Current approach to diabetes care in primary care

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The management of diabetes has, rightly, been given a high priority within general practice in recent years, with marked improvements in the level of pro-active care, reduction in risk factors, and prevention of co-morbidities being observed as a result. However, it is only recently that the direct relationship between type 2 diabetes and obesity has been accepted by the majority of clinicians. This chapter seeks to describe the way in which overweight type 2 diabetics might be managed in primary care. The distinction between type 1 and type 2 diabetics may be made at a very early stage in treatment, and the criteria for deciding when insulin treatment is required is dealt with elsewhere. It is also assumed that the ongoing management of diabetics, including annual reviews and dealing with complications is not within the remit of this chapter and will also be covered elsewhere in the book.

While up to 80 per cent of an individual's predisposition to developing type 2 diabetes is genetic (McCarthy et al., 1994), obesity is now acknowledged as the determining factor in that development, and, conversely, it is quite clear that even a modest reduction in body weight, of between 5 and 10 per cent, can lead to significant improvements in fasting blood glucose and Hba1c (Goldstein, 1992). In newly diagnosed type 2 diabetics a reduction in body weight by 10 per cent would lead to a return to normal fasting glucose in half of all cases, and sustained weight loss of 10 per cent would produce a 30 per cent fall in diabetes-related deaths (see Table 14.1). Faced with this compelling evidence many practitioners now accept that weight management should form an integral part of the management of type 2 diabetes. The difficulty then faced is how to deliver that aspect of care within a primary care setting?

Table 14.1 Benefits of 10% weight loss

>20% fall in total mortality >30% fall in diabetes related deaths > 40% fall in obesity related deaths fall of 10 mmHg systolic and 20 mmHg diastolic pressure 50% fall in fasting glucose 10% dec. total cholesterol 15% dec. in LDL 30% dec. in triglycerides 8% inc. in HDL

World Health Organization. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO, 1997 with permission.

LDL, low-density lipoprotein; HDL, high-density lipoprotein.

Mortality

Blood pressure

Diabetes

Lipids

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