Fouad Moawad, MD

1. Data support referring a patient wtih type 2 diabetes for weight loss surgery at a BMI of: 

Click here for answer, discussion, and next question. 

National guidelines support referring patients with type 2 diabetes for bariatric surgery when the BMI ≥35 kg/m

. This is particularly true if the diabetes cannot be adequately controlled through lifestyle modifications and medications. There is insufficient evidence to refer diabetic patients with a BMI <35 kg/m

and this needs to be assessed on case by case basis.

2. Which of the following is true regarding gestational diabetes?

 After delivery, there is no increased risk for developing type 2 diabetes

 First-line treatment includes oral hypoglycemic

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Answer: B. Age >30 years is a risk factor

Gestational diabetes is defined as glucose intolerance which develops during pregnancy. It is estimated to affect approximately 10% of all pregnancies, and this may be an underestimate of its true prevalence. Several risk factors have been identified, including age >30 years, obesity, and family history of diabetes. It can cause several complications after delivery to both mother and child. Mothers have an increased risk of developing metabolic syndrome and type 2 diabetes. First-line treatment includes diet and exercise. If these measures fail, then oral hypoglycemics or insulin can be used for glycemic control.

3. Screening for serum levels of which of the following should be considered after a diagnosis of type 1 diabetes in a child?

There is an association between type 1 diabetes and celiac disease. The prevalence of celiac disease in diabetes is up to 16% compared with approximately 1% in the general population. Measuring serum levels of tissue transglutaminase (TTG) is an excellent method for initial screening of celiac disease. If positive, referral to a gastroenterologist for duodenal biopsies can confirm the diagnosis. Levels of anti-Scl-70 indicate scleroderma; ASMA is a marker for autoimmune hepatitis; and ANA is a nonspecific marker for autoimmune conditions such as lupus. These 3 serum tests are not routinely recommended after a diagnosis of type 1 diabetes. 

Articles

Spot check your memory for these disease details. 

Diabetes Quizlet: 3 Quick Questions 

There are several well-known comorbidities associated with long-term diabetes, which include cardiovascular disease, hyperlipidemia, and obesity.

Comorbidities often seen in persons with type 2 diabetes include a higher prevalence of reduced testosterone levels (possibly related to insulin resistance), fractures despite having bone mineral density similar to persons without diabetes; and reduced cognitive function (the pathogenesis is poorly understood). There is no known association between diabetes and migraine headaches.

Poll

Conditions associated with long-term diabetes affect myriad organs and systems. Which one of these comorbidities is not associated with the disease?  

Comorbid Curiosity: Which One Doesn't Pertain?

Long-standing and poorly controlled diabetes can affect numerous organs, including the esophagus. Related gastrointestinal symptoms are most likely the result of diabetic gastrointestinal autonomic neuropathy.

Many patients with long-standing diabetes have esophageal dysmotility, which is characterized by impaired peristalsis, spontaneous esophageal contractions, and a decreased lower esophageal sphincter tone. These findings would predispose diabetics to reflux. Previous studies have demonstrated a higher prevalence of GERD among diabetic persons, and this is especially true in type 2 diabetes where central adiposity is common. Reduced LES relaxation is a finding characteristic of achalasia, which is not associated with diabetes.

What are some of the esophageal complications seen in patients with long-standing hyperglycemia? 

Diabetes Pop Quiz: Esophageal Ups and Downs 

In the international diabetes community the topic of hemoglobin A1c (HbA1c) continues to generate controversy for a number of reasons. 

D. Fasting is not required for measurement

According to an International Expert Committee on diabetes, convened in 2008, a HbA1c >6.5% can be used to diagnose diabetes (along with fasting glucose >126 mg/dL and 2-hour plasma glucose >200 mg/dL during oral glucose tolerance test). One of its conveniences is that it does not require fasting prior to measurement.

There is no evidence that male or female sex affects results. However, HbA1c levels can vary with race. African Americans, with or without diabetes, can have higher HbA1c levels than Caucasians. This is true even when matched for fasting plasma glucose levels.

Truths About HbA1c

Up to 75% of patients who are treated for diabetes will report significant GI symptoms. In fact, the entire GI tract, from the oral cavity to the anorectal region can be affected by the disease.

The primary mechanism in diabetes that underlies gastrointestinal complications is poor glucose control. The duration of diabetes is not necessarily associated with gastrointestinal complications, especially when the diabetes is well controlled.  Nephropathy and irritable bowel syndrome are not associated with GI complications in diabetics.

Three-quarters of persons with diabetes will experience significant gastrointestinal symptoms. What underlies the evolution of these GI ailments? 

Diabetes and GI Woes 

By most estimates, diabetes mellitus is now the most common cause of liver disease in the United States.

Chronic liver disease is associated with glucose intolerance and diabetes. This is particularly true in the setting of nonalcoholic fatty liver and steatohepatitis. The major difference between these two conditions is that steatohepatitis is associated with significant hepatic inflammation on biopsy. Both conditions result from insulin resistance, but only steatohepatitis poses a risk of cirrhosis. There is also an association between hepatocellular carcinoma and diabetes.  In some studies, the incidence of hepatocellular carcinoma in twice is high in diabetic patients compared to non-diabetics. The reason for this is not entirely clear. There is no known association between diabetes and alcoholic hepatitis.

Which one of these four liver disorders is not associated with diabetes mellitus?  