Why is Diabetes So Serious? - A to Z of the NHS - Dr Gill

hello and welcome to another a to z of the nhs you're joined by myself dr james gil one of the gps around here and one of the big dogs andy stein our renal consultant so we've already got our a b and c so carrying on that line we're going to do d's today andy what have you brought for us um i'll tell you about the d's in a minute but i noticed james that your hair seems to be growing and mine seems to be getting shorter it's not a biological thing it's just i like my relationship too much to risk beth cutting my hair at the moment understood okay i can't wait for lockdown to be over i'm gonna do or lead on two subjects they are diabetes very common disease and dvt deep veins thrombosis and i think you're gonna lead on two others aren't you yeah i've brought depression well i haven't brought depression but i will be discussing depression and also something slightly topical but kind of squeezing it in vitamin d it's our show if we want to work something we will do so they're the two that we've got but diabetes and dvt it's very interesting that you're bringing those because i tend to send a lot of those cases when they're difficult and i'm unable to deal with it up to secondary care so i'm hoping to gain some educational pearls from yourself well i'll do my best james um didn't we say earlier that we were going to discuss some things in the medical news though so yeah so actually as andy's just um highlighted we're going to try and add something new in perhaps to loosen ourselves up just a quick review of medical news that's caught our eye so what's what's triggered yourself andy i did read in the bmj this week an interesting editorial that stated that the number of alcohol related deaths is climbing particularly related to the lockdown so for example it was noted in the first nine months of last year that there were over 5000 deaths and that was a 16 increase in the number of alcohol rated deaths compared to the previous year so i think the go home message is that we all have to be careful about how much we're drinking during the lockdown and also not going too berserk after the lockdown well i actually read the same article it and i was a little bit troubled not so much by the lock down but the actual looking backwards so there's been a between 16 and 9 increase in alcohol related deaths for actually the last few years even before the lockdown so it shows that perhaps in the uk we've got an alcohol issue that you know the lockdowns brought to the fore and definitely something we need to look into i think so and i don't quite know why brits like their booze so much but they do so perhaps that's something as our first public health message today because we're going to be talking about lots of subjects where if in doubt talk to your gp if you or somebody that you know you're concerned about alcohol get them to talk to their doctor not necessarily a problem and they may find that there is no issue at all but if in doubt have a chat tell me what you've read in the medical literature recently james well i've actually seen something a new drug that's being trialled in glasgow which unfortunately i've just forgotten but we will put up the name in a moment and that's to do with endometriosis now the thing that i found fascinating about this it's not a hormonal medication now a lot of the treatments we use for endometriosis rely on adjusting a lady's monthly hormones which means that unfortunately it's going to stop them having children whilst we're trying to deal with those issues and this is a new drug that looks at lactate that tries to reduce the pain and the discomfort from endometriosis allowing people to pursue their families if they want to how interesting i must admit um if you ask me to say two facts about endometriosis i would struggle i think i need to do a bit of reading but i know it's an important disease and very painful for a lot of women out there well i was very surprised that a medication to deal with lactate has been investigated because as we discussed on the abg lactates are more more in your world than mine it is yes it's something we measure in very ill patients um if you remember i mentioned the arterial blood gas test and it's a very important number we measure to look for sepsis and other things so i'm surprised it's got anything to do with endometriosis but clearly it does apparently endometriotic tissue has a higher lactate turnover than others and that's the route they're looking at it really and they're thinking that because of that there's also been some research that endometriosis may amazingly share some links with asthma so they're thinking they may be able to repurpose or adjust some existing asthma medications for endometriosis wow that's interesting certainly some very interesting things well so that's our that's our brief review things that um we think they're worthwhile if you'd like us to carry on with these medical reviews drop us a comment down below so with the news out of the way shall we start off with our dvt or diabetes which do you want to go for i think we'll go for diabetes because diabetes in many ways is not new and it's not in the news in fact it's a very ancient disease first of all i thought it'd be worth educating us all in terms of the origins of the word diabetes and mellitus the full name for diabetes is diabetes mellitus you will of course know james the greek origins of these words i thought he was going to go latin not greek go on then give us some greek anyway the word diabetes comes from the word siphon and it was to do with the fact that the greeks and the ancient egyptians before them realized that the polyurea that you get in some patients with diabetes is like a liquid passing through a tube or a siphon so that's where the word diabetes comes from and the word mellitus means honed or sweet so what it really means is honeyed or sweet stuff passing through a tube or siphon and i find it interesting that our knowledge about diabetes hasn't really got on much further from the greeks and the egyptians well neither has your spiel because i am pretty confident i've heard that similar line when i was a first year one of your students it is story 472 yes anyway let's move on uh to diabetes so what is diabetes diabetes is an incredibly common condition and we'll go on to the epidemiology in a minute um it's basically a chronic that means lifelong condition characterized by high blood glucose levels or hyperglycemia is the technical word for it it's common and getting commoner what's the uk percentage do you know um it's about four million there are about four million people with it in the uk out of a population of 67 million ish and there's about another one million people out there who have it and don't know it and that's a real worry so what does that mean in terms of percentages or fractions basically it means about one in 20 the population about five percent have diabetes but if you start looking at subgroups for example people over 40 people like me you're getting up to about one in ten in other words ten percent of the population and this makes it one of the commonest in fact the most common chronic medical condition and i think from my perspective as a gp seeing a lot of diabetes i'm looking at this both with a patient hat on but also a financial hat giving you that such a huge number of people can be affected by this condition that potentially means that there's the ability to cost such a huge amount both in terms of patient suffering but also financially for the nhs so if we can hit these patients hard and improve their diabetes maybe even cure it or put it into remission we will improve their quality of life in the long term and hopefully not bankrupt the service too let's talk about how we diagnose it now um fortunately it's quite simple to diagnose you just do a blood glucose level i thought you're going to go greek on us then you know how they're used to diagnosis in greece don't you well in greece and other cultures they used to taste the patient's urine from my memory and and it should be sweet what shouldn't be sweet but in a diabetic it'll be sweet correct correct we've slightly moved on from that and we've stopped what stopped usually tasting the patients urine viewers back to the diagnosis so the normal blood sugar as you know is approximately four to six millimoles per liter now we diagnose diabetes if the fasting blood glucose is over seven or the random blood glucose is over 11 so it's quite a simple diagnosis and i think it's important that if a patient has those sort of numbers that they're repeated within two weeks so the gp or the hospital doctor who's looking after a patient with new diabetes is certain they've got it do these sort of patients ever present to you occasionally and they tend to come down from yourself at secondary care perhaps somebody's been into the a e department and they've been found to have a high glucose and we need to look a little bit further but as you say those two readings are important but there's another reading that i'm particularly passionate about in gp and land and that's the hba1c now with a regular random or fasting glucose there are things that patients can do to prepare for a test because we all want to look good however with an hba1c you can't that looks at the blood over the last three months so if someone's done really really well with their diet and they've reduced their carbohydrates and they've really pushed things we will see that in a three-month panel but conversely if they've not been quite as effective we'll also see that too and this hba1c number is important in terms of the diagnosis as well as not just the monitoring so another way of diagnosing diabetes is to do in hba1c and the bottom line is if it's over 48 you've got diabetes if it's under 42 you haven't and if it's in between you've got something in between and we call that pre-diabetes or sometimes impaired glucose tolerance it's got a variety of names but the hba1c is almost as important as the actual blood glucose diagnostically i actually prefer and treatingly i prefer because i've got more granularity and as you said those pre-diabetic patients they're the ones i really want to get my hands on because we may be able to turn things around and stop it going to diabetes sure and if there's anything you can do anything we can do to stop people progressing from pre-diabetes to diabetes and that's a really good thing in terms of the targets i'm not going to talk about that in great detail today because these have to be individualized to the patient but the bottom line is the target the best target is normality in other words i aim to get the fasting blood glucose below seven the random blood glucose below 11 and the hba1c below 42. with a lot of my patients that have got blood glucose meters at home because they're they're checking and often they're not sure what the readings mean i'm happy for them to be reviewed as is planned but i do tell them if the number goes over 15 i don't mind what time of day it is i need to know about that because it may mean that we actually need to send them to the hospital hopefully not but if it's 15 i want to know what's going on there i think 15 is a good danger line and if a patient has a random blood glucose of 15 or over on a friday it might be 25 on sunday and it might be unconscious on monday and so i think 15 is a good line when you've got to actually start thinking about i may have to do something today i'd like now to talk about risk factors for diabetes um there's essentially four or four big ones there's three that you can't affect and one that you can the three that you can't affect are your age as you get older like me you're more likely to get diabetes your race people from ethnic minority groups are more likely to get diabetes sadly probably about three times more likely in fact there is a group of native american indian called a pima indian and 50 percent of those people have diabetes sadly 50 it's incredible so apart from age and race the other important risk factor is family history now what we've been talking about so far as i expect you will have guest viewers is type 2 diabetes and in fact type 2 diabetes is now 90 of the diabetic population so it is largely the disease that we talk about when we do uh sessions like this as you say there is that family connection and i try to you know obviously type one if someone in the family has that it's something that the genetics were not going to be able to change but type 2 has much stronger environmental factors so when i'm dealing with patients who are worried their relatives have had type 2 diabetes i try to reassure them that this is something that we can look to prevent and manage and hopefully prevent them going down that same line yes and in fact this third risk factor which is family history is very important it is true that if you are asian and both your parents have diabetes you have a 90 chance of developing diabetes yourself which i find staggering and if one of your parents has diabetes you've still got a 50 chance of getting diabetes again a very high percentage the final and in some ways the most important risk factor is your weight obesity we've talked about in a previous video we talked about it in our bmi video is now the epidemic of our time and sadly sixty percent of the british population is overweight or obese and that can be altered that is a significant risk factor for diabetes in fact the diabetes epidemic is largely because it mirrors the obesity epidemic so we talk about diabetes um how you know what's what kind of things what symptoms might people get how might this present first time interestingly the communist way it presents is with an asymptomatic patient in other words they don't know they've got diabetes they don't have any symptoms they for example go into hospital for an operation or have an acute illness somebody measures a random blood glucose and it comes back at 12.8 and that's how we pick up diabetes in the modern age the other ways it tends to present are either with the symptoms of diabetes and these include polydipsia polyurea that means being too thirsty or passing too much urine or in another way in other words with a complication of diabetes such as an eye problem or a kidney problem for example i'm surprised at the number of patients who actually come to us having had suspected diabetes picked up at the opticians actually when they do the retinal photography looking behind the eye absolutely and in fact i think we owe a debt of gratitude to all the optometrists out there because i've seen them diagnosed by diabetes and severe hypertension just by looking in the back of somebody's eye and the reason it's so fascinating is that the fungi which is the thing that we see at the back of the eye shows us blood vessels in great detail in fact it's the only bit of the body where you can see a small artery and it's a great skill to have to be able to look at the fungi unfortunately i think in general practice you don't usually have enough time to look at the fun die do you we do always try but unfortunately we don't have the drops to be able to dilate the eye to get the best view from it but i think that point about the eyes is really indicative of diabetes there is not a single part of the body that escapes the ravages of diabetes which is one of the reasons we're so passionate about fighting this disease the thing that worries me more than the disease is actually the complications or the complications of the disease um and these are nasty so let's just go through them they can be largely divided up into large vessel complications and small vessel the large vessel complications include ischemic heart disease cerebrovascular disease peripheral vascular disease and reno that means kidney vascular disease and diabetes for reasons we don't really understand accelerates atheroma and causes large vessel disease the way i've kind of thought of a lot of those things is you said the large and small vessel disease it's more you know clear and invisible you know the patients that have got you know problems with their kidneys they have problems with their strokes they're losing damage to their limbs that's all the sort of things we're talking about there isn't it absolutely and as well as those large vessel complications we have the small vessel complications that you've just alluded to and so if a patient has diabetes for more than 10 years they also get problems in their small vessels particularly in the eyes in the kidneys again and in the feet they get something called neuropathy in the feet so we have four large vessel complications and three small vessel complications related to diabetes i've got a couple of patients with diabetic neuropathy and they complain of pins and needles to the feet and things like that and i have you know what i thought was appropriate sympathy for them and things like that and i got myself an injury at one point and i damaged one of the nerves briefly and i didn't fully comprehend how significant a neuropathy is the pins and needles which we've all had before and i just attributed that pins and needles that you cannot control and that you can't do anything about it really does completely take your focus away from the rest of your life for that time being that you've got it and i'm so grateful mine was just transient hence and i really really you know do try hard with those patients to find a medication where pins and needles is reduced without giving them sufficient side effects it's huge i think neuropathy in fact i've got a friend who's got a neuropathy affecting both of her legs and this causes her a lot of pain a lot of symptoms all the time and despite medication sadly it's only partially controlled one thing i'd like to talk about now is i'd just like to take a slight aside into a very simple question which has been troubling me for many decades and that is why and how how does diabetes do its damage the answer to that question is we don't know and i think it's fascinating that um human beings have recognized diabetes since the time of the greeks and egyptians and we still don't know why it's bad for us there are a variety of theories the commonest uh most popular theory is a rather simple one that it's the high blood glucose and you might think well that's obvious that must be the thing that causes the damage it's surprisingly difficult to prove and remember there are other metabolic things going on such as the insulin levels which may be high or low we're going to talk about that again in a minute it could be growth hormone it could be blood pressure it could be all sorts of other things but we don't really know how diabetes does its damage it seems that the glucose molecules attach themselves to a variety of proteins including something called enzymes this process is called glycation and this in some ways damages both the structure and function of those of those proteins and enzymes again just going back to the fact that i'm a bearer a very simple brain i've just thought that diabetes is too much sugar and it gums up the works it is interesting though we don't really understand even if the blood sugar does damage the proteins and enzymes what consequence is there of that and it's thought that in some way affecting the structure and function of these proteins and enzymes that causes a certain fragility in the tissues particularly in the blood vessels okay so we've got our patient and unfortunately you know their hba1c is cross that threshold of 48 and the works are beginning to gum up with the high levels of sugar what are we going to do about it now andy there's lots we can do the first thing is as ever to address lifestyle particularly if the patient is overweight or obese there's a lot you can do and if you can persuade the patient to lose weight the diabetes can go away completely in fact that's one of the most amazing things about helping somebody with diabetes you can get it to go away completely this does require a lot of weight loss and that takes months or years but it's possible and i've got a couple of patients where i've helped them trim down and their diabetes has gone away completely it doesn't really go away but it's always in the background but it has become a controllable phenomenon have you ever seen that yourself james actually i've seen it with quite a few patients but i'm sure there's quite a few celebrities out there that you'll be aware of to my favorite people to watch anyway penn teller amazing magicians i think penn the larger of the two he had quite a health scare and as a result of that he's been able to lose so much weight and put his diabetes into remission really isn't there a labor politician that had diabetes and lost weight ex-politician tom watson and not going down the political side of things i'm aggrieved as a doctor that we've lost someone in the political sphere who had and understands the importance of diabetes because i think that he was famed for the sizes of his lunches in the house of parliament and he gained quite a lot of weight which put him into diabetes but conversely he cut out carbohydrate he slimmed down tremendously and was able to kick his diabetes in and i think having people that we can see yes someone's had the problem and how they've overcome it can be great role models for us both as patients and as clinicians good well it's good that people out there are admitting they have diabetes and telling us and telling us about their weight loss and how important that is but sometimes even that is not enough and doctors have to start a variety of tablets so there's a very traditional tablets that were around in my day at medical school there's a group of drugs called biquinides particular drug called metformin which is still used there's another group of drugs called sulfonylureas particularly a drug called gliclocide not a phalloglycoside anymore there's three or four uh new drugs in diabetes and they have a complicated name so i'm just going to look at my sheet oh but there's some sexy drugs there there really are one of them is called the glp one analog or analog another group sglt2 now that is a sexy medication that is a sexy medication right i'm sorry i'm gonna jump in here this is science elegance so i tell you what let's let's work this through andy what what was what what was it that you told us with the original symptoms what do people tend to present with they present with polydipsia and polyurea and the cause of that is an osmotic diuresis related to the glucose in the urine so we get sugar in the urine and that's pulling water with it terrible symptom some amazing person works out that all of the sugar gets pulled into the urine and there are receptors that then try and pull it back in in the normal kidney what they did is they blocked this reuptake channel so diabetes dumps the sugar into the urine and this drug leaves it there so we lose so much sugar into the urine and that brings the blood pressure down as well it helps with weight loss because they're losing calories from that perspective but and this is probably where andy's not going to be too happy with me being overly enthusiastic with this i'm you i'm essentially abusing your kidney to get that sugar out aren't i yeah you are a bit but i'm for any drug that makes the patient better by by whatever method there's a final group of drugs the dpp4 inhibitors they usually end in a suffix like glyptin for example and they're another one of the more modern drugs are used in diabetes but i know they've got some great benefits do they yeah well with a patient with diabetes where possible we want them to try and lose weight and we get that benefit with the dpp-4 inhibitors that weight loss so we reduce the fat which then means that diabetes improves even further with it so again i know they're expensive i know that they have potential side effects but the patients that i've seen using these do tend to do so very well finally if the tablets don't work we have to resort to insulin it may be necessary for patients with type 2 diabetes particularly if they've had the disease for some years and the tablets have stopped working the pancreas gets exhausted and we have to use insulin in these patients i re i really feel sorry for patients not because they're going on insulin but the perception of it the number of times i have to fight and cajole and reassure patients that actually things aren't haven't gone well from a medical perspective and we need to go on to insulin and you frequently see this fear in their face but i am very very pro-starting medications and also reducing them and if we need to stabilize somebody for a few months maybe a couple of years with insulin whilst they are able to focus on their weight maybe look at as we discussed on the bmi video bariatric surgery there's no reason we can't stop something actually i have a story for you james about that i have a patient a lady who was on dialysis she was on dialysis because she was in kidney failure because of diabetes because of obesity and i was able to both slim her down with bariatric surgery make her diabetes go away and also persuade a transplant surgeon to transplant her and now she's alive and well with a functioning kidney transplant and no diabetes cracking cracking and this is this this is the thing we have this is a a disease that we have the ability to change but there is fear around it in terms of how difficult it will be to change and there's reluctance because of lifestyle changes and that that for me is such a tragedy in many ways because as you see sometimes people get to the end of the line and then they will make the hard decisions with their doctors but it does save them true true the final thing i'd like to talk about is who to refer now as you know you're a family doctor a gp i'm a hospital doctor you work a lot harder than i do when you do a clinic you see about 20 patients when i do a clinic it's 10 patients or less but of those 20 about 1 in 20 on average you refer up to the hospital for some reason and i think it's hard for you to know with patients with diabetes about who to refer there is however hope out there there is a new concept new phrase which is super six i don't know have you heard of that phrase uh we've heard it discussed but tell me about it okay so basically this phrase has been developed to help both you as a gp and the general public to know do they need to see a hospital doctor as well as their gp and the answer is for most patients they don't but if they have any of the following six conditions they probably do and the first two are pregnancy and pump pump meaning the heart in other words pump failure heart failure those patients do need to have joint care with somebody like me renal kidneys my area they should be referred to people like me if their diabetic nephropathy is bad enough ulcers leg ulcers need to be referred to a diabetic foot clinic leg ulcers can rapidly turn to gangrene and other things and they can be treated and they can be got rid of i have had two patients that have had gas gangrene and i'll be perfectly honest when i was at medical school i thought gas gangrene and stuff like that it's it's war stories and things like that i did not expect to see you know in 2010 a patient with gas gangrene i really didn't and that was diabetes incredible incredible and it i'll be honest it is as horrific as it sounds the guy came in um very bright chap and he'd he'd missed the fact that he couldn't feel his feet because it had just come so insidiously and he'd stubbed his toe about a week or two before and he was just a little bit unwell he wasn't really bad do you know why he'd actually come to the doctors because his mate said he smelt and i thought that that's that's really something and i saw it on the triage and i thought really really it was the gas gangrene and uh the guy we 999 the guy up to the hospital and he had his leg amputated within four hours but again this is why that diabetes can come up so so insidiously that people don't know about it which is one of the reasons why whenever a patient says can i have a health check the answer is yes and i always put a diabetic screen on that patient finally there are two other groups where hospital doctors should either be involved or the patient should be referred to people like us and they are young patients with diabetes and hospital in patients where the diabetes is a problem we've seen the video that vinod patel did and some of the the diabetic team they're like yourself in the renal team you're always happy to pick up the phone and just give us a bit of advice right i think that's enough about diabetes i think we should move on to the next subject which i think is vitamin d is that right james absolutely i'm going to sort of you know skew the abc and we'll put vitamin d in here