Diabetes: Section 2: Classification and Diagnosis

Diabetes: Section 2: Classification and Diagnosis


Hi everybody, all right, we’re gonna get start on Section to classification diagnosis of diabetes this section is super important to pay attention to this is how we Diagnose diabetes type 1 type 2 and then we’ll talk about the other more uncommon types of diabetes So we have type 1 type 2 Gestational and then there’s other types of diabetes as mentioned down here, which we will talk about But one thing to remember is go back to this pathophysiology. I’m going to post a video on Insulin resistance and type 2 but type 1 diabetes it’s more or less. It’s an autoimmune disease. It’s hereditary usually in first-degree relatives and They have complete beta cell destruction. And remember that is in the pancreas. So beta cell destruction is responsible for insulin. Insulin Secretion so these people need insulin type 2 diabetes is different. It’s insulin resistance So we’ll get more into that but again, how do you Diagnose these is what we’re gonna learn about as well as the different types And I know that we diagnosed with the a1c test now, which has been wonderful But we always have to remember to there are some variants And not to forget about that because we have to remember what the a1c really is. Remember. It’s the The amount of hemoglobin sitting or amount of glucose sitting on our hemoglobin and remember our red blood cells are recycled every 90 days or hemoglobins on the red blood cells and so people with issues such as sickle cell disease and even think people on dialysis or if they’ve had transfusions or blood loss if they’re on or ether appleton therapy and usually that’s with chronic kidney disease that a1c can be altered so you have to always take a look at what that Plasma glucose level is versus the a1c. And the other thing to remember with an a1c. It’s an average It doesn’t give Peaks and it doesn’t give the lows either And it’s a great test and it gives us a guide to see where the patients going or if they’re staying if they’re stable But just keep that in the back your mind because I think we take a 1c for granted and think okay. Well they’re You know five point seven, they’re fine. They’re just borderline. Just borderline But we need to take it more seriously with symptoms and stuff – all right. So this is staging of type one diabetes so remember it’s Complete destruction of the beta cell but there are stages of it So when someone is first diagnosed you might they might not have complete destruction of all the beta cells yet But over time it will eventually get worse and usually their insulin needs wound up going up Unless they follow a really good diet You know with carb less carbohydrates and stuff but most of these people just think like in the beginning that might not require as much insulin as When they get to stage three, but stage one. Let’s just say you have a first degree relative with Diabetes you can go ahead and get out about an anti Autobody. Oh my gosh. I can’t talk today Auto antibody testing done and I’m gonna show you in a minute the specific Auto antibodies and lab tests that Can be drawn is this done in primary care? I would say basic ones but then there what there are ones that get to be a little bit more expensive and that’s when you probably would send an endocrinology for that if you suspect that, but there’s no Reason why we can’t get an insulin level and a c-peptide level dust to see if they’re making insulin So stage one, you don’t have any symptoms yet and stage two You start having some abnormal glucose, but you’re really not symptomatic yet And that’s when you’re going to get that Flast fasting plasma glucose to our and you can also get an a1c Just remember and a1c is not the best way to diagnose type 1 diabetes, though then when you get to stage 3 you’re having clinical symptoms and All of a sudden they have the spike in Glucose and are symptomatic and unfortunately Many times we end up diagnosing type 1 diabetes because they end up and diabetic ketoacidosis In the hospital with the blood sugar of you know over 800 So this is a general criteria for the diagnosis of diabetes A flat of I can’t talk today. I’m fighting bronchitis, too. So sorry about that. Alright, so your plasma glucose fasting should be greater than 126 and you should be fasting for at least 8 hours. I say 12 hours is even better Or you can get a 2 hour Plasma glucose Greater than 200 during the oral glucose tolerance test. So this is the oral glucose tolerance test It’s really only used for pregnant women and Not so much. If you’re just diagnosing diabetes, it’s it’s inconvenient It’s just not as much of the standard of care as it used to be but it as an option also the a1c we can use now as a diagnostic tool for diagnosing diabetes and greater than six point five would be diagnostic of diabetes or In a patient with classic symptoms and they have a random plasma glucose of greater than 200 So these are the patients that they come in your office and they’re like I have really blurred vision. I have polyuria polydipsia you know, they have multiple symptoms and then you’re like, let’s just check your blood glucose and it’s like 340 that’s happened many times In my practice, so what do I do with that while I end up? Suspecting that they have diagnosed it or they have diabetes you can technically put a Diagnosis of diabetes in their chart at that point what I usually do is put elevated glucose. I’ll get an a1c I’ll have them come back In a couple of days, we’ll go through the labs I also get like a lipid panel complete metabolic panel and get more labs if they have not had those done, but technically yes, you can diagnose that and another thing to remember if Your page comes in for follow-up and they have a fasting glucose on their complete metabolic panel or basic metabolic panel Greater than 126 or equal to 126. I would repeat the test So that would be the best recommendation To do for diagnosing diabetes Alright so back to type one diabetes your plasma glucose rather than your a1c which I mentioned before is the best way to Diagnose the acute onset you will get an a1c and you know, it’s probably going to be high screen for type one diabetes risk though with a panel of auto antibodies is recommended only in the setting of a research trial or on a first-degree family member with a pro of a probe and With type one diabetes so really there’s no screening recommendation unless you have a first degree relative with type one diabetes And as far as the family member having a probe and of a probe and like they had genetic Testing you you I would still get the genetic testing done or would get more auto antibodies testing So if you have a persistence of two or more Auto antibodies, it predicts clinical diabetes and you can use that to do an intervention meaning that you can go further saying are we in a pre type one diabetes a stage one or a stage two Process of that I’m going to escape out here because I do want to show you the Lab testing All right, and I also I’m putting this in a Word document for you guys to see All right. So see peptide level is the most common one that’s done and see peptide Mears insulin level. So if you have low C peptide, you can say that your insulin level is low So you’re not secreting the insulin, so you’re eating the food? And insulin not enough can secrete to bring that the sugars that you had just eaten down and remember sugars are also Carbohydrates that break down into sugar so it could be pasta Turanians even whole grains I couldn’t do that, which we’ll talk about that later There’s insulin Auto antibodies and that looks for antibodies Are there any antibodies targeting the insulin and as well as insulinoma? associated to Auto antibodies And so as their zinc transporter islet cell In the gadda or anti gad now again, these are very expensive tests not as much the SI peptides not as expensive, but I’ve Drawn see peptides quite a bit as well as insulin Auto antibodies If those are abnormal, I will send an endocrinology. But again, it just depends on your practice What if you work in a rural area what if you have a collaborating that you know, really? Has specialize in that and he’s you know, hey, let’s let’s treat this way Or you become comfortable in doing that. I say go ahead. We are perfectly capable of Doing that and you know once you have those then you would send an endocrinology for management of type 1 diabetes if there’s I always have my type once in Under chronology and that’s that’s very common. All right, so I’m gonna go back to this and Go back. Ok. So now let’s talk about pre diabetes and type 2 diabetes Remember, this is a little bit different because these people have more insulin resistance problem So there’s risk factors, which on the next slide I’ll show you what the risk factors are but you should test for Do a fasting blood glucose In patients or you can get an a1c and/or In anybody who’s overweight or obese? So if your BMI is greater or equal to 25 or graders are equal in asian-americans and Who have one or more additional risk factors, which is on the next slide but in general all people you should test with it a fasting blood glucose greater that at 45 years old and Greater and then you should test them every three years now. Here’s the criteria So if you’re obese You look for any of these risk factors if you have one of them and usually people will fit fit that criteria pretty easily You know a lot of people have hypertension or history of a low HDL so this brings up a very important issue with metabolic syndrome and I had mentioned in my other sites if you do anything, let’s just really try to focus on prevention in our Primary care setting because we don’t want people that become diabetic We have to be more aggressive You’ll see physicians out there and I’m not trying to pick on them because there’s awesome physicians But there are some that just watch The fasting blood sugar granted. Yes, a lot of patients are resistant to starting metformin and stuff but I have seen some physicians just not tell the patients that they have a Fasting blood glucose and the borderline range and they just keep getting their labs drawn because maybe they have high blood pressure my cholesterol and our obese well, guess what that person is metabolic syndrome and again when I think of metabolic syndrome or pre-diabetes you have a carbohydrate intolerance you have a Metabolic issue and so these people are eventually going to be diagnosed with diabetes And as we know once you’re diagnosed with diabetes your risk factors for heart attack stroke go up at least fourfold Whoops okay and link it back to that. Okay All right. So and the other thing I want to mention is gestational diabetes We have to take that seriously too because there’s a huge increased risk of them becoming diabetic post having gestational diabetes including myself I was just a tional diabetic and With my third child at age 30, although prior to that. I had risk factors. I’ve had hydro lissa rides low HDL starting in my late 20s it’s very genetic and Because my BMI at that time was like probably nineteen I’ve always been more of a thinner person and So then I became gestational diabetic and you know, they warned me you get to watch it. Well, you know, I didn’t and I ended up with borderline diabetes for about five or six years on medications for my triglycerides and Then what happened? I became diabetic I was diagnosed a little over a year ago now. So since that time I have started I have lost More weight just because I’ve had to stop carbohydrates And then I’m at Forman Although I’m off at now because the lifestyle changes so not a majority of the population is obese But not everybody is that’s why metabolic syndrome is important to look at because I was not overweight but yet I had low HDL high triglycerides And I had a borderline fasting glucose. So you have three out of the five criteria for metabolic syndrome Please look up metabolic syndrome and see what the criteria are and have that on you waist circumference low HDL high triglycerides borderline fasting blood sugar or fat or elevated blood sugar in general and a waist circumference of greater than 35 in males and 40 in females. So if you meet three out of the five You just might as well say, you know what, you’re pretty much diabetic and you have to treat them as such It’s already go on my soapbox, but it’s just really important alright, so again for testing You can do the a1c and the fasting blood sugar I’m not going to go through this again because I talked about this on a slide Before and we also have to pay attention to children now because we are seeing much more obese children We have to think about that. I know you guys I think cover pediatric stuff in your next course, so You’ll talk about that. So I’m not gonna go through this but just know a one key takeaway, is that if For example, I was just a tional diabetic. So my son who’s now 18. He’s at risk for diabetes as He you know grows and becomes older so it’s not only the mother. It’s the child that is at risk This is an awesome tool and you should have this in your Office in every exam room. I think this this comes in handy for My patients and me this really helps to determine You know It helps me to say oh, let’s look at metabolic syndrome symptoms What do the labs show because again, I want to catch these people early so you can get that on the diabetes org the SOC risk test and then Pre-diabetes again, what we’re trying to capture is between 100 and 125 We usually don’t do oral glucose tolerance tests, although you can and the a1c is between 5.7 and 6.4 You have to really monitor those And again, you might see people let’s go back to this slide you might see people with the fasting blood glucose of 106 every single time but yet their a1c is 5.2 That’s happened doesn’t mean that the a once because that just tells me that average is still below 100 but morning-time They’re starting to have this insulin resistance because remember in the middle of the night between about 3:00 and 5:00 a.m Your body kind of wakes up and says, oh I’m need to feed myself so your liver excretes glucose into your bloodstream and If you don’t make enough insulin or have enough insulin to bring that down hence high blood sugars in the morning So it’s there something called a dawn phenomenon? Which is really common on people with diabetes in general There’s a samadhi effect where usually you go Hypoglycemic in the middle of the night but the dawn phenomenon is the opposite where you have this excretion of Secretion of glucose into your system and then you wake up with this fasting blood glucose Gestational diabetes it’s done in the second trimester. And that is where they do the oral glucose tolerance test it’s done between 24 and 28 weeks because you’re in the second trimester and That is when your body starts to secrete more glucose into the system due to all the hormonal changes and so those who are Pre-diabetic or Meaning insulin resistance you’re going to test abnormal and that usually will happen around that time. So what does that tell me that tells me that say you weren’t diabetic at all before but now at 24 28 weeks your body is unable to handle the Sugar that’s going in your system because of the insulin resistance The insulin is not being able to get into the cell to get rid of that sugar That tells me that you have probably a metabolic problem and you are at risk for that As time goes on in your life. Oh And as far as testing for that They should also be tested Afterwards at least every three years lifelong screening All right, and I’m not going to go through this but you can read through this if you want As far as testing on your certification exam, it does not get specific as far as alright What should your blood glucose be two hours? post and oral glucose tolerance tests no, it’s not going to be that you just need to know what the glucose tolerance test is how to diagnose diabetes and When you’re going to do the oral glucose tolerance test and talk about learn about gestational diabetes All right, so now there’s cystic fibrosis Related to diabetes and the pathophysiology – you’re just a brief summary of what that is is remember cystic fibrosis They have that sticky substance and it also gets on the pancreas and so it damages The pancreas and so then the beta cells don’t work and a lot of these patients have to end up going on insulin So these people should be monitored for that. Usually those people are an endocrinology and seen specialists All right, post transplantation diabetes. So if you have a Penc reacting me. You are at risk for that oral Immunosuppressants are going to be the key though So it’s not that you have to go out right away and say oh you this person needs insulin again? These people are going to be in endocrinology but immunosuppressive Treatments does show really good outcome And not necessarily need insulin, but you know, everybody’s different now monogenic diabetes Is a single allele like it’s a single band Abnormality on Your gene and it’s diagnosed within the first six months of life And so it’s one of those that you really don’t have type 1 or type 2. It’s called monogenic diabetes and They don’t have typical feature. So like you’re a nevado antibodies are negative. You’re not obese. No other metabolic Features With a strong family history of diabetes they usually have a stable mild fasting between 150 and a stable a1c between five point six and seven point six but remember these are early in life or These are diagnosed within the first six months or life up to early adulthood So all children diagnosed with diabetes if you’re less than six months old should have Jimmy D Engineers just seems like a no-brainer as you can see. It’s a recommendation level a and children and adults diagnosed in early adulthood Should have genetic testing also Now remember level e means expert like expert advice and the consensus in is in that so there’s a link down here beyond type one org and it explains more about monogenic diabetes and That is it on this set

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