You are a doctor at a busy general practice surgery in the city suburbs.
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1 You are a doctor at a busy general practice surgery in the city suburbs. Today, four patients who you feel are at risk of diabetes have appointments to discuss the results of recent 'glucose tolerance' tests carried out by the Practice nurse. As a GP you are highly trained and knowledgeable; you will be able to answer their questions about diabetes, but you are not a specialist. So, before your patients arrive, you check your understanding on the internet to ensure you are interpreting their test results correctly. Read on... Glucose tolerance test A glucose tolerance test (GTT) checks how well the body processes glucose. This is done by comparing the level of glucose in the blood before and after drinking a sugary drink. With type 2 diabetes the illness tends to develop slowly over a period of weeks or months. This is because in type 2 diabetes the beta cells still produce insulin but they do not produce enough. Type 2 diabetes may also be caused by the cells in the body not using insulin properly. This is known as 'insulin resistance' (See Graph 1). Once diagnosed, type 2 diabetes can often be controlled by diet. In most cases a simple blood test is enough to detect diabetes. However, a glucose tolerance test is useful because it helps diagnose patients whose blood test results were inconclusive. It also reveals those people whose response to high blood glucose levels is quite weak but is not yet at the stage of diabetes. This condition is known as 'impaired glucose tolerance' or 'pre-diabetes'. People with pre-diabetes are more likely to go on to develop type 2 diabetes but this can often be prevented by changes in the diet Page 1 of 6
2 A glucose tolerance test is also used to diagnose gestational diabetes. This form of diabetes only occurs in pregnancy and can put the baby at risk of health problems after birth and of developing diabetes itself later in life. It happens because the body cannot produce enough insulin to cope with the extra demands of pregnancy. Once diagnosed this type of diabetes is often controlled by diet although in some cases the patient may have to take tablets or have insulin injections. Gestational diabetes goes away after the birth. In healthy people, blood glucose levels always rise after a meal, but they soon return to normal as the glucose is used by the body or stored. A glucose tolerance test helps distinguish between this normal pattern and the pattern seen in diabetes or prediabetes. Before a glucose tolerance test the patient will not eat for between 8 12 hours. A sample of blood is taken and this shows their 'fasting' glucose level. The patient then consumes a drink containing 75g of glucose. Normally, the body quickly removes glucose from the blood stream and into the body's cells. This reduces the amount of glucose found in subsequent samples of blood. If there is a problem, the levels of glucose in the blood stream remain high. The glucose tolerance test results for all four patients are on Graph 2. Use the questions and information below to help you decide what the results are showing Page 2 of 6
3 Questions 1. Was the fasting glucose level the same for each patient? 2. What was the range of fasting glucose levels? 3. Why is the fasting glucose level required? 4. How many blood samples were taken from each patient? 5. For how long did the practice nurse take samples of blood? Important information Normal response: A person is said to have a normal response when the two hour glucose level is less than 140 mg/dl, and all values between 0 and 2 hours are less than 200 mg/dl. Impaired glucose tolerance (IGT): A person is said to have impaired glucose tolerance when the fasting blood glucose is less than 126 mg/dl and the two hour glucose level is between 140 and 199 mg/dl. Diabetes: A person has diabetes when two glucose tolerance tests done on different days show that the blood glucose level is high. This means either the two hour levels is greater than 200 mg/dl or the fasting glucose is greater than 126 mg/dl. Diabetes during pregnancy: A pregnant woman has diabetes if she has a fasting plasma glucose of over 92 mg/dl, or a two hour glucose level greater than 153 mg/dl. Now you are ready to make a diagnosis for patients 1, 2, 3 and 4 when they attend their appointments later in the day. Once you have given your diagnosis your patients are bound to have some questions to ask you. Their questions will be quite straight forward but you don't want to be caught out. Go over what you know about diabetes. Think about each patient. What will they want to know? Use Graph 3 to help you advise them about diet Page 3 of 6
4 For each patient write down the two questions you feel they are most likely to ask, but you cannot have a question more than once, so by the end you will have eight questions written down and you will know the answers in your head Page 4 of 6
5 Teaching notes This activity follows on from the GCSE work students do about the role of insulin/glucagon etc. in blood glucose homeostasis, diabetes and diet. There are graphs for them to interpret and the focus is on type 2 diabetes. A. Students could start with the graphs. Discuss what each graph is showing before moving on to the activity. B. Once the students have got to the point where they have written down their eight questions all the materials should be put away and students work in pairs, taking turns to be doctor and patient. C. The 'patient' chooses which patient to be (patient 1,2,3 or 4) and asks the doctor their two questions. The doctor tries their best to answer whilst maintaining a professional front. D. At the end, any difficult or unanswered questions can be put to the rest of the class. Answers 1. No mg/dl. Range of 30 mg/dl 3. To show the 'resting' or 'background' blood sugar level of a person. It can be used as a comparison with the level after 2 hours. If this level is above what is regarded as normal it shows the person's body is not removing glucose from the bloodstream effectively and suggest diabetes. 4. You would assume 7 including the one taken after fasting but it is not possible to tell from the graph. Line graphs are a useful way of showing this data because blood glucose levels between blood samples can be estimated mins. 2 hours Page 5 of 6
6 Notes on Graph 3 Notice that with fats and proteins blood glucose levels are continuing to rise after 2 hrs but remain very low compared to other foods; releasing energy to body very slowly. Also, note how, after 2 hrs, blood glucose level drops below starting level for white bread and iced cake, inducing a feeling of hunger which people often satisfy by eating more sugary/refined food, creating yo-yo effect in blood glucose levels. Patient Information Patient 1: Has diabetes. Although their fasting glucose level is below 126 mg/dl, after 120 mins their level is above 200 mg/dl. Patient 2: Shows a normal response no diabetes Patient 3: Has pre-diabetes Patient 4: Has gestational diabetes her level after 120 mins is above 153 mg/dl Page 6 of 6
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