NEWSLETTER - NOVEMBER 2012
PREVENTIVE HEALTH - Screening for Diabetes

Diabetes mellitus is the term used to describe a condition in which the body’s control of glucose levels by appropriate insulin secretion is compromised. This results in elevated blood glucose levels which damage the small blood vessels, particularly of the eyes and kidneys. Subsequent damage to the large blood vessels can result in cardiovascular disease

Although there are a variety of different possible causes of diabetes, the vast majority of cases can be classified as type1 or type2. Type 1 diabetes is an autoimmune disease in which the immune system attacks and destroys the pancreatic beta cells that normally manufacture insulin. Type 1 diabetes is usually diagnosed in early childhood and is sometimes referred to as early onset diabetes.

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Type 2 diabetes, also referred to as late onset diabetes, is usually seen in adults more than 40 years of age. However recent trends have indicated an increasing incidence of type 2 diabetes in younger adults and obese children

Diabetes is rapidly becoming a major health problem and has reached epidemic proportions in a number of countries. Worldwide, at least 171 million people currently have diabetes, and this figure is likely to more than double to 366 million by 2030. Countries with the highest incidence of diabetes include India, China, the United States, Indonesia, Japan, Pakistan, Russia, Brazil, Italy, and Bangladesh. It is estimated that the greatest percentage increase in rates of diabetes will occur in Africa over the next 20 years. Current figures suggest that at least 80% of people in Africa with diabetes are undiagnosed, and many in their 30s to 60s will die from the complications of this disease.

Type 2 diabetes is responsible for the majority of cases of diabetes. Early detection can prevent or dramatically reduce the incidence of serious complications.

Although some patients with diabetes will have the typical symptoms of excessive thirst, excessive urination and weight loss, most patients with type 2 diabetes will remain asymptomatic for years. Identifying and treating these asymptomatic patients is essential in any preventive health strategy designed to reduce the incidence and complications of diabetes

There is no consensus amongst health care providers or health professionals on the advantages or disadvantages of a general screening programme for diabetes; however there is general agreement on the advantages of a targeted screening programme. Targeted screening programmes aim to identify individuals at risk and offer appropriate testing. Risk factors for type 2 diabetes include the following

Patients with any of these risk factors should discuss the possibility of screening for diabetes with their health professional.

Screening Tests

The standard screening test for diabetes is a fasting glucose. Patients who have fasted for at least 8 hours have a blood sample tested for glucose levels, which should be less than 126 mg/d (7mmol/l). The main disadvantage of this test is that most patients who require or request a diabetes screening test have not fasted for 8 hours and therefore have to return for the test. Many patients fail to attend the follow up fasting appointment.

Another test commonly used for screening is the glucose tolerance test, in which blood glucose levels are measured 2 hours after the ingestion of a standard dose of glucose (75mg). Plasma glucose levels should be <200 mg/dl (11.1 mmol/l)

A recent report by the ADA, the European Association for the Study of Diabetes and the International Diabetes Association recommends the use of the haemoglobin A1c (HbA1c) assay for the diagnosis of diabetes. This test measures the amount of glucose bound to red blood cells and gives a historical and more constant indication of blood glucose levels. The main advantage as a screening test is that it does not require fasting.

A HbA1c level >6.5% is considered to be indicative of diabetes and requires further investigation. Levels > 5% should be monitored as this may indicate pre-diabetes.

None of the existing screening tests can accurately diagnose pre-diabetes and therefore patients who have levels at the higher end of the normal range should be retested at a later date.

Diabetes is usually described as a high calorie input, low calorie consumption disease, which translates into too much food and not enough exercise.

Individuals at risk from diabetes can reduce this risk by maintaining a good body weight, exercising regularly and eating a healthy diet. This will also reduce the risk of other health problems such as cardiovascular disease.

For more information see Diabetes in the disease list.

NEWS – Vitamin D Deficiency a Major Health Issue

When you mention vitamin D most people, including health professionals, think of diseases of the bone such as rickets or osteoporosis, however recent studies indicate that this vitamin may play an important role in a variety of other conditions.

Vitamin D deficiency is reaching alarming levels in northern countries, including the Unities States. The major source of vitamin D is sun exposure. With adults and children increasingly leading an indoor sedentary existence and the use of sunscreens proliferating, many adults and children do not receive adequate sunlight to generate normal levels of vitamin D.

Vitamin D deficiency in children causes poor bone mineralisation resulting in bone deformities and impaired growth (rickets). In adults, vitamin d deficiency can cause hyperparathyroidism, resulting in calcium depletion from bones and increasing the risk of osteoporosis, bone fractures and a painful bone disease called osteomalacia.

New studies indicate that there is much more to vitamin D than mineralisation of bones. There are vitamin D receptors on cells in the brain, prostate, breast colon and immune system and vitamin d is thought to play a role in regulation of the immune system and cell replication

There is mounting scientific evidence that links vitamin D deficiency with an ever increasing list of medical conditions, including type I diabetes, multiple sclerosis, rheumatoid arthritis, hypertension, cardiovascular disease, respiratory tract infections, asthma, muscle pain and weakness and many common cancers.

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Vitamin D comes in 2 forms: D2 and D3. Vitamin D2 (ergocalciferol) is derived from plants and yeast and may be more acceptable to strict vegetarians, yet it is only one third as effective as vitamin D3 at raising 25(OH)D levels in the body. Vitamin D3 (cholecalciferol) is made from lanolin, which is derived from sheep, and is more potent that vitamin D2 in the body.

The best food sources of vitamin D include fatty fish like salmon, mackerel, and sardines. Fortified milk and cereals have extra vitamin D added. Most regular milk is fortified with vitamin D3, while fortified soy milk is usually boosted with plant-based vitamin D2.

There is considerable disagreement over optimal levels of vitamin D however current recommendations are as follows

Because of the increasing importance of vitamin D it is recommended that levels be measured annually. Individuals who are deficient in vitamin D can boost levels by increasing sun exposure, however this should be done carefully to minimise the risk of skin damage and skin cancer.

It may be more appropriate to increase vitamin D levels using supplements. If taking vitamin D2, 3 times more is needed than D3 because vitamin D2 is only 30% as effective at increasing serum levels.

A supplement of 1000IU /day of D3 is appropriate for most individuals. Levels should be checked to ensure that vitamin D levels have reached normal values.

For more information on hyperparathyroidism, osteoporosis and vitamin D see disease list

DID YOU KNOW – The Spleen can Auto- transfuse in Emergencies.

The spleen is a fist sized organ weighing 100-150 g which is located in the upper left abdomen, under the ribcage. The spleen has an extensive network of small blood vessels that filter an estimated 10-15% of total blood volume every minute, removing old or damaged red blood cells. In normal circumstances the spleen holds a reserve of 40-50 mls of blood, however this volume can be significantly increased by changes in smooth muscle. The spleen can also store up to 25% of circulating platelets. Blood and platelets can be released from the spleen during episodes of severe blood loss.

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The ability to auto transfuse is much better developed in animals such as dogs or horses, where 25-30% of red blood cells may be held in reserve in the spleen, allowing these animals to respond more efficiently than humans to severe blood loss.

Apart from its blood filtering activity, the spleen is also a major component of the immune system. It removes bacteria, viruses and other microorganisms from the blood and manufactures antibodies to fight infection.

Though normally protected by its anatomic position, under the ribcage, the spleen is often injured as a result of blunt trauma to the abdomen. This may be the result of a motor vehicle accident, a blow to the abdomen or play activities such as skateboarding or cycling. Damage to the highly vascular spleen can be serious as it frequently results in extensive internal bleeding into the abdomen

Pre-existing illness or disease can markedly increase the risks and severity of splenic injury. Infectious mononucleosis, malaria, and hematologic abnormalities can lead to acute or chronic enlargement of the spleen, as it increases in size in response to increased demand for filtering or immune function This is often accompanied by a thinning of the protective capsule, making the spleen more fragile as well as creating a larger mass which is more susceptible to decelerating trauma. Minor impact in patients with splenomegaly may result in major splenic injury..

DEM.