Primary Care 10-minute consultation

Newly diagnosed type 2 diabetes mellitus

BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7403.1371 (Published 19 June 2003) Cite this as: BMJ 2003;326:1371
  1. Susan M Smith, lecturer in community health and general practice (susmith{at}tcd.ie)
  1. Department of Community Health and General Practice, Trinity College Centre for Health Sciences, Adelaide and Meath Hospital Incorporating the National Children's Hospital, Tallaght, Dublin 24, Republic of Ireland

    Introduction

    A 62 year old woman has returned to you for the results of blood tests. She had attended for a well woman check up two weeks earlier and had mentioned that she was experiencing persistent fatigue. A random plasma glucose test that day showed a glucose concentration of 11.4 mmol/l, so you had arranged for her to have a fasting blood glucose test. Her fasting blood glucose was 8.5 mmol/l. She has no history of vascular disease or other serious medical conditions. Her aunt had diet controlled diabetes and died of a cerebrovascular event at the age of 68.

    Figure1

    Initial management of newly diagnosed type 2 diabetes

    What issues you should cover

    Diagnosis-You can make a diagnosis on the basis of random (> 11.0 mmol/l) or fasting (> 7.0 mmol/l) venous plasma glucose concentrations or by oral glucose tolerance testing. Whichever method you use, a diagnosis of diabetes has serious implications and you should confirm it by repeat testing on a subsequent day. Could there be a secondary cause, such as pancreatic disease or hormone induced diabetes? Check too that she has not been taking any drugs that may have precipitated diabetes, such as steroids or thiazide diuretics.

    Treatment-Cardiovascular risk profiling is essential in people with diabetes, but including it in the initial consultation is likely to overwhelm most patients-though establishment of baseline behaviours such as smoking, diet, and exercise habits may be appropriate for some patients. Dietary change is important. Most patients should have a three month trial of dietary treatment before starting on oral hypoglycaemic agents. Education and psychological support-A diagnosis of diabetes can be devastating for some patients, but other patients are relieved to have an explanation for their symptoms. Provide her with written information and instructions (once you have established her literacy). Initial education may involve just a simple explanation of the nature of diabetes and clear advice on action to be taken if her condition deteriorates before the next review. See bmj.com for an example of the information you could put in a leaflet to give to patients with newly diagnosed type 2 diabetes.

    Useful reading

    What you should do

    • Should she be referred immediately? This is generally indicated if the patient is clearly unwell, if she has ketonuria, or if her blood glucose concentration is > 20 mmol/l. Recent weight loss is an indication of severity of disease.

    • Do an initial physical examination: measure blood pressure, measure weight and height to calculate body mass index, and check for possible secondary causes of diabetes, such as pancreatic disease. Check for any existing complications.

    • Initial investigations should include haemoglobin A1c, full blood count, renal profile, fasting lipid profile, and microalbuminuria testing.

    • Initiate a change in diet. Focus on the need for a healthy balanced diet, with restriction of refined sugars.

    • Organisational tasks include recording of findings and inclusion of the patient on the practice register and recall system; referral for assessment of eye complications; and referral to dietician, chiropodist or podiatrist, and community diabetes educator, if available. Ensure that the patient has a follow up appointment to see you.

    Footnotes

    • The series is edited by general practitioners Ann McPherson and Deborah Waller (ann.mcpherson{at}dphpc.ox.ac

      This is part of a series of occasional articles on common problems in primary care

    • The BMJ welcomes contributions from general practitioners to this series

    • Embedded Image Information that can be included in a leaflet for patients is on bmj.com

    • Competing interests SS has received partial funding for a research project from Servier Laboratories, Novo Nordisk, Bristol Myers Squibb, and Aventis Pharma, manufacturers of oral hypoglycaemic agents.

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