The problem of diabetes is one of the most pressing medical and social problems of our time, due to its widespread in almost all countries of the world. At present, on our planet, there are more than 300million diabetics (6.6 % of the world’s population), with about 50 % falls on the most active working age 40-59 years old. Experts of the World Diabetes Association predict that the number of patients with diabetes by 2030 year will increase by 1.5 times and reach t 438 million people.
In the United States, as in all countries of the world, there is a high rate of growth in the incidence of diabetes. According to the State Register of Patients with Diabetes , as of January 2013 in the USAthere are 3,779 referrals to medical institutions million people Meanwhile, the results of control and epidemiological studies conducted by Endocrinology Research Center in the period from 2002 to 2010, showed that the true number of patients with diabetes in the USA at about 3-4 times more officially registered and reaches 9-10 million people, which is about 7 % of the population. The most dangerous consequences of a global epidemic of diabetes its systemic vascular complications are nephropathy, retinopathy, damage to the great vessels of the heart, brain, peripheral vessels of the lower extremities. It is these complications that are the main cause of disability and mortality of patients with diabetes.
Diabetes is the most common cause of blindness in middle-aged people. The risk of developing blindness in patients with diabetes at 25 times the rate in the general population. The development of diabetic gangrene leads to disability, and in some cases death of the patient. More than half of the amputations of limbs not related to injuries are accounted for by patients with diabetes mellitus. According to scientists, more than 11,000 are produced annually in our country. Amputations of the lower extremities in patients with diabetes mellitus. The risk of cardiovascular disease in patients with diabetesincreases by 4 times, the number of cerebral strokes increases by 2–3 times
Metabolic disorders inherent in diabetes mellitus, and, above all, hyperglycemia play a leading role in the development of vascular complications. However, poor clinical presentation of diabetes 2 of the type, and sometimes the complete absence of symptoms in a significant part of these patients, causes a late diagnosis of the disease and the identification of a large percentage of vascular complications at the time of diagnosis. According to a prospective UKPDF study of up to 50 % of patients with newly diagnosed diabetes 2 type already have signs of diabetic microangiopathy, which determine the quality of life of patients and is a major cause of mortality and invalids hybridization.
Given the high prevalence of diabetes in some countries, his active search is carried out by laboratory examination of the entire population. This method requires a lot of material costs. It is more expedient to single out the population groups in which the probability of developing this disease is the highest with the help of questioning, the so-called risk groups. The latter are divided into groups of absolute and relative risk.
The greatest likelihood of detecting diabetes in the absolute risk group. It includes individuals with a genetic predisposition. In the implementation of genetic predisposition, environmental factors play an important role. With diabetes 2 such as the decisive factor most often is obesity.
Prevalence of Diabetes increases with increasing body mass. Thus, with the 1st degree of obesity, the frequency of type 2 diabetes is doubled compared with the prevalence of the disease among persons of normal body weight; at the 2nd degree of obesity – in 5 time; with 3rd degree – 8-10 time.
The relative risk group includes people who have: obesity, widespread atherosclerosis, coronary heart disease, arterial hypertension, chronic pancreatitis, endocrine diseases accompanied by hyperproductioncontrainsular hormones (Cushing’s disease and syndrome, pheochromocytoma, acromegaly, diffuse toxic goiter and others), renal diabetes, and also persons: long-term users of glucocorticoid drugs and people of elderly and old age, women who have given birth to a child with a body weight more than or equal to 4000 d, women with obstetric history – gestosis of the first half of pregnancy, stillbirth and others, pregnant with more than 20 gestational age weeks.
Persons with the above risk factors must undergo a laboratory examination to identify possible disorders of carbohydrate metabolism, including two stages. The purpose of the first stage is to establish an explicit, manifest. Diabetes . To do this, the fasting glucose level is examined (fasting glycemia means the blood glucose level in the morning before breakfast, after a preliminary fasting of at least 8 hours) or during the day. In a healthy person, the fasting glucose level in capillary blood is 3.3-5.5. mmol/l (59–99 mg %).
Diagnosis of Diabetes can be delivered in the presence of positive at least one of the following tests:
- fasting glucose level in fasting blood ³ 6,1 mmol/l (110 mg %);
- random detection of elevated glucose concentration in capillary blood ³ 11.1 mmol/l (200 mg %) (the study is conducted at any time of the day, regardless of the limitation of the last meal) .
Hyperglycemia on an empty stomach and during the day in most cases is accompanied by clinical manifestations of diabetes (polyuria, polydipsia and others). If you have these symptoms for diagnosis ofdiabetes enough to detect an increase in glycemia ³ 6,1 mmol/l (110 mg %) on an empty stomach or ³11.1 mmol/l (200 mg %) at any time. Additional examination in these cases is not required. In the absence of clinical manifestations, diagnosis of diabetes must be confirmed by re-determination of glycemia in the following days.
After exclusion of overt diabetes mellitus, the second stage of the examination is carried out – oral glucose tolerance test (PGTT) in order to identify impaired glucose tolerance. PGTT is carried out on the background of a normal diet. On an empty stomach after an overnight fasting lasting 10-14 hours inspected drinks the prepared glucose solution: – 75 g of glucose is dissolved in a glass of water. Blood sampling done on an empty stomach and after 2 o’clock.
In accordance with the recommendations of WHO experts the results of PGT carried out are assessed as follows:
normal tolerance is characterized by the level of glucose in capillary blood after 2 hours after glucose load <7.8 mmol/l (140 mg %);
increasing the concentration of glucose in capillary blood after 2 hours after glucose load ³7.8 mmol/l (140 mg %), but below 11.1 mmol/l (200 mg %) indicates impaired glucose tolerance;
the content of glucose in capillary blood after 2 hours after glucose load ³11.1 mmol/l (200 mg %) indicates a preliminary diagnosis of diabetes mellitus;
a new group of carbohydrate metabolism disorders is identified – impaired fasting glucose, including those with a fasting glucose level of 5.6 mmol/l (100 mg %) up to 6.0 mmol/l (110 mg %) with normal blood glucose levels after 2 hours after glucose load (<7.8 mmol/l or 140 mg %).
Impaired fasting glucose, as well as impaired glucose tolerance, is considered as a predictor of diabetes 2 type
Therefore, the diagnosis of diabetes can be delivered with an increase in fasting glucose level in fasting blood ³6.1 mmol/l (110 mg %) or ³11.1 mmol/l (200 mg %) – when conducting a study at any time of the day, regardless of the prescription of the previous meal, or ³11.1 mmol/l (200 mg %) – in the study of glycemia after 2 hours after load 75 g glucose.
Since 2011 WHO adopted glycated hemoglobin as a diagnostic criterion for diabetes mellitus. In a healthy person, the level of glycated hemoglobin is up to 6.0 % The level of glycated hemoglobin is 6.0-6.5 % is regarded as a high risk group for diabetes. And the level of this indicator is more than 6.5 % indicates diabetes. If there are no symptoms of acute metabolic decompensation, the diagnosis should be made on the basis of two numbers in the diabetic range, for example, twice the determined HbA1c or a single determination of HbA1c and a single determination of the glucose level .
Difficulties in timely diagnosis with 2 type of diabetes mellitus is explained by the slow gradual onset of the disease, usually without clear symptoms, and therefore, the disease remains undetermined for a number of years, which as a result increases the risk of developing late complications. Very often Diabetes 2 Type is diagnosed at the first visit to the doctor about vascular complications. This usually happens in 6-8 years after the onset of the disease. At the same time, the costs of macro and microvascular complications make up the largest part of all expenses for diabetes 2 type. An active search for disorders of carbohydrate metabolism is often not conducted.
The aim of the work is to identify and analyze the causes of late diagnosis of diabetes 2 type. We have studied 28 case histories of patients in inpatient treatment at the endocrinology department regarding newly diagnosed diabetes mellitus 2 type The age of patients ranges from 36 to 85 years, among them was an equal number of men and women. This hospitalization was associated with pronounced decompensation of metabolic processes. The average level of glycemia was 16.9 + 1.24 mmol/l. The average level of glycated hemoglobin is 11.3 % Y 9 (32 %) patients revealed ketosis when admitted to hospital. The examination revealed vascular complications of diabetes mellitus on the basis of characteristic complaints and the results of additional examinations. Angiopathy of the lower extremities was detected in 11 (39 %) patients, distal polyneuropathy in 9 (32 %), diabetic retinopathy , mainly non-proliferative stage – in 13 (46 %), chronic cerebral ischemia – in 12 (42 %), fatty hepatosis – in 22 (78 %) patients. Only 6 patients during the examination revealed no late complications of diabetes.
It should be noted that the majority of patients had risk factors for diabetes. Y 11 patients (39 %) was atherosclerosis, in 13 (46 %) patients – ischemic heart disease, 24 (86 %) patients were observed by the therapist for arterial hypertension, in 15 (54 %) patients had obesity of varying severity. In addition, 20 (71 %) patients had a genetic predisposition for diabetes, which is the basis for an active search for diabetes 2 type In the course of clinical examination, patients were examined in carbohydrate metabolism and in 5 (18 %) patients previously detected glucosuria , in 9 (39 %) of patients – hyperglycemia, but the patients did not go to the endocrinologist due to the lack of complaints and good health. This is probably due to the lack of information about possible complications of diabetes. It should be noted that if glycemia was detected in risk groups, PHTT was not performed; glycated hemoglobin was not studied. As a result, the diagnosis was made already at the stage of vascular complications, and in some cases emergency hospitalization was required in connection with the development of ketosis and intensive care, as well as the use of angioprotectors, hepatoprotectors, nootropes (trental, actovegin, Essentiale, piracetam), which leads to additional financial costs. In connection with pronounced decompensation of metabolic processes 9 patients required the appointment of insulin in the hospital (5 patients insulin therapy is recommended for outpatient treatment), in 3 – combination therapy with insulin and preformed tablets hypoglycemic agents. In the case of early diagnosis, many patients could be on dietary therapy for a long time or get tablets hypoglycemic drugs, which would significantly reduce the cost of treatment and improve the quality of life of patients.
Our results confirm the need to highlight diabetic risk groups and carry out preventive measures (treatment of obesity, arterial hypertension, atherosclerosis) and an active search for the disease (glycemic test, glycated hemoglobin and glucose tolerance test) using questionnaires. Patients at risk should be informed not only about the possibility of developing diabetes, but also about the risk of vascular complications.
In the US , the current diagnosis of newly diagnosed diabetes 2 The type is established in most cases by general practitioners and general practitioners. Reducing the likelihood of developing vascular complications Diabetes mellitus ensured by the continuity and quality of observation of patients at risk. It is necessary to expand the cooperation of general practitioners, GPs and endocrinologists, to hold joint conferences and seminars.
The modern level of scientific research allows for the early diagnosis of the disease and the widespread therapeutic and preventive measures aimed at reducing the prevalence of diabetes, reducing disability and mortality from this disease. Reduce the current costs of medical care, reduce the incidence and incidence of late complications Diabetes mellitus it is possible only with the proper organization of all links of the diabetic service and increasing the availability of information about diabetes.