result in loss of feeling there. If you’ve ever had your arm or leg fall asleep, you have an idea of what that sensation is like.
What if you got a blister on your foot and you couldn’t feel it You may not notice for a while, and by that time, it can become infected. That’s why it is so important to check your feet every day. The kidneys’ role is to help our bodies filter out waste. Diabetes can damage the kidneys and, over time, cause them to fail. If this happens, waste builds up in your blood instead of leaving your body. Another part of the body that can be affected by diabetesthe eyes. The most common eye disease in people with diabetes is retinopathy, a disease of the retina in the back of the eye.
Over time, retinopathy can possibly lead to vision loss, with little warning beforehand. You can even have retinopathy severe enough to threaten your eyesight without even noticing a difference in your vision. That’s why it’s so important to schedule regular exams with an eye doctor, at least once a year, to get your eyes checked. The sad truth is, someone with diabetes is twice as likely to have a heart attack or stroke as someone without diabetes. And people with diabetes tend to develop heart disease or have strokes at an earlier age.
So we learned that diabetes can have some pretty harmful effects. That’s why it’s important to educate yourself about the effects of diabetes and what you and your health care provider can do about them. Talk with your health care provider to learn as much as you can about how diabetes affects the body. So let’s break it all down Excess blood sugar can affect nerves and blood vessels all over the body, which can potentially lead to health complications in places like the eyes, kidneys, and the nerves in the hands and feet.
The good news is, diabetes can be managed. And keeping blood sugar numbers where they should be is an important part of your diabetes care plan. So that’ll do it for this episode of The Diabetes Download. We’ll continue breaking down diabetes with other helpful tutorials. Still have questions Find answers at Cornerstones4Care. It’s a great resource for learning more about diabetes. Sign up today and get 247 access to an online diabetes support program designed to help you manage your diabetes, your way. Cornerstones4Care is a registered trademark of Novo Nordisk AS.
Diabetic nephropathy Mechanisms
One of the most serious chronic complications of diabetes mellitus is a condition known as diabetic nephropathy. Which, if you break down the term into nephro and pathy literally means kidney disease that occurs secondary to diabetes. And it’s actually pretty common as it eventually affects about 20 to 40 of all individuals with diabetes, including both type I and type II. In this tutorial, let’s talk about the mechanism underlying the cause of diabetic nephropathy and how individuals with diabetes develop the condition. So diabetic nephropathy is a chronic complication.
Of diabetes mellitus. Meaning, it usually has a slow progression over decades after the initial diagnosis of diabetes. And to give you an overview of what happens, an insulin deficiency due to the diabetes results in hyperglycemia, which then causes hypertension and kidney dysfunction. This kidney function is actually then further worsened by the hypertension. And ultimately, all of this results in kidney failure, which can have very severe and potentially even life threatening complications, such as anemia, electrolyte imbalances, such as metabolic acidosis, and heart arrhythmias. Now, before we dive into the mechanism.
Of diabetic nephropathy, let’s briefly review the structure of the glomerulus in the kidney, by bringing in a diagram here. So, the glomerulus is the portion of the kidney where blood is initially filtered. So blood enters the glomerulus over here, through this afferent arterial, and then leaves the glomerulus through the efferent arterial. And you can remember this, that it leaves through the efferent arterial for E for exit, or efferent. And while the blood is within the glomerulus, there’s this advanced filtration system, which we’ll talk about more in a minute.
And the filtered fluid that exits the blood is known as a filtrate and it collects in Bowman’s space before it enters into the tubules of the nephron where further reabsorption and secretion occurs before it exits the kidney into the ureters as urine. Now, one last structure to point out in this diagram is this vessel coming off the efferent tubule, here. Now, this vasculature actually wraps around the tubules of the nephron, and contributes to the reabsorption and secretion of solutes. Now, to add to this diagram, let’s imagine we took a cross section of this glomerulus,.
And looked at it on its end. And it would look a little bit something like this. Now, we can use this diagram here to better depict some of the important structures within the glomerulus. So here you can see the capillary vessels, and each of them I’ve drawn in here a little red blood cell to help remind you that it’s a blood cell. And as you can see, these vessels are surrounded by a few additional structures that we couldn’t really appreciate in that first diagram. So these are the structures that contribute.
To the three layered filtration system of the glomerulus. The first layer is that of the vascular endothelium. So the endothelial cover, the inside of the blood vessel, so the capillary wall, there. And then the second layer is the glomerular basement membrane, or GBM for short, which is a specialized basement membrane that surrounds the vascular endothelium. And then the last filtration layer is the visceral epithelium, which is also known as the podocytes. Now, in between all these capillaries here is the mesangium, which is comprised of cells known conveniently as.
Mesangial cells. And they produce a collagen network that structurally supports all of these capillaries and it’s across this space that filtration occurs within the glomerulus of the kidney. So how exactly does diabetes, a problem with insulin deficiency, result in kidney damage Well, the answer includes multiple compounding factors. Now, the first component is an increased pressure state within the nephron. And this is due to two mechanisms. And the first is hypertension, which is a common comorbidity associated with diabetes mellitus. So hypertension or high blood pressure results in an increased pressure throughout.
The entire arterial vascular system. And this includes the afferent arterial of the glomerulus. So, to think about how this increases the pressure within the glomerulus, let’s think about a simple garden hose. So, in the middle of the garden hose, there’s a hole. And as water flows through the hose, a small amount of water will leak out through this hole. But if we open up the spigot all the way this is going to increase the pressure of the water traveling through the hose, and intuitively, this change is going to result.
In more water leaking from the hole here in the center and that’s because there’s increased pressure forcing it out of the hole. Now this is similar to what occurs in the glomerulus. The hypertension increases the pressure, just like turning on that spigot, which in return increases the filtration rate of the glomerulus, which can be thought of as that leakiness from the hole in the garden hose. Now, the other mechanism contributing to this high pressure state, is something known as vasoconstriction of the efferent arterial. Which is just a fancy way of saying.
That this blood vessel constricts or gets smaller in diameter. So, to understand why this occurs, we need to briefly review the reninangiotensinaldosterone system, or RAAS, for short. So renin is a hormone that’s secreted by the kidneys in response to decreased renal profusion, or low blood flow to the kidney. This is a sign of low fluid volume throughout the body. So in the response to a low fluid volume, renin has a cascade of effects in order to maintain blood pressure as well as volume status. And one of these effects is constriction.
Of the efferent arterial, which then maintains this pressure within the glomerulus in the presence of a decreased renal profusion. So once again, let’s go back to this garden hose to understand this a little bit better. Now, instead of turning up the spigot, as we did before, what do you think would happen if you were to kink the hose on the other side of the hole Once again, intuitively, this is going to increase the pressure behind the kink and subsequently will increase the rate at which water leaks out the hole.
So once again, this is similar to what occurs in the glomerulus in response to activation of this reninangiotensinaldosterone system. There’s a constriction of the efferent arterial to build up pressure within the glomerulus to maintain the necessary filtration and therefore, it will increase the filtration rate even further. But why exactly is this happening If I just said that individuals with diabetes often have increased renal profusion due to the hypertension, then why is a low pressure system such as the reninangiotensinaldosterone system activated And this is a good question,.
And the answer is not exactly intuitive. For some reason, the underlying physiology of diabetes, specifically the hyperglycemia, results in a direct intrarenal or within the kidney activation of this reninangiotensinaldosterone system. And subsequently, efferent vasial constriction independent of the volume status of the individual and therefore increases the glomerular filtration rate. So how does this increased pressure relate to diabetic nephropathy Well, as the pressure within the glomerulus increases, this results in a process known as mesangial expansion. The increased pressure results in trauma and damage to the mesangium of the glomerulus.
And in response to this damage, the mesangial cells respond by secreting cytokines that produce inflammation, as well as oxygen free radicals that result in endothelial dysfunction, and all of this kind of combines into hypertrophy and matrix accumulation within the mesangium, which is known as mesangial expansion. And as you can see over here on the right, as the mesangium expands, the spaces, or what are known as the fenestrations between the podocyte foot processes expand. Now, this has two effects. First, it decreases the surface area available within the glomerulus for filtration,.
And second, the dilation of the fenestrations causes the filtration system to be leaky, and larger molecules such as proteins are filtered out of the blood in the kidney. Then, the last factor contributing to diabetic nephropathy is a combination of the previously mentioned factors. And this is ischemia. As I mentioned earlier, the blood vessels supplying the tubules of the nephron come off of the efferent arterial, and vasoconstriction of this arterial from the intrarenal activation of the reninangiotensinaldosterone system decreases this blood flow. And in addition, the cytokines and free radials.
Produced from the barotrauma to the mesangium further damage the nephron vasculature. And over time these processes result in ischemia, or cell death, and atrophy of the vasculature that supports the glomerulus, as well as the tubules. So this will decrease the kidney’s ability to filter blood, and is ultimately what will lead to kidney failure in diabetic nephropathy. So as you can see, there are many different mechanisms that are going to contribute to the progression of kidney failure in individuals with diabetes mellitus. However, it’s important to note that they are all directly associated.
T2DM Diabetes and Indigenous Australians
Hi, I’m Warren Snowdon, Minister for Indigenous Health, Rural and Regional Health and Regional Services Delivery. It’s my pleasure to introduce this program, produced by the Rural Health Education Foundation and which is funded by the Australian Government Department of Health and Ageing. Five years ago, approximately 700,000 Australians had diabetes. Just three years later, the number had jumped sharply to more than 818,000 or 4 of the population. The majority of those 88 were cases of type 2 diabetes. Every day in Australia, about 275 adults develop some type of diabetes.
There are on average 10,600 deaths each year where diabetes is the underlying and associated cause, which represents about 8 of all deaths in Australia. In Indigenous populations, the figures are far worse. The prevalence of type 2 diabetes amongst Aboriginal and Torres Strait Islander people is at least three times higher than for nonIndigenous Australians. And incredibly, the rate of all types of diabetes amongst Indigenous Australians in some remote communities is as much as ten times higher. Yet, type 2 diabetes is considered to be largely a preventable disease.
This program examines evidencebased approaches to the management of diabetes, hypoglycaemic control and diabetesrelated complications amongst Indigenous Australians and is Part Four in a series of type 2 diabetes and the new NHMRC endorsed Type 2 Diabetes Mellitus Clinical Guidelines. This program will assist GPs, Aboriginal health workers, diabetes educators and all primary healthcare workers in providing support and good care needed for Indigenous Australians with type 2 Diabetes. I commend this broadcast as a key tool in improving Australia’s performance on this important health issue. I strongly believe that a better understanding of how to prevent,.
Detect and diagnose diabetes in Indigenous Australians will lead to improved health outcomes and life expectancy for all Indigenous communities. Thank you, Minister. I’m Norman Swan. Welcome to this, the fourth program as he said, on Type 2 Diabetes Guidelines and looking at diabetes in Indigenous Australians. And on behalf of everyone, I’d like to acknowledge that we are meeting on the land of the Wangal people. The Wangal people are the traditional owners of this land and form part of the wider Aboriginal nation commonly known as Eora. We also acknowledge elders past and present.
And the descendants of the Wangal people. Diabetes accounts for a significant proportion of the gap in mortality rates between Indigenous and nonIndigenous Australians. And as the Minister implied, this program focuses on a comprehensive and culturally appropriate multidisciplinary approach to prevention, detection, diagnosis and management amongst Indigenous Australians. Now, if you’re watching on your computer, you have the facility to type your questions in directly to the studio, just type your question in the LiveTalk text box below the slides. That also means of course that we can ask questions of you.
And here’s one to get you going. Tell us where you are located in metropolitan, regional, rural or remote Australia. And we’ll come back to the answers to that in a moment. As usual, there are a number of useful resources available to you on the Rural Health Education Foundation’s website rhef.au. Now let’s meet our panel. Dr Pat Phillips is the Director of the Diabetes Centre and Endocrinology at the Queen Elizabeth Hospital in Adelaide and has been for many years at the forefront of diabetes research and treatment.
And overseas, the State Diabetes Outreach program. Welcome, Pat. Thank you. What is the Diabetes Outreach program in your state in South Australia It’s really around building capacity in rural and remote areas so it’s focusing on the health professionals and trying to give them a better capacity to deal with diabetes in their communities. So it’s not parachuting in services, it’s getting the local services to be able to do it better. The principle is that if we can get the locals to do it, it’s a bit like teaching someone to fish rather than giving them fish.
NORMAN Dr Rob Way is a general practitioner at Katungul Aboriginal Medical Service in Narooma, NSW. Welcome, Rob. Thank you, Norman. You’d have a few people in your community with diabetes We have a few of our population, yes, with diabetes and perhaps a few with diabetes to come. NORMAN Sumaria Corpus is an Aboriginal health worker and diabetes educator from Darwin. Welcome, Sumaria. Hello. And we’re going to be talking about your program in the Top End shortly, which is you’re quite actively going out into communities.
Looking for people and helping people with diabetes. Yep. NORMAN Bernadette Heenan is a credentialed diabetes educator and registered nurse from Far North Queensland Rural Division of General Practice in Cairns. So you’re actually providing services. That’s right. We parachute in. And doing that. Right, can’t get away from it. Again, we will come back to both your experiences and Sumaria’s later. So, Pat, do you have anything to add to the statistics the Minister just gave I think that was a very fair summary, diabetes being very common.
And up to 50, 60, 70 in some Aboriginal populations depending on their age. I think it was also a good point made about the complications and the excess mortality in Aboriginal people related to cardiovascular death and renal disease, in particular those two. And I think the other comment which was really important was that it’s a disease that unfortunately is so common amongst the Aboriginal population that you almost have to assume that someone is going to get it and start looking for it and treating it very, very early.
Bernadette, is it different amongst Indigenous people, Aboriginal and Torres Strait Islander people, than in the general community Um, yeah, I think we notice it, certainly in the areas where I work. A lot of the clients that I, well, all the clients, most of them I see have got diabetes and there’s certainly a much greater proportion in each of the communities that I go to that would have diabetes than you would see in downtown Cairns, say, so. But how different is it from nonIndigenous people It’s hard to know to what degree it’s a different disease.
In the sense that it’s much more serious than in nonIndigenous people because the Indigenous people have more risk factors so they have more hypertension, a lot of dyslipidemia, a lot of central overweight. It’s also not clear also whether it may just be something that they are genetically predisposed to and the third potential factor, or at least a third one, is the prenatal environment so that their intrauterine environment is often breeding a tendency towards diabetes metabolic syndrome renal disease even before they are born. And instances of kidney disease, same with diabetes,.
Is huge compared to the nonIndigenous community. Very much so. So 30 of the population with type 2 diabetes, nonIndigenous, may develop microalbuminuria and potentially chronic kidney disease related to diabetes whereas it’s 70, 80, 90 of the Aboriginal people with type 2 diabetes and is a major cause of some of the other complications like cardiovascular disease. And that of course, Rob, changes the way you look after people That’s right, I think we are looking at everybody as a work in progress and we’re just trying to make sure that we minimise the risk factors.
As soon as we can and actually, you know, I think I treat everybody walking through my door with an Indigenous background as prediabetic. Sumaria, what impact does all of this have on communities It has a great impact ’cause they’re not functional at a higher level, a lot of people go to town for dialysis so it’s disrupting the family everyday activities. And the support, there’s no support. Like, in the Territory, they have to come, say, 800km to live in town and they can’t live in their own communities.
So they’re taken away from their homelands more or less. And how much awareness do you think there is There’s a lot of awareness but I think we have to just do more promotion, health promotion, and start in the schools. How young is the youngest person with type 2 diabetes you’ve come across in your communities, Sumaria The youngest is a tenyearold. NORMAN Tenyearold Yes and that’s from out in the remote area. And now she’s about 12 now and she’s on oral hypoglycaemic medications and for that age, to have tablets every day is really hard.
Sure is. What’s the youngest you’ve seen, Bernadette Nine years of age this year and she started on metformin straightaway. NORMAN Rob ROB Uh, 14. And that presentation was with acanthosis nigricans so, yeah. So this is something that not only happens more frequently, it happens at an earlier age And it also means that the children who develop their type 2 diabetes should they survive, they get the metabolic consequences of having type 2 diabetes and the duration of having diabetes that occurs in type 1 diabetes. So they get the complications of type 1 diabetes.
And the complications of type 2 diabetes so they get a real, a really bad set of problems. And we have the results to our first poll question where are you located and metropolitan a third of you, regional a third, and rural a third and, nobody’s admitting to, well, a small percentage in fact are admitting to being in remote so it’s a pretty. 8.3 and the. So welcome to you all. I just wouldn’t mind just checking your level, your selfperceived level of knowledge.
Are you aware, do you think, of all the risk factors for type 2 diabetes in Indigenous Australians Yes, no, maybe a bit. And we’ll come back to the answers to that in a moment. Let’s go to our first case study. Jim is a 30yearold Indigenous man with a wife and three kids, living in a remote community, he’s unemployed, they share. The family shares a threebedroom house with another family of four and all the four adults smoke. There is one store in the community. Jim enjoys playing cards,.
Having a few drinks with his mates and occasionally goes hunting in the community Toyota. Jim’s mum was diagnosed with diabetes at the age of 50. What’s your assessment of Jim, Sumaria Jim’s. With his mother being diabetic, it’s a risk factor and being inactive is another risk factor and not working and alcohol, smoking they’re all risk factors so yeah, it’s not too bright for Jim. So if he’s. Even before you do a single test on him, the assumption is he’s prediabetic and he may already even be, have diabetes.
Yeah, most probably undiagnosed, yes. So if you don’t have experience dealing with Aboriginal communities, looking after people in Aboriginal or Torres Strait Islander communities, you might throw up your hands in horror and say what could you possibly do Well, I am going to ask you. What can you possibly do about someone like Jim in your experience Just talk to him, give, tell him the truth and see what he wants to do, like, you build up your rapport and inform him on his risk factors and what’s going to happen to him and see what he wants to do about it.
If he wants to start diet exercise, just small goals just to start with would help. And what do you find motivates Well, to motivate him, employment would be a start. Getting the community involved, communitydriven activities. NORMAN What does that mean, though Not taking the Toyota when you’re going out hunting or what Well, they can go out hunting more often using the community’s vehicle, doing community activities with other families. NORMAN Do they get much exercise going out in the Toyota, though Rather than sort of getting out and walking.
No, they don’t get much exercise but what I am saying is going out to a spot and then go hunting from there, yeah. A lot of communities are starting to do that now taking people out and just leaving them out there. How practical is looking for bush tucker and converting from what might be a pretty unhealthy diet via the store to an expensive diet versus collecting your own bush tucker There’s a lot of bush tucker out in the Territory and it is, they can do it, it’s just easier going to the shop.
I promote going back to bush tucker, hunting and gathering instead of just going to the shop and buying meat where it’s much more healthier to have to walk, to have to work for it and they have to chase it so that’s natural. One of the traps I had was a guy, one of my patients was telling me, ‘Oh, you only ate bush tucker,’ and this is in Tennant Creek and what he meant by that was he ate a lot of kangaroo tail so he went down to the shop and he got the kangaroo tail and ate that.
That’s not bad, that’s lean meat, isn’t it, or is that pretty fatty That’s where the kangaroo stores all its fat. Fat, oh, alright, so kangaroo tail is not a good idea. And how would you monitor Jim, then What sort of things would you be looking for in terms of, or getting him to monitor himself Would it be things like waist circumference or you wouldn’t even. Start with waist circumference. Ask him to see if he can start 30 minutes a day and weight loss, look at weight loss and just set small goals.
And then he can grow on them. And make a change. NORMAN Bernadette, what would be your approach Very similar, personalised to suit him. We’d give him a selfmanagement folder and try and teach him a lot about best blood pressure, what to aim for, we even encourage our clients to selfbloodglucose monitor even if it’s only before and after a meal once a week and we use lots of visual stuff so rather than having them write it in diaries, we get them to download their monitors to laptops so we use all the latest technology.
Even if it’s out on someone’s verandah or out somewhere. We just take our laptops with us and so we do lots of pictures of, ‘This is when your blood sugars weren’t so good and this is what’s happening now’ so there is always before and after shots and always positive stories, so positive role models. Sumaria, you’ve developed some materials to actually help you or detect the symptoms of diabetes Yes, we did this in Darwin and it’s How Do You Feel and these are signs and symptoms. We’ve done five chapters so we went to What Now I Have Diabetes,.
Taking Medications, Doing BGLs and just helps them understand what they’re going through. And it’s a good tool and it’s on the web. So just show us a little bit of it. SUMARIA OK. The first steps is being lethargic, sleepy, no energy and they can relate to that. And they say, ‘Oh, yeah, that’s how I’ve been feeling.’ Some people are up all night going to the toilet so the first thing you say is, ‘How many times do you actually get up to go to the toilet’ And then, you know, that sends alarm bells.
OK and then you can say, well, going to the toilet if you get your blood sugars down, because your body is trying to get rid of that excess sugar in your body and it’s making you get thirsty and the body is trying to get rid of the excess sugar so they are urinating it out. And if people want to get a hold of some of these materials, how do they do that Contact your local diabetes office or look on the web under Diabetes Australia. Let’s talk now about your more active prevention, Pat.
What other more active things can be done I mean, for example, is there any role in Aboriginal communities for obesity surgery I guess, that’s a question I haven’t thought a lot about because I would imagine it is very difficult to access and also very difficult to support the person through some of the things that are associated with bariatric surgery so if you’re going for the malabsorptive surgery, for example, that really takes quite an investment in terms of educational nutrition and if it’s lap banding, it’s once again teaching people.
Not to switch from solid to liquid food which will just obviate the. So I’m not sure they would get the sort of support after the surgery which is likely to make the surgery successful. And is there any evidence that intervening in Aboriginal and Indigenous Australians with their high risk of or hypoglycaemic agents or insulin early actually helps to minimise the course There have been some not totally wellcontrolled but some intervention studies and in particular relating to the kidney disease that I was talking about a little while ago.
And in Northern Australia, in the Tiwi Islands, there’s a program which was organised by a doctor, Wendy How, who. MAN Hoy. Hoy, who thank you who actually basically gave everyone an ACE inhibitor, an angiotensinconverting enzyme inhibitor, because of the problems of chronic kidney disease, hypertension and showed a progressive decrease in both the total mortality and also the progression of endstage renal failure so it was, in that sense, historical controls but it was a demonstration that A it was feasible to do this on a populationbased scale and B it seemed to be effective.
So what do the guidelines say The guidelines suggest that an ACE inhibitor is a preferred medication in type 2 diabetes if the person has hypertension. There’s also been trials in nonIndigenous people that an ACE inhibitor has benefits in those who have type 2 diabetes and one other cardiovascular risk factor. Of course, everyone’s got one other cardiovascular risk factor so it’s virtually everyone with type 2 diabetes. That was the HOPE study with. It has been repeated with other ACE inhibitors. There have not really been a lot of intervention studies.
Which have been done in any sort of trial basis in Aboriginal populations so the diabetes prevention program, for example, was an American program and has been repeated in lots of other countries using metformin, other drugs have been used the glitazones, acarbose, several other drugs have been used. NORMAN But not proven Not in the Aboriginal population. In those populations they did reduce the progression of prediabetes to diabetes. Let’s go to our first case study oh, sorry, our second case study. This is a film case study.
It involves Greg, a 37yearold Indigenous man who presents to Western Sydney Aboriginal Medical Service at Mt Druitt in New South Wales. He’s screendiagnosed with diabetes and engaged in an intervention. Let’s take a look. I think once you’ve seen Indigenous patients who are very young having diabetes, having heart attacks, having all sorts of vascular problems as we see in this setting, it really gets your radar working and you have to apply the screening test at an earlier age than you would elsewhere. Greg. This morning, actually, a patient of mine called Greg.
Is coming back to see me. I saw him last week, we were discussing diabetes ’cause he has a few family members with the disease and we did some tests in fact and today he’s coming back to have me tell him unfortunately that he does have diabetes. Oh, I hope you got some good news for me. Well, look, yeah, last week we were discussing diabetes and. ‘Cause you were. Greg is getting on into his late 30s, almost 40 now, quite a young man for someone to be diagnosed.
With the mature onset type of diabetes. But being an Indigenous man, he has an extra layer of risk, we might say. He’s not a big man, he’s not the shape that makes doctors think, ‘Well, that person’s a suitor for type 2 diabetes.’ But I guess it goes to show that being Indigenous and even just being a little bit overweight, they are risk factors enough to actively look for diabetes. Can it go away or is this going to be the answers It’s something that will be with you for life.
Before we get too far ahead of ourselves, I’d like to go back to sort of explaining what diabetes is all about. It’s very important to actually make sure the patient knows the consequences of having poorly managed diabetes and, you know, so we’re talking about problems with the feet and problems with the eyes in particular but there are also problems as you know with the heart and kidneys and brain. That’s a good starting base then to say, ‘Well, what can we do about it and how can we prevent those things from happening’.
You know, if we are going to move forward now and manage this effectively, we want to involve some key people in helping you to manage it. It’s important simply to have a very explicit, you know, listed plan of what’s going to happen next and with whom so that everyone knows what is going on and nothing is overlooked. In the first instance, I referred Greg to the Aboriginal health worker whose specialty is diabetes and Louise has a very good understanding of the disease and can talk to Greg about that in a way that he’s,.
Make it easier for him to understand that perhaps I wouldn’t be able to do so well. So he’s in the waiting room now. So you want me to have a little chat to him and. If you could. What have you been through with him A bit about. Apart from that, obviously being Indigenous herself, she has that sort of innate cultural awareness and ability to attend to perhaps slightly different issues that would be different from my perspective. Just a question, did you understand what Dr Bill was talking about.
Yeah, I did, yeah, but just he told me there are ways of controlling it and so I just would like to talk about what things to eat now and. OK, then, so. When a patient like Greg or any of my patients come to me, I would normally talk to them about diet changes, exercise and the complications that diabetes can have in the long run if their diabetes is not managed. Did he put you on any medication Not as yet. No, so that’s good, so we’re just gonna go on diet control at the moment.
You got to try and focus on the first thing. Like, Greg today, really, about his diet changes ’cause it’s a big shock to their system, like, they’re coming in newly diagnosed and you try and tell them all these things, they’re just gonna forget about it mostly ’cause they’re still in a bit of a shock, you might just have to explain it a bit more in simple terms. You know, your diet, well, next time you go shopping, you might want to look at this and say, well, you know, go at the back here and say,.
‘Oh, on my shopping list I might choose from this today.’ You know, on the shopping list and your different choices. One thing too I do encourage is that they do get a glucometer so they can measure their sugar levels so they can keep an eye on it to see what’s going on but you know a lot of our patients can’t afford it sometimes so. But they do come in here and we can do it in here anyway if they don’t, if they can’t afford to buy their own glucometer.
So what have you eaten this morning, Greg Have you. Oh, this morning I had some vegemite on toast. 7.9 that’s still a little bit high. So is that all you had, vegemite on toast Oh, and a meat pie. Well, once the patients attend the service, you know, it’s usually a team approach. We do have a lot of our visiting specialists come in like a podiatrist, a diabetes educator so that’s all done but as for the eyes, we need to send them out. So you’ll book me in for a week’s time.
I’ll book you in for a week’s time with Heather. So I’ll see you in a week. Yeah. We can only do so much as health workers. Most of it we try and encourage it, put it back onto the patients themselves like for selfmanagement. By checking, buying a glucometer, checking their sugars, having regular checkups, making sure they’re taking their medications. I’ll see you next week. Thanks, Louise. Thanks a lot, have a good day. We still have a lot of our patients that have gone down the track and, you know,.
Ended up on dialysis. It would be so nice to catch these patients early before it gets to that stage, I suppose. After all, I know things are not 100 but at least I am still going to be here for as long as I can with the help of the Aboriginal health workers here. Greg’s story from Mt Druitt in New South Wales. How typical is that, Rob ROB It’s very typical. Mind you, Greg looks quite motivated and probably not too daunted by his diagnosis whereas occasionally we find people who are quite, quite upset,.
Quite concerned about a diagnosis. And so I think with. I think Bernadette was talking about emphasising the positive, the thing I would be making sure that Greg knows is that it’s great that we picked it up as early as we have. Hopefully it’s within a few months of his blood sugar popping up so that we can start all these preventions. The guidelines that we’re using here, this is a general practice set of guidelines too, are they not ROB Yes and there’s I don’t know if we’ve got a slide of that coming up.
But there’s some excellent diabetes management guidelines that cover pretty much most of the questions that we’re touching on today. Just going back to the earlier point about screening, how regularly do you screen people in an Aboriginal community In an Indigenous practice, I screen everybody every time they walk through the door so it’s a set process they get. They get their weight, we measure their waist regularly and we check their sugar probably every, at least once a month if they’re popping in. NORMAN What about you, Sumaria, what’s your advice.
We do waisthip ratio, weight, BGL, blood pressure. Do you use at risk tool with them or do you just assume everybody is at risk No, no. NORMAN You just assume it’s everybody It’s not designed, they never took it into account for Aboriginal people ’cause they’ve got the Aboriginal and Asians together and they’re totally different body shapes and ethnic background so it doesn’t work. And, Bernadette, you try and personalise the approach to somebody like this so that they’ve actually got their own book. Yeah, we’ve got a selfmanagement folder that we use for people.
So we tend to take their photo and give them a whole book that’s dedicated just to them. It’s full of lots of handouts and things that are actually showing what their blood pressure is, what their blood glucose levels are, what their HBA1C is and there’s lots of handouts done by our doctors, dietitian, podiatrist, etc., on how they can actually look after things themselves so they’re. NORMAN They even have an appointments book in there Yeah, there is an appointment book, yeah, with a whole ten or so people,.
We call it ‘The mob who help me look after my diabetes.’ ‘Cause what we haven’t said but a lot of people watching know it, this is multidisciplinary team. Multidisciplinary team, you can’t do it any other way, yeah. So that’s what this is about and the idea is that it is something big so our clients, it’s harder to lose. The original patient held record, you put it in your wallet and you lost it. This is so big that it’s hard to lose at home. And hopefully, clients will bring it with them to other appointments.
So we’ve even had people turn up in Cairns to see their specialist and they’ve brought their folder with them and the specialist has written a letter back to the GP up in the Cape saying what happened on the day. And then you’re also empowering the client so much because they’re in charge of that communication between a specialist and another doctor so it’s very much tailored for them and we invent things as we need them. Just before we go on, let’s take the results to that poll question.
Are you aware of all the risk factors for type 2 diabetes in Indigenous Australians And half of you say yes and the vast majority of you have this partial knowledge and no is 12.5. Thank you for being so honest, the 12.5 of you, and we’ll ask another poll question now which is, ‘Does your service have a local Indigenous diabetes education program to which it can make referrals’ Yes, no or it’s part of your own service. So let’s hear what the answers are to that. What are the treatment options for Greg.
I mean, the guidelines say start with lifestyle but some people would argue with Aboriginal people, given their high level of risk, you might move a little bit more quickly. Well, actually, the Americans and the Europeans have both sort of adopted that second approach, that is, you’ve got type 2 diabetes, you counsel people on lifestyle and start metformin at the same time. In Australia, we tend not to do that. We tend to use lifestyle first and then add in metformin fairly shortly thereafter. It does have the advantage, if you focus on lifestyle,.
Is that you’re not taking their diabetes away from them so that you’ve just been diagnosed with type 2 diabetes and I give you a pill and say, ‘Take this pill and that’s all you have to do about it’. Then the diabetes is now my problem I’m prescribing the pills, you just take the pills and that’s the end of your responsibility. And if the pills don’t work, that’s your problem, doctor. That’s right. But focusing in on the lifestyle engagement in the lifestyle and engagement in understanding diabetes and then using the medication,.
It might delay the medication, starting the medication by a little while, but probably not much more than weeks or a month or two. And in the context of the type 2 diabetes, actually engaging the person in their selfmanagement is really very important. And what about this incredibly high risk of kidney complications I think there is a very strong case. Now, I’m not a practitioner who deals a lot with rural and remote populations of Aboriginal people but there’s a very strong case I think of in much the same way.
Considering starting an ACE inhibitor pretty well straightaway too because you can be very, very confident that that person if they don’t have hypertension already, they will get it and if they haven’t got kidney disease already, they will get that. And ACE inhibitors have been shown to be good medications for hypertension and reduce the risk of chronic kidney disease. And you don’t necessarily have to have hypertension to have them No. Rob, what’s your practice I’m also wondering. I mean, yes, I think so. I think that we should be, there’s evidence that both those medicines.
You know, delay the onset of complications. The other question would be, should we be starting a statin at the same time Well, there is the. There’ve been, as you are implying, there’ve been several studies using statins in people with type 2 diabetes so there is the heart protection study and there’s a card study and the a priori guess would be that that same benefit reply to an Aboriginal population. Although stronger for antihypertensives. Sumaria, there’s an affordability problem here. You have all these doctors throwing around the scripts,.
People have actually got to pay for the drugs. Um, in the Territory, because they’re remote, we’re under the S100 so they get Webster packs from the local clinic and then their medication is reviewed every three months. So it’s. And, say, if they’ve moved that’s the difficulties or they come to town, they leave their medications at home and Indigenous people out bush are always in and out of town so you just have to make sure they understand why they’re taking the medications and to take the medications with them.
We give them a little esky to take their insulin when they go fishing or they go bush so then they can take their insulin with them. Just making things easy for them to take it with them. How aggressive are you with insulin in the remote communities We’re quite aggressive with insulin because I look after the gestationals as well and this is young girls with gestational diabetes and the only treatment for that is insulin. So we have to look after their baby for the whole term so, yeah, we have to be there, we have to.
Like, a lot of people say, ‘Oh, it’s impossible to get them to do four, five blood sugars a day’ where, if you educate them on the realistic what’s gonna happen to the baby if they don’t, they’ll do it. And people say, ‘How can you have them on basalbolus’ That’s four injections a day but they’re willing to do it so the right information and being consistent in what messages you are giving them. I think that is really important. And what about nongestational diabetes, people with just regular type 2.
Type 2, yeah, we do that once they’re on maximum orals and then we’ll start them on maybe a longacting at night and it seems to work, yes. So less of a problem than you might imagine Yes, with the right information, right support you can. Tell me a bit about your program in Cape York for people like Greg although Greg’s in metropolitan Sydney, really. Yeah, what we have up there is we’re part of an improved primary healthcare initiative and there’s a group of us who travel around together.
GP, podiatrist, dietitian and a few other people and these are the areas that we cover. So we cover a few of the remote communities up Cape York and the Royal Flying Doctor Service covers the other areas. And we try and cover the full spectrum of primary health care, comprehensive primary health care across all the different. As well as just doing the clinical areas, we go right through to trying to educate and prevent and prevention in terms of engaging with local shopkeepers, etc. So, um. Yeah, we try and encourage the client.
To learn as much about their condition as possible. That’s one of the large areas that we’re involved in and the key person to our whole project is our community engagement coordinator. No matter what we do, we don’t go anywhere or engage in any activities, etc., without involving that person. And as you can see from the slide up there at the moment, our CEC is the most important person. They’re always Indigenous so we have one in each of the major areas we work the Weipa Cluster, Cooktown Cluster.
And Mossman Gorge area. So if we were seeing someone like Greg, then it would be our CEC who would go out there and make the initial contact if we were seeing him out in the community and invite him to come in and see us or we do home visits, whatever was appropriate. And we tend to be quite aggressive with our management as well. NORMAN And your booklet provides the care plan Yeah, it’s the care plan, the communication document, the education and it’s all best practice, there’s no second best, second rate, it’s all. yeah.
Good. Let’s take some questions now from you. Kirsty from Charles Sturt University asks, ‘How do you explain to someone with little formal education what diabetes is and the importance of regularly taking their medication’ Bernadette When describing what diabetes is, we would often draw things so we’d draw things on a bit of scrap paper, maybe on a board, whatever’s available, and do a basic drawing and show what happens. We use all sorts of things, big drawings on pieces of material or the other day we started using a clear plastic container with little balls,.
Green balls for glucose and red ones for red blood cells and you fill it up with 20 green balls to show how clogged things become with glucose. We use lots of analogies in our storytelling so whether it be BluTack or chewing gum on a keyhole on a door and how, you know, talk about how the insulin won’t work with that so we use, so we draw pictures, we also do blood. You know, when we’re drawing, putting people’s blood pressure into their book, if they happen to come on a day that they forgot,.
They haven’t taken their medication this morning, you put that little note in there so the next time they come and their blood pressure is in a good range, the person is learning straightaway the relationship between taking your medications or not taking them and what it’s having on their body and they’re seeing it in a picture form so you don’t have to read to use the books. Sorry, Rob Can I just say, I think one thing that doctors often really get worried about is that understanding initially for a patient.
And I think that comes with time and sometimes, I don’t know, I found when I was young and keen, I really wanted to tell the patient all about diabetes upfront and I think and, really, I think I put people off and I think, really, keeping the message as simple as possible so that people feel more in command of what’s happening is actually. And then go with the patient as they want to understand more then, you know, you talk more about their condition and go into. And, Sumaria, you’ve used those materials you were showing us earlier.
Yeah, I find more colour, the more they understand and just keeping your messages simple and just grow on that. Our next question comes from Natalie in rural Victoria, who asks, ‘There’s been mention of a traffic light in the food labelling program in remote communities in Western Australia. Has this been applied in other communities Can you comment on whether you think this would assist’ Yeah that’s traffic light. It’s actually a British system, isn’t it It started in Britain. Mm, I don’t know, I’d have to ask the dietitian that one.
But I know that sometimes they use green ticks and things like that in some other shops up the Cape and I know it’s still used in some of the healthy food programs. A general practitioner from Melbourne asks, ‘Should there be any difference between treatment approaches between urban and remote Indigenous people’ Which we have kind of answered but, Pat, do you. I think there are practical differences between the two populations and one of the practical differences is the availability of S100 medications in South Australia and some other states.
I understand they’re not available in every state but this is a Commonwealth program whereby the Aboriginal people in rural and remote parts of Australia can actually get their medication free of charge. NORMAN But they don’t in the city. But they don’t in the city. And when people from rural and remote come to the city, they no longer have access to those medications. Rob was telling me earlier that the program doesn’t apply in New South Wales so that would make a big difference to the rural and remote people in New South Wales.
Compared to those in South Australia, for example, because New South Wales, they’re going to have to get their medication some other way, South Australia, they can get it through the S100 scheme. And is there any evidence that adherence to medications is lower in the cities I’m not sure that there’s actually ever been done a trial but there’s lots. It’s really a wellknown phenomenon that people come to the city and they don’t get their medication because they no longer have access to the S100. The Aboriginal medical officers in Adelaide are very,.
Are continually lobbying the Commonwealth to make the S100 drugs available to city people and particularly to the rural and remote people who come to the city. A nurse in Central Queensland asks, ‘Is there a simple way, any simple way of assessing diabetes risk in Indigenous people Would we use the AusDrisk tool’ I think you can certainly use that tool and. NORMAN But Sumaria reckons it’s not much cop. Laughs That’s right. No, well, it’s not designed for Indigenous. They’ve got a different body frame to Asians so you can’t just throw everyone in and say, you know,.
They’re all, we’ll just use this. As I said the best way is waisthip ratio. The jury may be out. Personally, the way I would use the risk assessment tool is to say, is to show people that if you’re, say, like many of my patients, Aboriginal, and you have a family history of diabetes, you’ve already got five points on your way to 15 points of being at the high risk. However the other points, the other risk factors are actually things that you don’t necessarily have to have you don’t have to be a smoker,.
You don’t have to actually, you can eat vegetables and fruit each day, you can do some exercise so you can actually. So it points out a way of showing how you can change your behaviour as much as anything else. ROB That’s right. Jane from the North Coast of New South Wales asks, ‘How early should we start screening Aboriginal people for diabetes’ Pat. The comment was made by the earlier speakers that they’ve seen children aged nine and ten and I think Rob has the practice of starting screening aged ten.
And that seems like a very reasonable thing. I think it’s also just worth commenting here is that the teenage girls, it’s particularly important to look out for early pregnancy because those girls then get gestational diabetes and that has adverse outcomes for their pregnancy but also for the child so I think that group in the younger women is a really important group. Sumaria, what do you think I think that’s a good point, yeah. We have to, um, screen them at the age of ten and the younger women as well and get them prepared for pregnancy.
Instead of unplanned pregnancy. Those sorts of things have to be addressed and reviewed as well, yes. Let’s get the results of your last question does your service have a local Indigenous diabetes education program to which it can make referrals Answers half of you, yes, half of you, no and a little bit of you say that it’s part of your service. So then the next question for you is We’re not giving you a little bit of option here so let’s see what your answers are to that.
Let’s go to our next film case study the Aunty Jean’s Good Health Team and it’s built around the idea that better results for chronic disease management can be achieved if the community works together with the elders leading the way. The program is a comprehensive approach to improved selfmanagement in Indigenous people. Let’s have a look. It’s named after Aunty Jean Morris who was a very much respected elder in the Illawarra. She did a lot of volunteer work for the community over her lifetime and she passed away.
Permission from her family was sought to use her photograph and her name as the Good Health Team. I first came here, my sugar level was about 19. Now it’s dropped back down to four or five, you know. So it’s good for me. Aboriginal people don’t go to the doctor until they have to. It’s a lastminute thing with the Aboriginal people. They won’t go to doctors but coming up here, I know where I stand with my health. I think it’s the creation of a culturally safe environment. Most of the people have chronic illness.
And we look beyond the clinic rather than the prescriptive which is normally clinical focus which is normally given in other programs. We look at abilities, not disabilities, wellness rather than illness, strengths and really engaging people and letting them build up their confidence in selfmanaging and I think in that culturally safe environment, it works really well. We’re gonna push down and out and then back down. We saw the need when Caroline first came on to the program as the program manager. She’d done some background work in talking to other service providers.
And organisations and asking about what they actually provided for Aboriginal people with chronic care or chronic conditions and she found that there was a great big gap in service provision. Some of the programs were either too wordy and there was a lot of reading material and the other thing I guess was isolation, they felt isolated because they didn’t have other crew people attending the program, etc. And some of them found it difficult so those were some of the findings and we did some community consultations and asked the Aboriginal community in the Illawarra and Shoalhaven.
And their carers what they could identify as gaps in service provision to them as well. We invited a group of elders in the Illawarra to help us put the framework and the flesh, I guess, of the program together. I’m one of the first and still attending and I was very down and very depressed. I used to hate to get up and face the day. Coming here every week, I’ve enjoyed it. It was something to get out of bed for. I’m not just sitting around waiting to die now.
I couldn’t move on Friday. I’m living a beautiful retirement. Much better than what my mum did. They didn’t have all this around them but I have and I am very grateful for it. Went to the Wollongong specialist for my kidneys and he said to me, ‘Well, I’m afraid I think we’ll have to take your kidney out.’ I said, ‘You’re not taking parts of my body, I’m not giving them away.’ And he said to me, ‘Well, get into exercises and so forth.’ I started doing weights here Mondays and Tuesdays.
And then I went back and saw the doctor six months later and he was so thrilled. He said whatever I’m doing there, keep up the good work. He said he wished all his patients would have been just as healthy, what I am now. Some people are actually staying out of hospital because of the program. Those people with really chronic and complex conditions come along and they’re, you know, improving their flexibility and strength and learning to manage more. I do exercise which I’ve never ever done. I get up on a morning and I start walking.
I’ve never ever done that, never. ‘Cause I used to sit home and feel sorry for myself. But now I’ve got a life. I can walk further, I can swim better and I can annoy a lot of people a lot better too now. I can touch my toes and do up my shoes easy without puffing and blowing because since I’ve been doing this, I have also gone off the asthma machine as well. I only use the puffers now because I was an asthmatic when I first came here.
WOMAN You have to have good nutrients so that means you got to be eating the right thing. For diabetic people, your blood sugars must be under control. WOMAN They help us, they talk to you and explain everything to you, you know, with your diabetes and things like that. My sugar level was just high, too. This means a lot to me. I wouldn’t stop coming here ’cause this is my family, my friends. So only for Aunty Jean’s exercise classes, it’s really put me on top of the world.
The Aunty Jean’s Good Health Program. Rob, what do you think ROB I think it’s fantastic. My only concern with this type of program is that people go often enough to get that exercise regularly throughout the week and my only concern was one of the comments from one of the ladies is that she looks forward to the Aunty Jean’s Program every week. I suppose, Sumaria, if you look at it and you think, ‘What are they actually doing there They’re moving their feet up and down. Are they actually doing anything significant’.
But in fact that’s actually movement against a background, not just for Indigenous people but for nonIndigenous people too where there’s obviously, there’s probably not very much movement in their lives. No, that’s a good program. Out in the remote areas, they don’t think about, like, exercising because they think, ‘Oh, we live a long way so we’re exercising walking around.’ NORMAN We’re exercising driving the Toyota. You know and stuff like that but, yeah. The communities have to start being communitydriven and start exercise programs in the communities and a lot of the problems is dogs.
You know, getting bitten by dogs and stuff like that. And what we say is just take a group of youse out and just go for a walk, you know, along the beach is beautiful and a lot of those areas have spectacular views. And it’s just people supporting and just prompting people, I think. And your program is basically an outreach program going to those communities and has links to specialists, etc. Yes, we do, we promote selfmanagement, we give them the tools to make changes and ongoing education, support and we do outreach from Port Keats.
Over to Borroloola so we’ve got the Top End, so, yeah, and. So you’ve spent your life in a Toyota No, aeroplane. Too far to go. Yeah. And we do followups with them and stuff like that so we’re in contact with them. So, yeah, we’re slowly doing it, we’re only a small team but. I think we’ve got the results of your last question And three quarters of you are saying yes and a quarter of you, no. Let’s just talk quickly about complications and the management of complications. Rob.
What’s the. What should be the approach here I think it’s prevention, I think we, you know, from diagnosis, we brief the patient that because they have a condition which can affect many parts of the body, we are going to have many parts, many experts looking to prevent those problems occurring. And I think we make sure they’re off to the ophthalmologist for an initial visit, off to the podiatrist, the diabetes educator and other people as needed, perhaps the endocrinologist if it’s a young or an unusual case. Pat, I mean, what about management of complications and prevention.
We spoke earlier about medications and I suppose we should really talk about blood sugar control in this group and the medication regimes, just remind people what the approach is. For nonIndigenous people, there’s a tablet which is called the type 2 tablet which is recommended for all people who have got type 2 diabetes and that’s got metformin, statin, ACE inhibitor and aspirin in it. And in an ideal world, everyone who has type 2 diabetes would take those medications which are pretty evidencebased in terms of reducing the risk.
Now, that would apply even more probably to the Indigenous population but then you’ve got the problem that you use four different medications, it’s six different medicationtaking occasions so it’s quite a burden. And I think in medication, one probably needs to say, ‘So what’s likely to give us the best bang for our buck’ And I think we can be pretty confident with metformin, we can be pretty confident with ACE inhibitors, pretty confident with insulin, they are three good medications and blood glucose control is important because of the microvascular complications.
And if you don’t develop neuropathy, you probably won’t get foot problems and if you don’t develop nephropathy, your risk of cardiovascular disease is also very much less so glycaemic control and blood pressure control are really important priorities because the blood pressure also predisposed to the kidney disease. But the guidelines say no insulin until you’ve maxed out of your oral hyperglycaemics. Well, that’s not entirely true either. The Americans and Europeans have recently come out with a guideline that says you start with metformin, your next medication could be a sulfonylurea,.
It could be insulin, it could be a glitazone, it could be one of the other less commonly used medications. So I think people are recognising that insulin is very likely to be needed at some stage and earlier may not be a bad idea. And, Sumaria, how well or badly do people cope with hypoglycaemia particularly when you get on to the sulfonylureas and insulin We make sure they are selfmonitoring, we don’t put anyone on insulin unless they’re selfmonitoring. They do manage, we have blind people doing insulin injections.
And they count the clicks, those sort of tools, you know, we try and work out what’s good for them and with the right information and the right tools, people can do things. And in the Top End and in Cape York, what do you do about retinal screening, foot care, that sort of thing We have a podiatrist who travels with us and plus, most of the health workers in any of the communities know how to do simple assessment forms as well and there is an eye team that comes up a couple of times a year.
Up there as well. Plus, we link in with the. The endocrinologist does a visit up there from the Cairns Diabetes Centre and we also link in with the Cairns Diabetes Centre so if there is foot problems or whatever, we telehealth in tutorial conference in to them as well. So we’re in constant contact with specialist areas as well for that. It’s been fascinating, thank you all very much indeed. What are your takehome messages from people from the program Bernadette Educate people as much as you can, keep it simple so that you can empower them.
Yeah, ’cause if they can be the boss of their diabetes, I think that’s where we are going to see change is when the people feel they are in control. Make it a positive story and no growling. NORMAN No growling. No growling. No bullying, you’re not a bully, Sumaria. No, no, we don’t do bullying. I think it is just being consistent, being supportive and being truthful and, you know, everyone has got holes in their feet, they do muck up, they, you know, get off track, just have the patience to help them back on track. Yeah.
NORMAN Rob Treat the individual and, I think, be positive about the story that they’ve. They’re actually the people who can control most of their risk factors in their diabetes. NORMAN Pat Assume all people of Aboriginal descent are very likely to get diabetes. I think, screen Aboriginal people at regular intervals, for example, yearly. Intervene actively in so far as one can with metformin, ACE inhibitors in particular and monitor for complications particularly for neuropathy because that is the way you will prevent foot problems. Thank you all very much and I hope you’ve enjoyed the program.
On type 2 diabetes in Indigenous Australians and got a lot from it, I certainly have. This series will be available of all four programs in December and that will be free on DVD. If you want to order, you visit the Foundation’s website and if you’re interested in obtaining more information about the issues raised tonight, there are a number of resources available on the website at rhef.au and that includes links to all the new type 2 diabetes guidelines. Don’t forget to complete and send in your evaluation forms.
T2DM Diabetic Retinopathy, Chronic Kidney Disease
Hello, I’m Norman Swan. Welcome to this program in our series on guidelines and type 2 diabetes. Every year there are about 3.8 million deaths globally attributable to diabetes. In Australia, type 2 diabetes is the fastestgrowing chronic disease, with the total number of Australians with diabetes and prediabetes estimated at a whopping 3.2 million, and it’s the sixthleading cause of death. This program looks at two NHMRC evidencebased guidelines that are new and address complications and comorbidity in type 2 diabetes. They are the evidencebased guidelines for diagnosis and management.
Of kidney disease in type 2 diabetes, and the guidelines for the management of diabetic retinopathy. For those of you watching on your computers, you can type your questions directly in to the studio. Just click on the LiveTalk tab at the top of the web page you’re looking at. That also means, of course, that we can ask questions of you. Here’s one to get you going away on that one, and we’ll give you results of that in a moment. As usual, there are a number of useful resources available.
On the Rural Health Education Foundation’s website Now let me introduce our panel to you. Stephen Twigg is an endocrinologist at the University of Sydney and President of the Australian Diabetes Society. Welcome, Stephen. Good evening. Alan Cass is the senior director of the George Institute for International Health, and director of the Poche Indigenous Health Centre at the University of Sydney. Welcome, Alan. Good evening, Norman. Paul Mitchell is Professor of Ophthalmology at the University of Sydney, and runs the Blue Mountains Eye Study. Welcome, Paul. Thanks, Norman. Good to be here.
And David Guest is a rural general practitioner in Goonellabah in NSW. Welcome. Thanks, Norman. David, challenging, dealing with comorbidities in general practice, I assume. It’s a growing area. It’s a bigger and bigger problem. It’s something that’s taking more and more of GPs’ time. If you get systems in place, you can probably cope with the challenge. Talk to me about the trends that are going on, Stephen. As you’ve mentioned already, diabetes is on the rise. We believe that approximately 100,000 people per year in Australia are developing diabetes.
It’s very similar to the worldwide trend. There are a number of factors that are probably critical in the process in terms of the development of diabetes. The prevalence changes in different groups in Australia Yes, there are certainly higherrisk groups, particularly an ageing population. There are certain ethnic groups that are at higher risk than others. There are also issues to do with lifestyle change. As we can see on this slide this data is from the turn of the millennium approaching a million people, or 7.4 of adults aged over 25 had diabetes.
In Australia at that time, well over 90 of it being type 2 diabetes. The other conditions, impaired fasting glucose and impaired glucose tolerance, or as you referred to them, the prediabetes conditions, also extremely common. So approaching one in four Australian adults have some form of glucose abnormality. NORMAN Extraordinary. It’s a remarkable figure. NORMAN It’s also agedependent Yes, very much so. If we dissect this out further, the same study, the AusDiab study, demonstrated a strong agedependence for diabetes, indicating that the ability of the pancreas to produce insulin tends to deteriorate with time.
Approaching one in four Australian adults in their 70s will have diabetes in comparison to a much lower percentage of people earlier in their life. We’re trending upwards faster than we thought Very much so. World Health Organisation data, recent trends have suggested, rather than seven million people per year developing diabetes, it’s more like ten million people. We’re going to hear about that in the more recent estimates, in the next year 2010 data from the International Diabetes Federation and WHO. NORMAN This graph shows we’re tracking faster than we thought.
And the Australian data, very similar. In the AusDiab study, whilst ‘e’ on the far right is an estimate based on previous decades, in the last decade, the late ’90s, then into the 2000s, the figures are well above what the estimates were on the trend line. A study from the Australian Institute of Health and Welfare 2006 indicated it’s more like 1.5 million people who have diabetes, then increasingly, 100,000 a year. So really, even off that scale, if we look at more recent estimates of diabetes in the Australian community.
We’re talking here about absolute risk, global risk, just as much as we’re talking about glucose Definitely. Glucose, if you like, is the marker. People with diabetes have two to fourfold the rate of cardiovascular disease as the general community. As you’ve pointed out, it does emphasise global cardiovascular risk and the importance of tight blood pressure and cholesterol control. David, on the day of broadcast, yesterday’s Medical Journal of Australia described the fact that general practitioners are not measuring absolute risk to the rate they should be. What are the barriers to measuring absolute risk.
It’s a GPeducation problem to start with. There are tools available now that make it much easier. I have a preference for a computerised electronic health record. Getting data out of the computer makes these sort of assessments much easier. A website which I think is the one recommended by various colleges to assess absolute cardiovascular disease risk is available on the web and available on the desktop. That’s a very useful tool for GPs. You’ve got an example of this risk tool that’s in the guideline That’s right, Norman. If we look at the next slide, this is an example.
This is for people with diabetes. The charts are divided into those with and without diabetes. People with diabetes are a highrisk group. They can be stratified on the basis of their cardiovascular risk in terms of looking at their systolic blood pressure, their cholesterol, HDL total cholesterol, HDL ratio, gender status and smoking status. It’s possible then to identify whether a person would be deemed at a high cardiovascular risk, in which case the intensity of the management of their surrogate markers their blood pressure, their cholesterol, their glucose.
And also antiplatelet therapy can be modified appropriately. NORMAN You’re arguably more likely to save their life by managing those other factors than their sugar It’s not one or the other, but it’s both. All of them are important. For example, diabetic retinopathy glucose is the major factor that will contribute to that complication. In terms of cardiovascular disease in people with diabetes, the risk is probably approaching 15 to 20 of the variation in risk will be glucose, depending upon the degree of glycaemic control. And cholesterol and bloodpressure control, very important in that setting.
How important, Paul, are these other risk factors than glucose We know that glucose control can help diabetic retinopathy, but those other risk factors There’s growing evidence, isn’t there That’s right. The effect of good diabetes glucose control on preventing the development and progression of diabetic retinopathy has been shown both in type 1 and in type 2 in the UKPDS. That latter study, UKPDS, actually demonstrated almost an equivalent effect in type 2 diabetes of bloodpressure management. Indeed, recent studies, the ACCORD studies and the RASS study, just recently published,.
Have shown that in fact really tight bloodpressure control, perhaps with modern bloodpressure agents, ARBs, can actually reduce the incidence of diabetic retinopathy and may result in regression of existing retinopathy lesions. And in kidney disease, Alan Cass Again, the key factors to control are blood pressure. Also, how well you control glycaemia is a key factor in terms of progression of kidney disease. NORMAN What’s the management challenge, Stephen Diabetes, as we know, is extremely challenging. There’s the combination of lifestyle management and pharmacotherapy. There’s the importance of vigilance with respect to diabetes management,.
Because, as we know, targets can be difficult to maintain over time. When we look at the optimisation of care, in terms of patient care, we have tight blood pressure, blood glucose and cholesterol targets monitoring for complications. This slide indicates that in general, we will achieve a lot if we have a generic, crowdbased approach. If we go on to the one which shows the management challenge to optimise care, once we can assess cardiovascular risk for the individual and we can target more appropriately lipids and blood pressure and glycaemia.
For the particular person the career stage of their diabetes then we can expect to achieve even better outcomes when we customise or individualise the care. Whilst the world is obsessed with obesity, it’s not the whole story Definitely not. We have these other major risk factors, we have to target those. We try and bring our waists in and reduce body weight if not stop it going higher, but there’s a lot we can do to prevent endorgan damage from diabetes. Alan, you’ve got a lot of experience working with Indigenous communities.
Indigenous rates of type 2 diabetes and complication rates are enormous. Is it a different disease or just worse I think the evidence is that it’s not a different disease, that the issues of poverty, poor access to care, a whole series of factors come together that make the same common problems of diabetes and related chronic illnesses worse rather than an entirely different approach being needed. What are the targets we should be aiming for The RACGP has generic targets, as shown here glycaemia, total cholesterol and blood pressure.
In general, these will work well for patients and for health professionals. So, the A1C target, less than or equal to 7. Total cholesterol, less than 4. These days, we focus on LDL cholesterol, less than 2.5, if not down to 2. Then blood pressure, less than or equal to 13080. However, if we do customise or individualise it for the person who has significant proteinuria, we want a tighter bloodpressure target than that. People with known ischemic heart disease, we want a tighter LDL cholesterol level less than 1.8.
And depending upon the stage of the person’s diabetes, early on we know that tight glycaemic control can reap rewards decades down the track. There’s even quite a push for HbA1c levels 6 to 6.5 early on after the diagnosis. That’s controversial. If you look at the most recent type 2 diabetes guidelines for glycaemic control, which you might address in subsequent weeks I know we’re not addressing those today the generic targets, A1C, less than 7.0, and we know we can achieve that for a lot, if not all, of our patients.
We can achieve it for a lot. There’s increasing data, again from ACCORD and ADVANCE and VADT, a number of studies over the last 18 months, 2 years, that early on in the diagnosis and also from the UKPDS followup early on, we need to aim for very tight glycaemic control, get in early. We know that in general, type 2 diabetes is a delaying diagnosis of four to five years between when it develops and when it’s diagnosed. We’re missing years there when we can help achieve tight control.
Of these surrogate markers for our patients. Paul, you’ve been following this group of people in the Blue Mountains for many years, many of whom have diabetes. Getting them early makes a difference Absolutely. In fact, one of the messages that has come out in the last year is this issue of metabolic memory. So, good control of diabetes in the first period of diabetes is really important. It’s been shown in the UKPDS in type 2 diabetes that good diabetic control over the period of the study persisted, despite the fact that the haemoglobin A1C levels.
In intensive versus routine control. We’ve got a graph to that effect to show. That metabolic memory effect was shown initially in the DCCT and is now being shown in UKPDS for retinopathy and for other complications. That probably tells us where the challenge is. We know that on average, we’re picking people up with diabetes several years after the diabetes is established. For primary care and the health system generally, what can we do to opportunistically pick up people For example, coming each year, most Australians do attend a general practitioner’s at least once.
There is strong evidence in the Australian context that if we opportunistically screen 50 to 69yearolds for diabetes, we can pick it up earlier and intervene and prevent heart attacks, strokes and premature mortality. Are you doing that, David Putting you on the spot. Yes, probably indirectly. A lot of patients have lots of blood tests. You’ll flip through and see that the sugars are in the 6s or occasionally higher, and it behoves us to concentrate on that and get a fasting glucose, get a twohour glucosetolerance test done and see where we’re up to.
Just take us through quickly the algorithm to remind us of the basic management of the glycaemic side of things before we move on to the complications. The algorithm involves intensive lifestyle management. That is both the diet and regular physical activity. We do find in most people as time goes on they do require pharmacological agents in addition to focusing on lifestyle. In terms of the HbA1c targets that will help determine what type of additional medications are needed and when, following the initial lifestyle intervention, metformin is our firstline agent.
It certainly is effective at lowering bloodglucose levels, has a relatively low sideeffect profile, well tolerated, and on top of that, in the UKPDS we’ve referred to, had good outcomes in terms of cardiovascular and microvascular outcomes. Subsequent to that though, as time goes on, HbA1cs often deteriorate and people need more than metformin alone. Sulphonylureas in Australia for decades have been our second port of call. Then, multiple thirdline options. Each of the thirdline options will sit on that line because they are newer agents which might be less well studied.
Than sulphonylureas, or they have challenges associated with them, for example, injections, as in the case of insulin. NORMAN We’ve got the results of your first poll question. We asked where you were located Here are the findings. 16 evenly split between metropolitan, regional and remote. And that big one, the blue one, is rural. Welcome to you all. It’s good to see such an even split and an appropriate split in terms of your location. I’m going to ask the second question now, which is So, we’ll get your answers to that while I ask David Guest,.
What is the general practice annual cycle of care when you’ve got somebody with diabetes With patients with established diabetes, it’s a protocol with which to manage them. It involves clinical measures that we probably should do every time we see the patient, but certainly sixmonthly, you need to check the blood pressure, the weight and hopefully the feet, but that’s sometimes something we don’t get around to. Annual tests needed, HbA1c certainly annually, more frequently depending on the level of control. We want to know what the lipids are doing,.
And HDL in particular in relation to some new riskfactor calculators. With diabetic nephropathy, we want to keep an eye on the albumin in the urine. There’s also the necessity for secondyearly eye examination, either yourself or more commonly where I come from, with optometrists and ophthalmologists. Keep on eye on the social factors smoking, alcohol, exercise, diet areas. If you get yourself into a regular pattern with that, either on your own or with the help of your team, you can keep your diabetic patient under control. Take us through the issues.
In terms of chronic kidney disease. Chronic kidney disease is common in diabetes. Chronic kidney disease is manifest evidence of kidney damage. The way that this is picked up is either through a simple blood test, then estimation of the glomerular filtration rate, where the GFR is less than 60ml per minute, evidence of significant kidney damage. The other way is through picking up protein leakage into the urine microalbuminuria through to more overt nephropathy. When we think about how we measure these things in terms of the serum creatinine on one hand,.
How much protein in the urine on the other hand and the estimation of GFR, it’s sometimes complex. Some of the keys to be cognisant of is that often leakage of albumin into the urine, microalbuminuria, is one of the earliest markers. This usually occurs when someone has normal renal function. NORMAN How best to measure that There are different ways in which that’s measured. Ways that are felt to be equally valid would be a spot, particularly morning urine for albumincreatinine ratio or a timed urine collection, again, looking for albumin.
We were originally trained in terms of 24hour urines, but in terms of common use in primary care, both of those methods are commonly used. NORMAN That should be part of the annual cycle of care Yes. Today’s patients expect fasting blood tests, so during the urine test at the same time has become part of the protocol, part of the routine. So that’s. You’ve knocked off a lot of your kidneys before your creatinine rises. Absolutely right. That’s the way to pick it up early, focusing on the albumin.
A key thing with the creatinine, a common measure we do it on many patients is that you might have lost half of your kidney function before you get an abnormally elevated creatinine measure. That’s where the simple calculation of the estimated GFR, which is done routinely by labs throughout Australia now, will provide a more ready measure of the amount of renal dysfunctional damage. Why are we interested in that Both of those are important. Both the level of albumin in the urine and the level of kidney dysfunction.
Are known predictors of events for people with diabetes. In other words, chronic kidney disease predicts heart attacks and strokes. Correct. Why are we interested It’s very common. From AusDiab, perhaps a quarter of people with diabetes have evidence of chronic kidney disease. And of all people with chronic kidney disease, what’s the diabetes in relation to the cause for endstage kidney disease Diabetes is now the leading cause of endstage kidney disease in Australia and in similar countries throughout the world, and interestingly also in developing countries. That relentless drive of diabetes contributing to endstage kidney disease.
Is quite clear in the Australian context. The ADVANCE study related cardiovascular disease risk with albuminuria and renal disease. Absolutely correct. The ADVANCE study was a large, randomisedcontrol trial with over 11,000 type 2 diabetics looking at bloodpressure control and glycaemic control. There is quite clear evidence there that both of these markers are predictors of heart attacks and strokes and progression of kidney disease to renal death or dialysis. Both independently and together, they add one to the other, so people at highest risk are people with reduced kidney function and.
Significant albumin leakage in urine. NORMAN Do they go hand in hand They do go hand in hand. The figure that one in four people with diabetes probably has some early kidney disease is about the figure for retinopathy. It used to be thought that retinopathy occurred before kidney disease. That’s before we measured kidney disease properly. They do go hand in hand. We know that once kidney disease really starts to accelerate, retinopathy really gets a hold on particularly macular oedema. People, as their creatinine starts to rise, that’s when we see retinopathy, if it hadn’t already needed treatment,.
Really become aggressive. Because they’re parallel processes according to severity Probably a parallel process, but certainly people who have got significant proteinuria have a major increased risk for macular oedema. What are the other risk factors for diabetic retinopathy The principal risk factor is glycaemic control, but in type 2 diabetes, it looks like blood pressure control is probably almost or as important. Lastly, blood lipid control might also be important. Data from field studies suggests that an aggressive approach to blood lipids might also be helpful, although that’s not so solid.
We certainly know that elevated lipids are associated with macular oedema specifically. The nice thing about that is, it’s blood pressure and glycaemic control that are also related to progression of kidney disease. So similar approaches to management of these factors that complicate diabetes can reap the rewards in terms of keeping people’s vision and keeping their kidney function. How reversible is diabetic retinopathy It’s quite reversible in the early stages. The recent data on this came from the. Got a blank on the study It’ll come to you later. One of the most recent study of ARBs.
Showed that if you had retinopathy at the first two stages, microaneurysms only or a few microaneurysms and retinal haemorrhages, those stages were reversible with really tight bloodpressure control. But once the retinopathy became slightly more advanced than that, then it was not reversible. These are the direct study findings. We’ll come back to do more on diabetic retinopathy in a moment. I’ve got the answer to the poll question, which is The red is sixmonthly, and it’s 27. 18 said it depends on the patient. 54.5 said annually. What’s the right answer, Professor Twigg.
STEPHEN I would say annually, but it depends on the patient. You’re happy with both You’ve got a thinking physician there. I’d prefer a thinking physician any day. Annually is the cycle of care. NORMAN So most people have got it right. As is recommended in the NHMRC guidelines, which Stephen cowrote. Just testing, just testing. We’ve talked about screening, just to go back to kidney disease. We’ve talked about the test that you do. What about albuminexcretion rates What validity does that have People use both albumincreatinine ratios and albuminexcretion rates.
In screening for damage to the kidney causing albumin leakage into the urine. Both are tests that are valid and have good sensitivity and specificity in terms of their role in screening and measuring response to therapy for diabetics. What are confounders when you’re doing urine tests It’s critical that there are a number of key confounders. Urine infection, menstruation in women, people who might have exercised significantly in the preceding 24 hours. Many Australians who eat highprotein diets, these people will have artificially elevated readings, for example, and some medications, for example nonsteroidals.
And others that are commonly taken. When you’re talking about blood pressure control, are we talking about angiotensin receptor blockers and ACE inhibitors or others work as well The answer is both. Yes, there is accumulating evidence from a number of trials that for people who have, in terms of prevention of early chronic kidney disease in diabetes and people with early stages that ACE inhibitors and ARBs might have a particular protective role. As well as that, it’s the overall level of blood pressure control. Indeed, there now seems to be added evidence.
That even for people who are normotensive with diabetes that there is the same benefit as people with any level of blood pressure in lowering their blood pressure in terms of kidney disease, for example. As you implied earlier, Paul, similar findings now for diabetic retinopathy Certainly the UKPDS didn’t differentiate between different blood pressure agents, and there’s never really been fantastic data suggesting that one class of blood pressure lowering medication would be better. Recent studies of ACE inhibitors and ARBs seem to show the best effects, but there hasn’t been a headtohead comparison.
Stephen I agree. You look at all the national and international guidelines and firstline for hypertension for people with diabetes is an ACE inhibitor or ARBs. As Paul and Alan mentioned though, the critical issue is tight blood pressure control. Lipid control is not as strong but still worth doing Lipid control is important, because people with diabetes have high cardiovascular risk. There is not strong evidence that lipid control prevents progression of kidney disease. But they are at high risk of heart attack and stroke, therefore require good lipid control in that context.
David, were you going to say something Just agreeing that at the macrovascular level, that’s what you’re looking for. The place of aspirin in patients Does aspirin help with kidney or eye disease Here we go. Put on your seatbelts. We’re in for a rough trip now. Perhaps I can address the issue of lipids. No, let’s have the aspirin question. Professor Twigg For secondary prevention, there’s no question antiplatelet therapy is critically important, and that gets back to the cardiovascular link. You’ve got to have an event before you start the aspirin.
for it to be of benefit Yes. For primary prevention, this is where cardiovascular risk tables can be extremely helpful. If a person is deemed to be at high risk, you’d be prone to use antiplatelet therapy. I would under those conditions. NORMAN But there’s no evidence for it. That’s for cardiovascular protection. There is, but you have to extrapolate. There was the Hypertension Optimal Treatment study, which had 1,700 with type 2 diabetes in it, but they’re only 10 of that population. Aspirin worked very well there.
There was also the Physicians’ Health Study for primary prevention. From a cardiovascular point of view, there’s a basis for using aspirin under those conditions. It is complex in people with diabetes. There’s some evidence that maybe aspirin resistance occurs resistance to the action of aspirin. And what is the correct dosage From the point of view of kidneys and eyes, we’ll move on to my esteemed colleagues. But from the cardiovascular point of view, tables can be helpful for antiplatelet therapy. I’ll come back to Paul ’cause I so rudely interrupted him.
To go on the aspirin point, one of the original diabetic retinopathy studies, the ETDRS, looked at whether aspirin was beneficial for people with diabetic retinopathy. It really showed no benefit over no aspirin. Of course, in people who needed aspirin for cardiovascular reasons, there was no contraindication to giving aspirin because there was no increase in haemorrhages, even in people with severe retinopathy. There was no increase in vitreous haemorrhage. So it’s safe, but there are no protective effects on its own. Can I add to that Stephen talked about the HOT trial.
There was a recent analysis, presented this year at the World Congress of Nephrology, showing that people in that trial who had chronic kidney disease people we’re talking about here with chronic kidney disease in the context of diabetes had the greatest absolute benefit from aspirin therapy of the entire group. Because they’re at much higher cardiovascular risk. Even though they had some increase in some risks, the added benefit in terms of the prevention of, in that case, heart attack and vascular events outweighed that. So people with CKD had particular benefit from aspirin therapy.
And smoking cessation affects the kidneys and eyes Smoking has been looked at a lot in terms of retinopathy, but no good data suggests that cessation of smoking benefits retinopathy. NORMAN So smoke doesn’t get in your eyes I’m sure it does, and it’s great to stop if you’ve got diabetes. It gets in your eyes from macular degeneration rather than anything else. What about kidneys There is evidence people who smoke are at greater risk of progression of chronic kidney disease. What about protein restriction with grade 3 renal disease.
I wouldn’t advocate that now. That was something. So generations of people with impaired kidneys have been eating that horrible stuff all that time Correct. The evidence of benefit is that it might at best delay the onset of dialysis by one or two months. And you feel every month of that. The clinical care guidelines are very helpful here in terms of the points that Paul has raised about aspirin not being a risk in terms of intercurrent retinopathy. They are nicely covered in the guidelines, and as Alan points out, the smoking issue too.
Even the executive summary, I’d encourage people to go online and have a look at it. Excellent marketing, Professor Twigg. We’re most impressed. What about salt reduction in kidney disease Does that have any benefit Salt reduction is becoming increasingly an issue of focus in Australia. In general we eat a highsalt diet. A lot of that is about not salt that we add but that salt is in..takeaway foods and foods that we buy at the supermarket. It’s quite clear that the highsalt diet has implications for hypertension. Therefore, I think it will be an area of increasing focus.
How can we reduce that in terms of interaction with the food industry, for example, so we can lower blood pressure That will be very relevant for management of diabetes. A question from New South Wales ‘What is the incidence of chronic kidney disease with gestational diabetes’ Maybe I can answer the gestational diabetes part, then pass on to the colleagues for chronic kidney disease. Gestational diabetes by definition is diabetes that develops in pregnancy, then usually resolves shortly afterwards. You wouldn’t expect kidney disease with it Yes. It does affect about 5 of the pregnant population.
After saying that, pregnancyinduced hypertension and preeclampsia and eclampsia, they do cosegregate with gestational diabetes, probably through body weight and equivalent risks. In terms of renal disease per se, in some of the renal diseaserelated conditions, there is some link. I’ll stop there and pass on to others. The actual risk of significant renal disease at the time of gestational diabetes or preeclampsia, for example, is low. People who might already have overt diabetic nephropathy at the time of becoming pregnant and high blood pressure and things are at more risk.
In that condition of worsening of renal function and of having greater difficulty in managing those comorbid conditions. There are a lot of people interested in following people after having the pregnancy, having a baby, in terms of their then ongoing risk of developing type 2 diabetes and related chronic kidney disease, where it does appear that there is, in longterm, some increased risk. Another question is, ‘How does steroid abuse influence the incidence of chronic kidney disease in existing type 2 diabetes’ I assume we’re talking anabolic steroid abuse here.
That’s not something I have any particular knowledge about. You haven’t got many muscledup. What about steroids as in corticosteroids There’s obviously concerns about obesity and its interaction with diabetes as to whether that’s a risk factor for development and progression of chronic kidney disease in diabetes. But again, it’s not something that features steroid use, in terms of development of chronic kidney disease. Let’s have a look at our first case study. Back a while, back about 10, 11 years, I was working in the coal fields then. I went to the doctor because the diabetes had sort of caught up with us,.
The high blood pressure and that. The doctor had taken blood tests and that and said, oh, yeah, there’s something wrong with your kidneys. So I had to go to Townsville. They took a biopsy on the kidney. They thought it was a diseased kidney. They took a biopsy, and the result of that was, neither kidney was diseased. We had to go and see a dietitian in Mackay when he came back. They said, don’t eat this and don’t eat that. Eat this and eat that. So he did it, but nobody ever said, you’ve got to follow it up.
It wasn’t until about five years ago that he started feeling down. He said he was feeling a bit tired a lot. I said, you need a good sleep. Stop eating so much. He got the flu. He was away working in a mine. He used to fly in and out. And then he got sick. He flew back in, and I couldn’t believe he was a person when I opened the gate. I thought, what’s wrong with you He said, I’m really sick. Jeez, it nearly killed me. It was just something unbelievable.
That’s when he asked his doctor if he could get his kidneys checked, and lucky he did do that. Next I know, I’m at the renal area of the doctor’s. It just went from there. I knew something was wrong when he didn’t come out. I kept seeing people going out, and I thought, something’s wrong. Then I thought, oh, no. When I walked in and saw the faces, I knew then. It just hits you like a brick. It all happened so quick. It obviously was over a long period of time.
Probably the good life caught up. Personally, it gets back to the way you’re brought up, I guess. The foods that you eat when you’re in your younger days, grog, everyone does it. A lot of people overindulge. It just depends. It gets back to your diet and the way you look after your body. I didn’t show him, I’d just go out and cry. I couldn’t handle it. Not only my father died, his father died of it. I’ve got aunties on my mother’s side that have died of it.
Down in South Australia. So you think, he’s got it, so I must have it. It knocked the whole lot of us. Really knocked the family. The grandkids just couldn’t believe Poppy could get sick, not their poppy. Not a good story there, David. No, no. Like he said, it happened so quick, but it really is something over a decade or more, isn’t it I think it’s probably a good idea when we have patients with diabetes early on that we have our registers set up so we can keep track of them.
It would be even better if we could negotiate some plan on how we’re going to manage it according to the cycle of care so they don’t get away from us. And using a team. And using a team to ease the burden, particularly on rural GPs who don’t have much time. He looked as if he was trucking along with a haemoglobin of about 9. I think that’s right. They talk about the devastating impact of diabetes and kidney disease on the family. The key issue is multiple missed opportunities for engagement.
In the management of the diabetes. He talked about all the factors we know are crucial his blood pressure, diet, all of the approaches to management that could have made a difference and prevented his severe kidney failure. This problem is writ large again and again across the country. I’m going to ask you another question. How would you rate your understanding of correlation between serum lipid levels, good blood glucose control and blood pressure control and eye complications It’s probably a bit better since we’ve been speaking about it for a while.
Let’s see how you rate it now. While you’re answering those questions, we’ve got another case study to watch. Let’s look at Darren’s story. My name’s Darren Dorey. In September, I’ll be 43. I live in Warrnambool, in the southwest corner of Victoria. It’s approximately 300km or three hours from Melbourne, a little seaside town that is a nice, little friendly community. I was diagnosed with type 2 diabetes when I was 27. I was told to change diet, and I was put on some tablets. But as time went by and I didn’t feel any different,.
I got more and more slack with it. Probably for the next ten years, I lost focus on control of the diabetes. At the time I was told, you have to have your eyes checked. OK, well, that’s pretty serious. I drive a truck for a living, so I’ve got to keep on top of the eyes. After a couple of years of going, yep, your eyes are fine, you stop worrying about it. Around about 2001 I was starting to struggle a little bit with seeing some road signs. I went in to the optometrist’s to get some glasses.
She had a look in my eyes and said, you’ve got a massive bleed in the eye. She said, you need laser surgery and you need it now. I walked out of the ophthalmologist’s rooms after having something like 300, 400 shots of laser in the eye. I ended up having a vitrectomy. Probably 18 months later, I developed a cataract, which I had out in about 2006, in the left eye. That brought back vision beautifully. It was like, wow, a whole new world. This is all good. In 2007 I’d actually gone back to truck driving.
I guess going back into trucks was, for the diabetes, one of the worst things I did. I did a lot of travel where you’d take off for a few days’ trip and forget to take your medications with you. I noticed it was getting harder to read the paperwork, and the headlights of cars started to become more glarey the lights would flare. I thought, I’d better go back to the ophthalmologist. He looked at my eyes and said, ‘Are you still in sales’ I said, ‘No, I’m a truck driver.’.
He just said, ‘Not anymore you’re not. Hand in your licence tomorrow.’ I then had to go home to my wife and four kids and say, ‘I don’t have a job, and it looks like I might be going blind.’ The same day, our landlord called over to mention that he’d put the house on the market and we’d have to move. Yeah, life just crumbled. Paul Mitchell, entirely preventable I think that blindness from diabetic retinopathy should be preventable. There really should not be any cases of people who go blind from this disease anymore.
There are still people going blind from it, and there will still be some people. But if you look at every one of those cases, you can really detect what went wrong. Clearly, in the early stages of his diabetes, he was poorly managed. He put his head in the sand. Maybe his doctors didn’t impress on him the absolute importance of having regular checks, but it should have been prevented. After he had that first lot of therapy, it looks like he again lost contact. He should have had pretty intense followup after that first therapy.
But he didn’t go, and he went back to driving again. If you look at Darren’s story, there are many circumstances where really, the wrong path was taken, and his blindness, or severe vision loss, could have been prevented. How do you screen your patients for retinopathy, David Do you send them to the optometrist I send them off to the optometrist or ophthalmologist, probably a 5050 split, or a bit more to the ophthalmologist where we are. Question from Michael Stuckey in Queensland ‘Why not annual retinopathy screening’ Paul.
It’s been looked at. Around the world, most diabetes associations recommend annually, but in fact, the development of retinopathy occurs relatively slowly. It’s been shown that twoyearly is actually sufficient. If someone has difficulttocontrol diabetes, if they’ve already got other complications, of course they need to be seen more frequently, even if they have no retinopathy. How good are the screening tests This is ophthalmoscopy Yeah, this is ophthalmoscopy. The eye doctor, or optometrist, wouldn’t use a handheld ophthalmoscope. He would use a slit lamp with a much wider area, being able to screen the retina much more effectively.
Than the handheld ophthalmoscope. We also have the potential availability for clinics of nonmydriatic photography. This is what they’re using in some Aboriginal communities That’s right. That’s very effective. You see a blownup picture, you can immediately see if there are any retinopathy lesions. The standard though, at the moment, would be pupil dilation Yeah. The standard is pupil dilatation, then examination of the retina by someone who can do it properly an ophthalmologist, an optometrist or a welltrained GP or physician. What are the criteria for referral to an ophthalmologist.
Certainly nonophthalmologists can manage people with diabetes in terms of retinal screening until the point at which any significant retinopathy is present anything more than the occasional haemorrhage or microaneurysm. From that point people should see an ophthalmologist. Marisa Pilla from North Queensland asks, ‘Is there any ACE inhibitor that’s superior to the others in helping to prevent retinopathy or the worsening of the condition’ We don’t know. There are two recent studies looking at two different ARBs and they both showed beneficial effects, but there’s been no headtohead comparison.
She also asks about antioxidants. The AREDS study suggested that a certain cocktail might help macular degeneration. Does it help in diabetic retinopathy There’s no evidence that it helps diabetic retinopathy. Talk us through laser photocoagulation here. There are some new therapies coming on when you’ve got microaneurysms and bleeds. Once ophthalmologists take over followup and management of people with diabetes, what they’re really critically interested in doing is evaluating the patient at an interval so that they would detect visionthreatening retinopathy and could apply laser treatment at the optimal time.
The indications for laser treatment are the presence of either new vessels, and this is an advanced stage of the background type of retinopathy. New vessels are fragile, they bleed, they don’t really help, they don’t bring new blood to the area. The second is macular oedema. This is the more frequent and more important complication to detect. That is harder to detect with ophthalmoscopy. That’s why you really need an ophthalmologist or optometrist to examine the patient. And the treatment of macular oedema The treatment of macular oedema is currently laser treatment.
Using the guidelines that have been around for 25 years. It’s reasonably effective but not brilliantly effective. Certainly many people will still lose vision. We now have some other adjunctive therapies that can help. The main one is antiVEGF therapy. This is vascular endothelial growth factor. This is like Avastin or Lucentis. That’s right. These agents are an adjunct to therapy. They don’t do away with the need for laser, but they can help to dry out the macula until laser treatment can be a bit more effective. Laser treatment is probably more effective if it’s applied.
When the macular oedema is resolved. And the role of fluorescein angiography Becoming less and less. Fluorescein is not a particularly pleasant test to have done. We actually do it very rarely. We might do it at the onset, before we start laser treatment for macular oedema, once, but we rarely repeat it these days. We don’t do it at all for screening or for the followup of people with diabetic retinopathy. Unlike retinal detachment, vitrectomy has a different reason. You’re trying to get rid of the haemorrhage from the vitreous.
There are two circumstances. The first is to get rid of the haemorrhage and scar tissue, because new vessels that bled will then develop scarring, and that scarring will cause traction on the retina. Because retinal detachment is increased in diabetes Correct, and it’s a tractional type of retinal detachment. The other type of need for vitrectomy surgery is for traction on the macula itself, which can cause macular oedema to persist and be chronic. But we are doing less and less vitrectomies now because physicians are managing people with diabetes much better.
We’re seeing less people presented at Act V, Scene IV, and we’re needing to do a lot less vitrectomy surgery. Just to explain, the vitrectomy involves microdissection to remove scar tissue. Correct. It involves usually two ports on the side of the eye with instrumentation which can dissect and peel off membranes and coagulate blood vessels. People have said that doing cataract surgery can also damage the retina. What risks are there in cataract surgery and diabetes This is an important issue, and it’s still important. We know that people with diabetes develop cataract much earlier.
Than people without diabetes. There’s a direct effect of glucose on the lens in the eye. The type of cataract they get is a cortical cataract the spokes when you dilate the pupil you can see them quite easily with an ophthalmoscope or an opacity on the back of the lens. The problem is that when people with diabetes develop cataract, they may also be developing retinopathy. If there is any early macular oedema or moderate retinopathy, then you can develop macular oedema after cataract surgery, perhaps as a response to the inflammation of the surgery itself.
One of the issues that all ophthalmologists know is that we must stabilise the retinopathy before cataract surgery as much as we possibly can. What about access to good ophthalmological care when you’re living in a small country town This is always difficult. Ophthalmologists like to live in the nicer suburbs, and don’t necessarily go to the country so often. But in all country areas in Australia, there is some degree of access. It always needs to be better, but there is reasonable access. And if there isn’t, you need to let us know.
So the College of Ophthalmologists can look at this. Local ophthalmologists in some of the larger rural areas will be prepared to travel to smaller areas if they think there’s a reasonable need. This nonmydriatic screening can be transmitted for people to look at. Correct. Right now there’s another application to the Medicare group to consider funding nonmydriatic photography. This would produce a fantastic way of screening people. It means they wouldn’t have to travel a long way to see an optometrist or eye doctor. GPs themselves could read the photographs quite well.
With relatively minor training. That has not yet been approved, but we’re hoping it will be. Let’s have a look at Darren’s story again, and what his life is like now. My left eye has been left with 25 vision. The right eye, about 10. The hardest thing with the eyes is that they see totally differently. I describe it as being like the old fun mirrors at Luna Park, where everything is distorted, or fog up your windscreen, jump in your car of a cold morning, going for a drive without a clean windscreen.
Then put a few little lines and black dots into your line of vision then go crosseyed so you’ve got double vision on top of that. I was never actually told about the correlation between diabetes and depression. If my sugar levels were high, my moods would swing. But once I lost the sight, the depression came in like a tidal wave. It became allencompassing to the fact where I attempted suicide. I lost all selfesteem, I lost all selfworth. It cost me my marriage. I haven’t seen my children for two years.
October ’07, my life fell into a hole a very, very deep black hole. It took me another six months to crawl my way out of it and restart my life. One of the biggest things that helped me get my life back on track, or helped me out of the hole that I was in, I made an appointment to see my GP and couldn’t get in, so they said, we’ve got another doctor here with an appointment open. Do you mind seeing someone else I said, I just need a script, so that would be great.
I sat down with this new female doctor. Very young, she was. She had a look at my file and said, you haven’t had this test done for a while. You haven’t had this test. What’s going on here What’s going on there We’d better take control of this. It was almost a lightbulb moment for me, like, someone is listening, someone is taking note. The GP I was seeing, we had a good rapport, but it just became the usual, yep, I’ve run out of tablets. Can you help me here.
It was in and out, script in hand, thanks very much, see you later. She also linked me in with the local psychiatric services through the local hospital, and I was given a case manager, who, once again, showed a lot of compassion and care and was listening to me. Also Vision Australia really came on board and helped me with a lot of adaptive stuff. They sent out a person to help me learn how to walk again. It sounds silly, but you learn to feel the ground rather than see the ground.
I couldn’t see the normal, everyday things anymore, simple things like how to put something in the microwave, push the button to go. I couldn’t see that button. I couldn’t feel that button ’cause they’re flatpanel. Vision Australia said, we’ve got these dots, put them on the go and stop buttons. I can’t read how many minutes I’ve got up, so I count how many times it beeps. It’s just one of the little things you take for granted that suddenly become an issue. It was the supports behind me that helped me.
I’m now employed by South West Healthcare, Psychiatric Services Department. Vision have come down from Melbourne and put in a program which helps with email, it enlarges the font automatically. I can’t read normalsize font. Also, enlarged keys or enlarged stickers on the keyboard. Without them, I’ve got no hope. The main thing for someone who’s new to diabetes, or even a doctor that’s treating a new diabetic, is to emphasise what it is and how it works. Doctors need to emphasise, you won’t feel it coming. As I said earlier, I expected to have signs.
If there’s any damage, I expected to have the signs of it coming. You don’t feel it coming. It creeps up very, very slowly until suddenly it’s out of control. A lot of the things I did was, if it’s serious, they’ll tell me about it. Of course they think you’ve understood it, so they let it go. Suddenly it becomes a huge issue down the track. I honestly feel, if it had been more of a team effort between my GP and myself, maybe I wouldn’t have lost the sight.
Tragic, David. DAVID Yes. You feel bad as a GP when you see a story like that. There’s a place for having a register of your diabetic patients and reviewing that regularly and getting your team to help you in the management of these patients and make sure they’re not lost to followup and you can keep on them. I joke with our diabetes educator who visits our surgery that we play good cop, bad cop. She tells them all the things they have to do, then I come in and say,.
Sharon says this, so you’d better do the right thing for next time. Let me get the results of the poll question 6 of you said you had no understanding. Hopefully we’ve improved that tonight. 62 said you’ve got moderate, and 31, comprehensive. So over 90 of you have got a reasonable understanding, at least on a selfassessment basis. We won’t be administering any multichoice questionnaires tonight. Paul, not a good story there, but you’re saying it’s becoming rarer. It’s becoming rarer. One of the points we could say about Darren.
Is that he’s been through the gamut of therapy. Usually their vision is stable from that point. Usually there’s no further progression, because the disease becomes relatively quiescent after it’s done all that damage. He probably will hold his vision from now on. We should be looking at his case and say, this should have been prevented. We really need to work hard to prevent all these cases, and I think we can. We mustn’t forget the psychosocial issues. Depression goes along with it. It makes diabetes worse. Absolutely. It’s an important part of the package.
We know people with diabetes have a two to threefold higher prevalence rate of depression. It’s a vicious cycle. What are your takeaway messages for the audience, David Know who your diabetic patients are, and keep them under careful, close review. Don’t try and do it all yourself. Your diabetes educators, dietitians, podiatrists, they’re all there to help, and make sure the necessary gets done. And get the targets right. Get the numbers right. Paul At least twoyearly, I review by competent examiner. Make sure that you really work hard.
At the control of diabetes blood pressure and blood lipids. Alan Chronic kidney disease is common. It can be readily detected and followed with simple blood and urine tests. And again, blood pressure and glycaemic control are crucial to preventing progression. For me, those two case histories show that too many people fall through the cracks. Both as individuals in our own clinical practice and the health system generally, we need to do something better to prevent those disastrous outcomes. Stephen Vigilance is key. Diabetes does tend to be a progressive condition,.
And the complications. We need to get to know our patients well. Work with them as one of the key members of the team. Recognise that we can prevent at many different levels. Hopefully we can prevent many people from developing diabetes, many others from diabetes complications developing once they’ve been diagnosed with diabetes. Even those who develop more severe laterstage complications, there’s a lot that we can do. Never give up, prevent at multiple different levels and get to know your patient. Thank you all very much. Very interesting and very important.
I hope you got a lot from the program too. The series of four programs we’re making on type 2 diabetes guidelines will be available in December free on DVD. To order, visit the Foundation’s website. Copies of the guidelines can be downloaded from Diabetes Australia diabetes.au. If you’re obtaining even more information about issues raised in tonight’s program, there are a number of resources available on the Rural Health Education Foundation’s website Don’t forget to complete and send in your evaluation forms and register for CPD points by completing the attendance sheet.
Diabetic nephropathy Clinical presentation treatment
Voiceover Diabetic nephropathy is one of the most common and serious chronic complications associated with diabetes mellitus. In this tutorial, let’s discuss how the mechanisms underlying diabetic nephropathy correlate with the clinical presentation as well as the treatment of the disease. Now fortunately the mechanisms underlying diabetic nephropathy, directly correlate with the clinical presentation. And the first clinical finding of the disease is somewhat paradoxically an increased kidney filtration rate or glomerular filtration rate. So, diabetic nephropathy, if you break down the term into nephro and pathy literally means kidney disease caused by diabetes.
Now typically kidney disease is marked by a decreased filtration rate, so why is it that the first clinical stage of diabetic nephropathy is that of an increased glomerular filtration rate Well recall that the earliest mechanism contributing to diabetic nephropathy is an increased pressure state, over here in blue. And this is due to hypertension and efferent vasoconstriction. So let’s use a common garden hose to help illustrate how this increased pressure state will ultimately result in an increased glomerular filtration rate. So, imagine you have this garden hose and it has a small hole in the middle of it.
So first you’re gonna open up the spigot and increase the pressure and flow through the hose. Intuitively, this is going to increase the rate at which water is leaking from the hole in the hose. Next, you partially kink off the end of the hose distal to the hole, and once again this is gonna further increase the rate at which water leaks from the hose. This is essentially what’s occurring in the glomerulus with the hypertension representing the opening up of the spigot and increasing the pressure before the glomerulus,.
In front of the glomerulus, and the efferent vasoconstriction representing the kinking off of the hose, which causes this back pressure. Both of which are going to increase the filtration rate. This stage of diabetic nephropathy is most commonly asymptomatic, so it goes typically unnoticed. However, it’s going to set the stage for the next clinical step of diabetic nephropathy and that is detectable proteinuria. And what proteinuria is is protein in the urine. So this increased pressure state causes trauma on the mesangium, in the middle of the glomerulus here.
And it results in mesangial expansion, which is this second mechanism of diabetic nephropathy. Now as the mesangium expands, this also increases the size of these fenestrations or spaces between the podocyte foot processes, so let’s go back and look real closely at these fenestrations and watch how they increase in size. Now, these podocyte fenestrations are a component of the glomerular filtration mechanism. So, let’s think of these podocyte foot processes as a coffee filter. A proper coffee filter is porous enough to allow for the water to flow through,.
But will retain the coffee grounds within the filter. This is because the molecules of water are much smaller than the size of the coffee ground, so over time the coffee pot is gonna fill just with the coffee but no coffee grounds. Now imagine if the coffee filter was replaced with a cooking strainer, which has considerably larger pores. If you were to try and use a cooking strainer as a coffee filter, when you pour the hot water through, it’s not gonna work because the pores of this cooking strainer are much larger.
Both the coffee as well as the grounds are gonna start to spill through and you’re gonna end up with coffee grounds in your coffee. So in the glomerulus, the fenestrations between these podocyte foot processes are kind of like coffee filters and normally in the filtration of blood no proteins or large molecules are allowed though. However, with mesangial expansion these fenestrations become much larger and when filtration occurs they become leaky, and they allow for molecules, such as proteins, to be spilled out into the urine. So this is what causes the detectable proteinuria.
In diabetic nephropathy. One of these proteins is albumin. Urine tests are available to detect the presence of albumin in the urine, so frequently individuals with diabetes will have routine screening to test for this albumin or for protein in their urine, which is a sign that they may be developing diabetic nephropathy or kidney disease due to diabetes. Then the next clinical stage of diabetic nephropathy is that of a decreased glomerular filtration rate. So you can see that we’ve gone from an increased glomerular filtration rate, then to a decreased glomerular filtration rate.
So what exactly causes this Well, recall that part of the reason for this mesangial expansion is the release of cytokines which cause inflammation and oxygen free radicals. Now, these cytokines and oxygen free radicals damage the mesangium, resulting in the mesangial expansion. However, they don’t just damage the mesangium. They damage the cells throughout the tubules as well as the vasculature that supports the nephron. Now in addition to the cytokines and oxygen free radicals, this vasculature is further damaged by this efferent vasoconstriction here. Which is one of the causes of that increased pressure state.
And this combination of damage from decreased blood flow and cytokines and oxygen free radicals results in ischemia and atrophy of this vasculature. As this vasculature kind of dies off, it no longer can support the tubules of the nephron, so the nephron itself begins to die off as well, and so there’s a decreased ability to filter the blood. Now initially this occurs in just a small percentage of the nephrons in the kidney, and the kidney’s able to compensate, but eventually over time if this diabetic nephropathy is not treated, a large enough number.
Of nephrons throughout the kidney are gonna die off, and it’s gonna be detected as a decreased filtration rate. The kidney’s no longer able to keep up with the dying off of nephrons. If this is present, this decreased filtration rate is present for more than three months in a row, then it’s known as chronic kidney disease. As it continues to progress, eventually it will become a permanent decrease, which is then known as endstage renal disease. Now that we have a better understanding of the mechanisms that cause diabetic nephropathy.
And how they correlate with the clinical presentation, let’s just briefly touch on how diabetic nephropathy is treated. This is, once again, gonna be directly correlated to the underlying mechanisms. So, the most important thing in diabetic nephropathy is to treat the underlying diabetes. This is because the hyperglycemia associated with diabetes is the cause of this increased pressure state, so if you can treat the diabetes, you can prevent the increased pressure state, which will then prevent the cascade of effects leading to diabetic nephropathy. However, if this increased pressure state.
Does start to occur, the next step is to treat the pressure. And what I mean by that is treat the hypertension. So if you can decrease the blood pressure, that goes into the afferent arteriole here, you’ll decrease this increased pressure state. In addition, one of the most common medications to treat blood pressure are known as ACE inhibitors. Now ACE inhibitors stands for angiotensin converting enzyme inhibitor and angiotensin is one of the hormones in that reninangiotensinaldosterone system that results in the efferent vasoconstriction. So by treating the blood pressure with an ACE inhibitor,.
You’re also going to decrease this vasoconstriction to further decrease this pressure state within the glomerulus. These two treatments should be occurring regardless of whether or not an individual with diabetes is in any of these clinical stages of diabetic nephropathy. So these are not only treatments, but they’re also good for preventing the progression of diabetic nephropathy before someone even enters this first clinical stage. However, if someone does develop diabetic nephropathy and it unfortunately progresses far enough to have this decreased glomerular filtration rate and they end up in endstage renal disease,.