Special Interest: Diabetes

Diabetic kidney disease is associated with a very high risk of cardiovascular disease (CVD) and premature mortality from cardiovascular events. There is good evidence that multifactorial interventions that optimise BP, limit proteinuria and minimise cardiovascular risk can reduce morbidity and premature mortality. Early diabetic kidney disease is asymptomatic. Microalbuminuria, defined as a urinary ACR of 3-30 mg/mmol on two occasions three months apart is the earliest clinically detectable indicator of diabetic kidney disease. Excellent glycaemic control can delay onset of microalbuminuria.

In older people living with diabetes, geriatric syndromes, which indicate frailty, are emerging as a third category of complications in addition to the traditional microvascular and macrovascular sequelae. Frailty is defined by the presence of three or more phenotypes (weight loss, weakness, decreased physical activity, exhaustion and slow gait speed). Patients may progress from a non-frail to pre-frail or frail state. With timely intervention, there is a greater chance of an individual recovering from pre-frail to non-frail than deteriorating into frailty.

Type 1 diabetes affects around 370,000 adults in the UK, about 10% of all those diagnosed with diabetes. In type 1 diabetes there is a lack of beta cell insulin secretion as a result of autoimmune destruction of the beta cells. However, patients are not affected by insulin resistance, and so do not routinely experience the features of metabolic syndrome that occur in type 2 diabetes. It is therefore important to classify the type of diabetes correctly and to recognise that type 1 diabetes is a condition with its own management requirements. Structured education is the cornerstone of care providing tools to allow effective self-management.

Diabetes risk increases exponentially with increasing BMI particularly if fat accumulates centrally and/or in the skeletal muscle, liver and other organs such as the pancreas. Those with diabetes and co-existing obesity, particularly if it is severe, are also at risk of other obesity-related conditions, such as cardiovascular disease, obstructive sleep apnoea, joint pain, many cancers and depression. Supporting patients to lose weight should be considered a key goal of diabetes care for all overweight and obese patients with type 2 diabetes.

In older people, diabetes is a disabling disease due to the associated vascular complications, multiple comorbidities and the increased prevalence of geriatric syndromes. Because of the complexity of diabetes in old age a comprehensive assessment is important at initial diagnosis, with the aim of preventing loss of autonomy and preserving independence. Cognitive and physical dysfunction are common in older people with diabetes which may affect health outcomes and quality of life. Individual therapeutic targets should take into consideration functional status, life expectancy and patient preferences.