Diagnosis and prevention of type 2 diabetes in conditions of general medical practice

O.V. Chernysh, S.A. Cherenkevich

Belarusian Medical Academy of Postgraduate Education, Minsk; UZ "City Endocrinological Dispensary", Minsk

Sightshot data on epidemiology, diagnosis and prevention of comorbide patients with type 2 diabetes (type 2) are set out, attention was focused on early diagnosis of carbohydrate disorders using screening.

Keywords: pre -Aibet, type 2 diabetes mellitus, diagnostics, screening.

The incidence of diabetes (diabetes) - chronic and at this stage an incurable disease - acquired the nature of a “non -infectious epidemic”. According to the International Diabetic Federation (IDF), about 380 million patients with diabetes will be registered in 2025. However, already in 2011, the number of sick people approached this value, reaching 366 million people, and the vast majority of patients - from 85 to 95% - suffer from type 2 diabetes and in 183 million people remain not diagnosed. The prevalence of diabetes in some regions of the world reaches 20% or more [1]. In the Republic of Belarus, according to statistical data, on January 1, 2013, 240 019 patients with diabetes were recorded, including SD type 2 - 222,656 people (92.8%). There is an increase in the disease by 8-10% (20-22 thousand) patients per year. Such a progressive increase in the prevalence of diabetes (mainly the 2nd type) is associated with an increase in both incidence and early detection due to modern screening methods. Among the main reasons for the growth of incidence of diabetes of type 2 are the aging of the population and the spread of obesity. It is known that with an increase in life expectancy, the number of so -called “normal diseases of aging” grows. These diseases include obesity, arterial hypertension (hypertension), atherosclerosis, menopause, depression, cancer, diabetes. In recent decades, the number of obesity people has increased not only among middle -aged and elderly people, but also among young people and adolescents. Metabolic syndrome or insulin resistance syndrome (IR), which is based on abdominal obesity, is determined even in children who are increasingly diagnosed with type 2 diabetes [2].

The number of patients suffering from type 2 diabetes is such that endocrinologists cannot help all patients. In this regard, there is a need to conduct them with therapists and doctors of general practice.

At the same time in people over 40-50 years, as a rule, the incidence is not limited to one or two pathologies. General practitioners need to treat “not a disease, but a patient”, thus, the therapist is a gastroenterologist, a pulmonologist, and a cardiologist. However, in relation to such a common pathology as type 2 diabetes, doctors and general practice doctors experience uncertainty in appointments, and any complaints of patients attribute to this disease. Due to the fact that type 2 diabetes has long grown from the framework of just endocrinological pathology and has become a satellite state for a number of “vascular” diseases, it is often difficult to understand clinical and diagnostic criteria and prescribe treatment in conditions of acute time deficiency.

An example of this is the following clinical case. Patient D., 57 years old, turned to the local therapist of the clinic, in which she was constantly observed for a long time, with complaints of moderate dry mouth, chill, a feeling of “crawling goosebumps” in the legs, a decrease in the sensitivity of the fingers, legs, shortness of breath during walking, palpitations, increasing blood pressure (blood pressure) to 170-180 mm Hg of RT. At the use of antihypertensive drugs, rapid fatigue. From the anamnesis of the outpatient card, the patient in chronological order indicates: obesity II Art. (1990), early menopause (1996), SD type 2 (1997), AG (2001), 12-perimal ulcer (2007), gallstone disease (2010), diabetic micro-macroangiopathy, polyneuropathy of the lower extremities (2010), osteomyelitis of the 1st finger of the left foot (2011), complex Encephalopathy of complex genesis (2012), acute myocardial infarction (2013), postinfarct cardiosclerosis (2013), blood circulation insufficiency II f. K. (2014).

This clinical example clearly traces the evolution of the patient's somatic status, which has gone from normal physiological and hormonal restructuring in the woman’s body, the first manifestations of metabolic disorders and IR to diabetes, its micro- and macro-vascular complications, as well as painless myocardial ischemia, cardiovascular catastrophe and chronic heartfelt. insufficiency. At the same time, it is quite obvious that, as new diseases that naturally arise from previous diseases join, past problems were not resolved. In this case, one cannot be sure that the severity of the patient’s condition is currently due only to the lack of blood circulation, because in the foreground in the clinic of her disease today and for almost 20 years there are manifestations of diabetes.

Currently, the SD has acquired a massive and uncontrolled nature, it is prone to a difficult complicated course and reserves many unresolved issues of timely diagnosis, and, accordingly, treatment. Knowledge of pathogenesis, current, control, prevention of this pathology is especially relevant at present.

Domestic and foreign endocrinologists came to the conclusion that diabetes is a group of metabolic (metabolic) diseases characterized by chronic hyperglycemia, which is the result of insulin secretion, insulin’s actions or both of these factors [2].

The classification of diabetes mellitus is quite simple, according to it, it is distinguished by: type 1 diabetes, destruction of pancreatic cells, leading to absolute insulin insufficiency; SD type 2 - IR and relative insulin deficiency; specific types of diabetes (genetic-and infectious-concentrated, etc.); Gestational type of diabetes [3].

Every day, patients with type 2 diabetes are addressed to doctors of general practice and therapists, as a rule, this disease is characterized by two main pathogenetic mechanisms: a decrease in the sensitivity of peripheral tissues to insulin, or IR, and impaired insulin secretion. IR, as a rule, preceding the development of diabetes, is extremely common in the population and exacerbated with age. The inadequacy of the insulin response at the initial stages of the development of the disease is characterized not so much by insulin secretion as a violation of the normal rhythm of the hormone secretion. This is manifested by a decrease or absence of the first phase of insulin production in response to the intake of glucose with food, which, first of all, is reflected in an increase in postprandial glycemia. With a prolonged increase in glycemia, the effect of “glucoseotoxicity” develops, causing the death of β cells and a decrease in insulin secretion. Thus, a gradual change in the stages of a violation of carbohydrate metabolism from IR and impaired Glycemia on an empty stomach (NGN), a violation of glucose tolerance (NTG) ultimately leads to the manifestation of type 2 diabetes [4].

According to the protocol of type 2 diabetes, at the outpatient stage of assistance, preventive measures include a mandatory assessment of the risk factors of the disease, the patient’s awareness of the risks of pathology and prevention. The significance of the therapist in the identification, examination and treatment of patients with type 2 diabetes is confirmed by a huge number of clinical conditions characterized by a high risk of developing this disease. Among them: age older than 45 years; Excess body weight and obesity (body mass index (BMI)> 25 kg/m²); family history of diabetes; habitually low physical activity; NGN; NTG; gestational diabetes; history of large fetus (4 kg or more); AG; dyslipidemia, polycystic ovary syndrome; The presence of cardiovascular diseases [5]. How often, identifying some factor from the above, the district therapist draws parallels with the risk of development of diabetes? Not often, and therefore the case of a patient D. is no exception: risk factors (obesity, early menopause, arterial hypertension, etc.) - are underestimated, time is lost, the moment of development of diabetes is lost, complications of diabetes are half diagnosed.

In addition to risk factors, despite the degree of own workload, the local therapist should know the diagnostic criteria of type 2 CD (Table 1), as well as target levels of other indicators (blood pressure, lipid fractions), which have their characteristics in patients with diabetes [2, 3, 6].

An absolutely necessary requirement is to determine the level of glucose on laboratory equipment. The use of glucometers to diagnose carbohydrate disorders is unacceptable, they can only be used for self -control by a patient with diabetes. To prevent glycolysis and erroneous results, the determination of glycemia should be carried out immediately after taking the analysis, or blood should be immediately centrifugated, or stored at a temperature of 0–4 ° C, or taken into a test tube with a preservative (sodium fluoride). Laboratory examination of the level of glucose in the blood is the main method for making a diagnosis of type 2 diabetes, which is preferably supplemented by determining the level of glycated hemoglobin (HBA1C).

Table 1

Diagnostic criteria for diabetes and other violations of glycemia (WHO, 1999-2006)

*Diagnosis is carried out on the basis of laboratory definitions of glucose levels.

** The diagnosis of diabetes should always be confirmed by a repeated definition of glycemia in the following days, with the exception of cases of undoubted hyperglycemia with an acute metabolic decompensation or with obvious symptoms.

*** In the presence of classic symptoms of hyperglycemia (polyuria, polydipsy, acetonuria, weight loss).

The term "on an empty stomach" means determining the level of glucose in the morning after preliminary starvation for at least 8 hours and no more than 14 hours. A random determination of blood glucose (postprandial) means glucose at any time of the day, regardless of the time of food intake [3].

PGTT - oral glucosotolerant test. It is carried out in case of dubious glycemia to clarify the diagnosis.

PGTT Rules:

PGTT should be carried out in the morning against the background of at least 3-day unlimited nutrition (more than 150 g of carbohydrates per day) and ordinary physical activity. The test should be preceded by night fasting within 8 to 14 hours (you can drink water). The last evening meal should contain 30 - 50 g of carbohydrates. After blood fence, the patient should drink 75 g of anhydrous glucose or 82.5 g of glucose monohydrate dissolved in 250 - 300 ml of water in no more than 5 minutes. For children, the load is 1.75 g of anhydrous glucose per kg of body weight, but not more than 75 g in the test process is not allowed smoking. After 2 hours, a second fence is carried out.

PGTT is not carried out:

• Against the background of an acute disease
• Against the background of short-term administration of drugs that increase glycemia (glucocorticoids, thyroid hormones, thiazides, β-blockers, etc.)

In 2011, WHO approved the possibility of using HBA1C (irreversible hemoglobin compound with glucose) for diagnosis of diabetes [7]. HBA1C is a biochemical blood indicator that reflects the average blood sugar for a long period (up to three months), in contrast to measuring blood glucose, which gives an idea only at the time of the study (Table 1).

The level of HBA1C> 6.5 % (48 mmol/ mol) was selected as a diagnostic criterion of the SD.

The study should be performed using the HBA1C determination method, certified and standardized in accordance with reference values ​​adopted in diabetology. The HBA1C level is considered to be normal up to 6.0 % (42mmmol/mol).

Translation HBA1C from % to mmol/mol: ( % x 10.93) - 23.5 = mmol/mol

In the absence of symptoms of an acute metabolic decompensation, the diagnosis should be made on the basis of two digits in the diabetic range, for example, the twice defined HBA1C or a single determination of the HBA1C + one -time determination of the glucose level.

The HBA1C indicator is further used to select individual treatment goals, monitoring sugar -lowering therapy.

As part of the prevention of the disease, it is necessary to treat concomitant pathology - hypertension, polycystic ovary, dyslipidemia as significant risk factors of type 2 diabetes (Table 2; 3).

Lipid metabolism control indicators

Table 2

• Translation from mmol/l to mg/dl:
• General cholesterol, LNP cholesterol, LVP cholesterol: mmol/l x 38.6 = mg/dl.
• Triglycerides: mmol/l x 88.5 = mg/dl.

** <1.8-for persons with cardiovascular diseases and/or chronic kidney disease

3a and more

Table 3

Blood pressure control indicators

Unfortunately, the patient is not always easy to make a diagnosis with type 2 diabetes. Difficulties arise due to the fact that the disease is less predictable than SD type 1. In patients with type 2 diabetes, less symptoms with varying degrees of severity can occur. During the disease, periods may occur, sometimes a duration of several years, when the symptoms of diabetes are practically not manifested and, as a result, the disease remains unnoticed.

When analyzing the work of several therapists of one of the clinics of the districts of the city of Moscow over a certain period of time, it was recorded that out of 514 patients with cardiovascular diseases who turned to therapists for help, only 16 patients (3%) were indicated on the outpatient card. This cannot be, and therefore, doctors continue to pass this disease, allowing it to develop, progress and give their complications.

Having received such results, disappointing in the organizational plan, and making the appropriate conclusions, therapists of the same clinics were instructed for several days to conduct a spontaneous determination of the level of blood glucose with portable glucometers for each patient with cardiovascular pathology or high risk of its development, analyzing their testimony in express regiments. During the week of work, 340 glycemia studies were conducted: in 91 patients (26.8%), the blood glucose level was higher than 6.1 mmol/l on an empty stomach or 11.1 mmol/l postprandial. Of the 91 people, 39 patients (42.9%), whose average age was 60.3 ± 4.7 years, previously knew about the presence of diabetes and, although they received sugar -free drugs, were not compensated. The remaining 52 people (47.1%) (average age 52.1 ± 9.3 years) have learned for the first time about the increased level of blood glucose. There is no doubt that it was precisely they required additional diagnosis of carbohydrate disorders in the form of oral glucosotolerant test (PGTT) and determining the level of glycated hemoglobin.

Examination of 52 patients with hyperglycemia identified for the first time gave the following results: 5 people (9.6%) without explan the reason categorically abandoned further examination; 19 - (36.5%) had a violation of glucose tolerance; 8 patients (15.4%) were diagnosed with type 2 diabetes; In the rest, 20 people (38.5%) were not detected.

Thus, out of 340 patients who have been screened to detect disorders of carbohydrate metabolism as a whole, the pathological levels of glycemia are determined in 66 people (19.4%), while the proportion of previously diagnosed diabetes was 11.5% (n = 39), the first identified diabetes - 2.4% (n = 8), a predecessor - 5.6% (n = 19) [8 Early Diagnostics].

Given the existing adverse situation in the diagnosis of carbohydrate metabolism in the entire civilized world, including Belarus, there is a mandatory recommendation to identify type 2 diabetes, namely by screening. Screening tests are carried out taking into account the levels of glucose of plasma on an empty stomach or during PGTT. Type 2 sd screening is carried out without exception to persons who have reached 45 years of age, regardless of the presence or absence of their risk factors for the development of type 2 diabetes. With the normal result of the test-the frequency of examination 1 time in 3 years. Persons younger than the indicated age with BMI> 25 kg/m²Screening is also mandatory if they have at least one risk factor for this disease. With the normal result of the test - the frequency of examination 1 time in 3 years, in persons with pre -Aibet - 1 time per year. However, in real practice, this routine diagnostic standard is far from always fulfilled, and the common screening of hyperglycemia (often examined by a glucometer) and hypercholesterolemia gradually replaced the concept of SD screening, which is absolutely not a synonymous or an alternative to the latter.

To provide timely assistance, it is especially important to identify the patient at the stage of pre -wabbed. The concept of "pre -Aibet" includes states such as NGN and NTG. The use of this term emphasizes the high risk of diabetes in the future (approximately 4-9% of cases per year). Patients with pre-Aibet already have an increased risk of cardiovascular diseases, and in patients with diabetes, this risk is increased by 2-4 times.

According to many studies, if you observe a healthy lifestyle at the stage of pre-abit, you can avoid or delay the development of type 2 diabetes. So, for example, in a study on the study of diabetes in the USA (The Diabetes Prevention Program), it was demonstrated that weight loss by 5-7%, compliance with a healthy, low-calorie diet, 30-minute Physical activity 5 times a week can reduce the risk of diabetes by 58% [9].

Hyperglycemia screening, being an undoubtedly useful study, but allows us to identify mainly only the late stages of the disease. Even such a detection of type 2 diabetes is better than with the already incident acute heart attack or stroke. It is proved that in the absence of a properly conducted screening, early carbohydrate disorders are never revealed in a timely manner. As a result, β-cell dysfunction progresses, and late treatment is not much or ineffective. It is the late diagnosis of type 2 diabetes that largely determines the further fate of these patients [10].

One should also not forget about the age of patients. The features of diabetes in elderly patients are: often asymptomatic course (there is no polyuria, thirst, dry mouth); the predominance of non -specific complaints (weakness, memory impairment, cognitive impairment); the presence of a clinical picture of micro- and macroangiopathy at the time of detection of diabetes; abundance of diseases (comorbidity); lack of hyperglycemia on an empty stomach; Isolated postprandial hyperglycemia and an increase in the renal threshold for glucose [2]. Faced with such patients in their daily practice, but at the same time possessing the necessary minimum of knowledge about type 2 diabetes, the district therapist should know, first of all, the range of his competencies.

Within the framework of the outpatient stage of the provision of medical care, local therapists or general practitioners need to carry out the following diagnostic minimum [2]:

• screening;
• Clinical examination: complaints (dry mouth, polyuria, thirst, weakness, headache, nausea), anamnesis (age, heredity, hypodynamia, hypertension, dyslipidemia), physical examination (overweight, trophic changes), laboratory tests (glucose, creatinine, HBA1C, ketone bodies, cholesterol);
• training of patients (recommendations on nutrition and physical activity);
• the appointment of oral sugar -lowering drugs;
• prevention of acute complications;
• prevention and detection of chronic complications;
• treatment of concomitant diseases (achieving target levels of blood pressure and cholesterol);
• Determination of indications for insulin therapy.

With decompensation of diabetes, the presence of severe complications requiring insulin therapy correction, observation and treatment of patients is carried out in endocrinological departments and centers of medical institutions.

According to world experience, conducting patients with compensated type 2 diabetes, in particular, primary and secondary prevention of this disease is carried out by general practitioners, which significantly reduces healthcare costs. Primary preventive measures should be aimed at [2]:

1) Identification of risk groups taking into account the following factors-abdominal obesity (waist circumference> 94 cm in men and> 80 cm in women), family history of diabetes, age> 45 years, hypertension and other cardiovascular diseases, gestational diabetes, the use of preparations that contribute to hyperglycemia or body weight.

It is possible to use simple questionnaires as an example (see questionnaire for patients).

2) assessment of the degree of risk - measurement of glucose level: determination of glycemia on an empty stomach; PGTT with 75 g of glucose, if necessary (especially with glucose plasma on an empty stomach 6.1 - 6.9 mmol/l).

Assessment of other cardiovascular risk factors, especially in people with pre-Aibet

3) a decrease in the degree of risk - an active change in lifestyle: decrease in body weight; Moderately hypocaloric nutrition with a predominant restriction of fats and simple carbohydrates. Very low -calorie diets give short -term results and are not recommended. Fasting is contraindicated. In persons with pre -Aibet, a decrease in body weight by 5 - 7 % of the initial one is a decrease in body weight. Regular physical activity of moderate intensity (fast walking, swimming, bicycle, dancing) lasting at least 30 minutes (at least 5 times a week). Medication therapy is possible if it is not possible to achieve the desired reduction in body weight and/or normalize the indicators of carbohydrate metabolism with one change in lifestyle. In the absence of contraindications in people with a very high risk (NTG or NGN), the use of metformin 250 - 850 mg 2 times a day (depending on tolerance) - especially in people younger than 60 years with BMI, 30 kg/m can be considered². In the case of good tolerance, the use of akarbose can also be considered.

Secondary prevention of type 2 diabetes includes the prevention of its complications, and for this purpose, compensation for diabetes and the achievement of recommended targeted laboratory indicators is necessary. Therefore, a general practitioner must ensure that the patient adheres to all recommendations, and this should be confirmed by monitoring (Table 4) [2].

Table 4

Monitoring of diabetes of type 2 without Opodation

If signs of chronic complications of diabetes, the addition of concomitant diseases, the appearance of additional risk factors, the question of the frequency of examinations is solved individually.

Attraction of family doctors to the management of patients with type 2 diabetes will help improve the conduct of measures to prevent this pathology, ensure the sequence and continuity of this disease, will lead to a decrease in the incidence and disability, as well as the costs of the healthcare system as a whole.

Do you have a pre -Aibet or type 2 diabetes mellitus?

Questionnaire for patients (http://www.idf.org/webdata/docs/findris_english.pdf)

Instructions

• Answer all 8 questions of the questionnaire.
• For each question, select 1 correct answer and mark it in the corresponding square.
• Fold all the points corresponding to your answers to questions.
• Use your total score to determine your risk of developing diabetes or pre -ibet.
• Pass the completed questionnaire to your doctor/nurse and ask them to explain the results of the questionnaire.

1. .Age

• Up to 45 years 0 points
• 45 - 54 years 2 points
• 55 - 64 years 3 points
• Older than 65 years 4 points

2. Body weight index

The body weight index allows you to identify the presence of excess weight or obesity. You can calculate your body mass index yourself:

Weight ___ kg: (height__ m)²= ___ kg/m²

• Less than 25 kg/m²0 points
• 25 - 30 kg/m²1 point
• More than 30 kg/m²3 points

3. The circumference of the waist

The waist circumference also indicates the presence of excess weight or obesity

4. How often do you eat vegetables, fruits or berries?

• Every day 0 points
• Not every day 1 point

5. Are you doing physical exercises regularly?

Do you do physical exercises for 30 minutes every day or 3 hours for a week?

• Yes 0 points
• No 2 points

6. Have you ever taken medication regularly to reduce blood pressure?

• No 0 points
• Yes 2 points

7. Did you ever find the level of glucose (sugar) of blood above the norm

(During medical examination, prof. Examination, during illness or pregnancy)?

• No 0 points
• Yes 5 points

8. Did your relatives have type 1 or 2 diabetes?

• No 0 points
• Yes: grandfather/grandmother, aunt/uncle, cousins/sisters 3 points
• Yes: Parents, brother/sister or own child 5 points

Results:

The amount of the points__.

• If you scored less than 12 points: you have good health and you must continue to lead a healthy lifestyle.
• If you scored 12 - 14 points: perhaps you have a pre -Aibet. You must consult your doctor how you should change your lifestyle.
• If you scored 15 - 20 points: perhaps you have a pre -Aibet or type 2 diabetes. It is advisable for you to check the level of glucose (sugar) in the blood. You must change your lifestyle. It is possible that you will need drugs to reduce glucose (sugar) in the blood.
• If you scored more than 20 points: in all likelihood, you have type 2 diabetes. You must check the level of glucose (sugar) in the blood and try to normalize it. You must change your lifestyle and you will need drugs to control the level of glucose (sugar) in the blood.

Reducing the risk of pre -Aibetes or type 2 diabetes

You cannot influence your age or hereditary predisposition to pre -Aibet and diabetes, but you can change your lifestyle and thereby reduce the risk of these diseases.

You can reduce body weight, become more active physically and consume more healthy food. These changes in lifestyle are especially necessary as age increases or if you have hereditary burden on diabetes.

A healthy lifestyle is also necessary if you have already diagnosed a pre -Abet or type 2 diabetes mellitus.

To reduce the level of glucose (sugar) in the blood, body weight and reduce the adverse prognosis of the disease, drug therapy may be needed.

LITERATURE

1. International Diabetes Federal. Diabetes Atlas 6th Edition. 2013. (15)
2. Specialized medical care algorithms for patients with diabetes / Ed. I.I. Dedova, M.V. Shestakova. 6-strokes. M., 2013.
3. Definition, Diagnosis, and Classical of Diabetes Mellitus and Its Complications: Report of a Who Consultation. Part 1: Di Agnosis and Classification of Diabetes Mellitus (Who/NCD/NCS/99.2). Geneva: World Health Organization; 1999.
4. Defronzo, R.A. Lilly Lecture. The TriumVirate: Beta Cell, Muscle, Liver. A Collusion Responsight for Niddm. // Diabetes. - 1988. - Vol. 37. - P. 667–687.
5. American Diabetes Association. Standards of Medical Care in Diabetes - 2013. Diabetes Care 2013; 36 SUPPL 1: 11-66. DOI: 10.2337/DC11-S011.
6. Who. Definition and Diagnosis of Diabetes Mellitus and Intermediate HyperglyCemia: Report of a Who/IDF Consultation. Geneva: Who; 2006.
7. Who. Use of Glycated Haemoglobin (HBA1C) in the Diagnosis of Diabetes Mellitus. Abbreviated Report of a Who Consultation. World Health Organization, 2011 (Who/NMH/ChP/CPM/11.1).http://www.who.int/diabetes /publications/report-hba1c_2011.pdf
8. Demidova, I. Yu. Early diagnosis and treatment of disturbed glycemia, on an empty stomach slows down the pace of its conversion into impaired glucose tolerance and type 2 diabetes mellitus / I.Yu. Demidova, V.V. Boeva ​​// Pharmacate. - 2013. - No. 10. - S.48–52.
9. Diabetes Prevention Program Research Group. Reduction in the Incidence of Type 2 Diabetes with LifeTyle Intervents or Metformin, The New England Journal of Medicine, 2002; 346: 393–403.

Nichols, GA. ProgRESSION FROM Newly Acquired Impaired Fasting Glucose to Type 2 Diabetes / Ga. Nichols, Ta. Hillier, Jb. Brown // Diabetes Care. - 2007. - No. 30 (2). - S.228–33.