AJM Boulton, F.A. Gries and J.A. jervell
Definition
Assessment as Part of the Annual Review of the Patient
Management
Appendix 1: International Guide on the Outpatient Management of Diabetic Peripheral Neuropathy
Introduction
Peripheral Neuropathy in Diabetes
Definitions
Stages of Neuropathy
Assessment
Patient History
Examination of the Patient
Other Investigations
The “At Risk” Foot
Management
No Clinical Neuropathy (Stage 0/1)
Clinical Neuropathy (Stage 2)
Late Complications of Clinical Neuropathy (Stage 3)
Patient Education
Who Should Provide Patient Education?
What methods should be used?
What elements should the education programme contain?
Summary of the Management of Neuropathy
Acknowledgement
Appendix 2 List of Participants
Pilot Working Party, Brussels, Belgium 13 April 1995
Full Working Party, London, UK, 20-22 October 1995
1 Diabetes Mellitus: An Introduction
F.A. Gries, J. Eckel, P. Rösen, and D. Ziegler
The aim of this introduction is to provide a general understanding of diabetes mellitus and its impact on the diabetic individual. It will focus on aspects of epidemiology, pathobiochemistry, prevention, and therapy. Given the scope covered, selectivity and bias of topics and citations have been accepted as unavoidable.
The term “diabetes mellitus” comprises a number of chronic diseases characterized by hyperglycemia due to absolute or relative insulin deficiency. Hyperglycemia is only the most obvious biochemical marker of complex metabolic disorders that affect carbohydrate, lipid, protein, and electrolyte metabolism and may impair numerous organs and functions of the organism.
The diagnosis of diabetes mellitus is based on classical symptoms (weight loss, polyuria, thirst, muscular weakness and fatigue) and persistent hyperglycemia. Glucosuria and elevated glycosylated hemoglobin (HbAlc) levels should not be used for diagnosis. The criteria for diagnosis of hyperglycemia and the classification of diabetes mellitus are not uniformly accepted. Some physicians use the criteria of the United States National Diabetes Data Group of 1979 [1], which was endorsed by the World Health Organization Study Group on Diabetes Mellitus in 1985 [2], while others prefer the criteria of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus of the American Diabetes Association 1998 [3] (Table 1.1).
The criteria published in 1998 tend to diagnose diabetes in younger and more obese subjects than the WHO 1985 criteria, while subjects with postprandial hyperglycemia, microalbuminuria, and those with other predictors of cardiovascular disease are less likely to receive this diagnosis despite the fact that they are at similar risk of premature death [4–8].
The diabetes mellitus classification of 1979 [1] was based “in large part on the pharmacological treatment used in its management.” This was reflected in the terms “insulin-dependent diabetes mellitus” (IDDM) and “non-insulin-dependent diabetes mellitus” (NIDDM) and the further subdivision of patients with the latter into obese and nonobese. The typing of 1998 is based on etiology and pathogenetic mechanisms (Table 1.2). About 50 different types of diabetes mellitus have been identified, the majority of cases being type 1, type 2, or gestational diabetes mellitus.
Table 1.1 Criteria for the diagnosis of diabetes according to the World Health Organization [2] and the American Diabetes Association [3]
| World Health Organization | American Diabetes Association |
|---|---|
| Clinical: | |
| Increased thirst and urine volume, unexplained weight loss, established by casual blood glucose | Polyuria, polydipsia and unexplained weight loss plus casual plasma or capillary blood glucose ≥ 200 mg/dl (11.1 mmol/l) |
| or | or |
| Biochemical: | |
| Casual venous plasma glucosea > 200mg/dl (11.1 mmol/l), fasting venous or capillary plasma glucose b ≥ 140 mg/dl (7.8 mmol/l) and 2 h venous or capillary plasma or capillary whole blood glucose c ≥ 200 mg/dl (11.1 mmol/l) after glucose loadd | Fasting plasma glucose ≥ 126 mg/dl (7.0 mmol/l) or capillary blood glucose ≥ 110 mg/dl or 2 h plasma or capillary blood glucose ≥ 200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test |
a Values for capillary plasma > 220 mg/dl, for venous whole blood >180 mg/dl. for capillary whole blood > 200 mg/dl
b Value for venous and capillary whole blood ≥ 120 mg/dl
c Value for venous whole blood ≥ 180 mg/dl
d Performed as described by WH01985 [2] using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water
There is a great similarity between type 1 diabetes and IDDM and between type 2 diabetes and NIDDM. However, these pairs of terms should not be used indiscriminately as being respectively synonymous. Type 1 diabetes mellitus may for a limited time after manifestation remain non-insulin-dependent, particularly when it begins in an adult (latent autoimmune diabetes in adults. LADA; see page 10). On the other hand, NIDDM, like any type of diabetes mellitus, may become insulin-dependent at an advanced or critical stage.
Epidemiological research on diabetes mellitus is hampered by methodological problems. The criteria and methods for both the diagnosis and the classification of diabetes mellitus have changed over time. Population-based studies are rare, studies based on subgroups are usually biased, and even random samples are not always representative. The epidemiology of diabetes