James Morris, David Morris

Latent autoimmune diabetes in adults (LADA) is a slowly progressing form of autoimmune diabetes with antibodies directed against the pancreatic beta-cells. It typically presents in people over the age of 30 years and has a clinical and biochemical picture intermediate between type 1 and type 2 diabetes. Because there is no immediate requirement for insulin, it is often initially misdiagnosed as type 2 diabetes. This case report of a younger adult with an uncertain diagnosis of type 2 diabetes illustrates the characteristics and clinical implications of LADA, its differential diagnosis and its possible management strategies.

Authors

James Morris, GPST3, Priory

View Medical Centre, Leeds, and GPST Visiting Lecturer, University of Leeds; David Morris, Retired GP and Specialist Doctor in Diabetes, Undergraduate Clinical Tutor, Keele University.

Citation: Morris J, Morris D (2024) Case report: LADA – assessing diabetes in a non-overweight younger person. Diabetes & Primary Care 26: [Early view publication]

Case presentation

      Susan, a 39-year-old lady with a two-year history of type 2 diabetes, attended general practice reporting symptoms of thirst, increased micturition, lethargy and abdominal discomfort. She reported a weight loss of 2 kg over the last year.

      Initial management of Susan’s diabetes had focused on lifestyle adjustment and treatment with metformin, which had been titrated up to a dose of 1000 mg twice daily. While this strategy initially improved glycaemic control, Susan’s HbA1c levels continued to fluctuate, running as high as 75 mmol/mol, despite careful diet, regular exercise and taking her medication as prescribed. As a result, sitagliptin (subsequently stopped because of pruritus) and more recently empagliflozin were added to Susan’s regimen.

      Susan, a car driver, had declined gliclazide, wishing to avoid the risk of hypoglycaemia. Susan was up to date with her diabetes foot checks and retinal screening, and there were no diabetes complications.

Latest results (2 months previously):

HbA1c 63 mmol/mol (7.9%); total cholesterol 4.7 mmol/L; non-HDL cholesterol 3.8 mmol/L; Hb 135 g/L; eGFR >90 mL/min/1.73 m2 ; urinary ACR <3 mg/mmol.

Past medical history: Gestational diabetes.

Medication: Metformin 1000 mg twice daily; empagliflozin 25 mg once daily.

Social history: Secretary; ex-smoker; alcohol only

Family history: Mother and first cousin with type 1 diabetes.

Examination: BMI 24.1 kg/m2 ; blood pressure 125/72 mmHg. Cardiovascular and respiratory systems unremarkable. Abdomen: no significant

Investigations: Dipstick urine: glucose +++, nil else. Fingerprick glucose: 12.3 mmol/L. Blood ketones: not significant.

What is your clinical assessment of the situation?

What further investigations would you consider?

Claire Davies

Questions by:

Pam Brown, GP, Swansea

Jane Diggle, Specialist Diabetes Nurse

Practitioner, West Yorkshire

Citation: Davies C (2024) Q&A: Lipid management – Part 2: Use of statins. Diabetes & Primary Care 26: 91–5

Author

Claire Davies, Diabetes and Endocrinology Specialist Pharmacist, Gateshead Health NHS Foundation Trust.

Claire Davies, Patrick Wainwright

Questions by:

Pam Brown, GP, Swansea

Jane Diggle, Specialist Diabetes Nurse Practitioner, West Yorkshire

Citation: Davies C, Wainwright P (2024) Q&A: Lipid management – Part 1: Measuring lipids and lipid targets. Diabetes & Primary Care 26: 85–9

Acknowledgement

This Q&A was originally authored by Patrick Wainwright in 2022. Claire Davies has revised the answers in response to updated NICE recommendations published in December 2023.

Authors

Claire Davies Endocrinology Specialist , Diabetes and Pharmacist, Gateshead Health NHS Foundation Trust; Patrick Wainwright, Consultant in Chemical Pathology and Metabolic Medicine, Betsi Cadwaladr UHB, North Wales.

Andrew Hill

Diabetes mellitus continues to be a challenging health problem and affects well over half a billion people globally (International Diabetes Federation [IDF], 2022). The complications of diabetes are multi-factorial and serious with an estimated 48% of all diabetes-related deaths occurring before the age of 70 (World Health Organization [WHO], 2024). One of the greatest predictors of diabetes-related death is diabetic foot ulceration (DFU) and subsequent amputation (Jeyaraman et al, 2019). It is widely believed that with appropriate disease management and effective self-care behaviours, many complications of diabetes, including DFUs, may be entirely avoided (National Institute for Clinical Excellent [NICE], 2020). Furthermore, the International Working Group on the Diabetic Foot (IWGDF) in their 2023 update to guidelines cite good foot self-care behaviours as a key approach to prevention of DFUs (Bus et al, 2024). However, good self-care behaviours in diabetes — particularly around foot self-care — are often not consistently undertaken by people with diabetes and the reasons for this are many and their interplay quite complex (Matricianni and Jones, 2015). Adherence to care more broadly is a multidimensional phenomenon, determined by the interplay of social and economic, patient-related, health-systemrelated and condition-related factors (Kardas et al, 2013). This complexity appears to surround patient motivation, lived experiences, knowledge, access to health services and interpersonal relationships between patients and the healthcare professionals engaged in their care (Hill et al, 2022). This interplay may mean that ‘one size fits all’, standardised approaches to patient advice and education are not the most effective way to improve patient self-care behaviour in diabetes. This links with the work done by Engel (1977) who presented his biopsychosocial model of health. This model posits that health and illness are the product of biological, psychological and social influences with the latter two components being absent from the more traditional biomedical model. Indeed, by providing a more explicit focus on the psychological and social influences on health, this has resulted in the development of greater understanding of the behaviours of individuals in the context of their health.

Citation: Hill A (2024) Understanding personality traits: could this help us support better foot self-care behaviours in people with diabetes? The Diabetic Foot Journal 27(1): 14–9

Key words

- Psychological influence on health

- Self care

- Social influence on health    

Article points

1. Good self-care behaviours in diabetes — particularly around foot self-care — are often not consistently undertaken by people with diabetes

2. ‘One size fits all’, standardised approaches to patient advice and education are not the most effective way to improve patient self-care behaviour in diabetes

3. By providing a more explicit focus on the psychological and social influences on health, this has resulted in the development of greater understanding of the behaviours of individuals in the context of their health.

Authors

Andrew Hill is Senior Lecturer & Programme Lead – BSc (Hons) Podiatry, The SMAE Institute, Maidenhead, UK