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DIABETES

MANUAL
7th Edition

A guide to diabetes management

Published by Diabetes Outreach

© Diabetes Outreach 2009


Published by Diabetes Outreach
8 Woodville Road
WOODVILLE SA 5011

Phone: (08) 8222 6775


Fax: (08) 8222 6768

Diabetes Manual: A guide to diabetes management


th
7 Ed. September 2009

ISBN: 978-0-9756985-7-0

1. Diabetes – Handbooks, manuals, etc

616.462
Acknowledgements
th
EDITORIAL TEAM – 7 Edition 2009

Melissa Carapetis Dietitian, Diabetes Centre,


The Queen Elizabeth Hospital
Martin Dowell Diabetes Educator RN CDE
Salisbury Primary Health Care
Hilary Durrant Specialist Pharmacist,
The Queen Elizabeth Hospital
Helen Edwards Diabetes Counsellor,
Diabetes Counselling Online
Shelley Farrent Dietitian, Diabetes Education Unit,
Flinders Medical Centre
Jane Giles Manager – Education RN CDE,
Diabetes Outreach
Lyn Green Clinical Services Coordinator, Diabetes Centre,
Royal Adelaide Hospital
Dr. Mitra Guha Director, Diabetes Services,
Royal Adelaide Hospital
Mary Hodgson Diabetes Educator RN CDE, Diabetes Centre,
The Queen Elizabeth Hospital
Collette Hooper Clinical Services Coordinator, Diabetes Education Unit,
Flinders Medical Centre
Dr. Bill Jefferies Director, Department of Medicine,
Lyell McEwin Hospital
Sara Jones Senior Lecturer Podiatry,
University of South Australia
Mirella Kakogianis Dietitian, Diabetes Education Unit,
Flinders Medical Centre
Jill Lyon-Green Clinical Services Coordinator RN CDE, Diabetes Service,
Lyell McEwin Hospital
Sally Marotti Specialist Clinical Pharmacist,
The Queen Elizabeth Hospital.
Sue McCullough Diabetes Educator RN CDE, Diabetes Education Unit,
Repatriation General Hospital
Kaye Neylon Project Consultant, RN CDE
Diabetes Outreach
Dr Pat Phillips Senior Director, Endocrinology,
The Queen Elizabeth Hospital
Diana Sonnack Clinical Nurse Consultant RN CDE,
Royal District Nursing Service
Connie Stanton Dietitian, Diabetes Centre,
The Queen Elizabeth Hospital
Kate Visentin Clinical Nurse – Education CDE,
Diabetes Outreach
FOREWORD
Welcome to the seventh edition of the Diabetes Manual. We are pleased to
acknowledge that the Diabetes Manual continues to be a consistent and evidence
based resource for rural and remote health services in country South Australia it is also
recognised and utilised by many metropolitan health services.

Diabetes is and continues to be a significant and rapidly growing global public health
issue and in fact could be viewed as a disease in the numbers akin to an epidemic.
Type 2 diabetes affects over 6% of the Australian adult population and makes up about
85 – 90 % of all diabetes. Type 1 diabetes makes up about 10 – 15 % of all diabetes
and is increasing at a rate of approximately 3% per year. Gestational diabetes affects
4.9 % of all pregnancies and is a significant risk factor for the development of type 2
diabetes later in life.

In Australia, diabetes is the second most common reason for renal dialysis, the most
common cause of blindness in people over the age of 60 years, the most common
cause of non-traumatic amputation and one of the more common chronic diseases
amongst children.

Developed in consultation with a team of very experienced and committed health


professionals, the manual’s main objective is to provide users with information on the
latest trends and guidelines on the management of the education and information. The
Editorial Team welcome and invite any user of this manual to submit their ideas on
further improvements for future editions.

I commend this manual to you the user and trust that you will find it informative and
useful and encourage you to introduce other health professionals to it to assist them in
managing their clients and patients. This manual is a very valuable resource tool in the
management and continuing education for individuals with diabetes.

The Editorial Team 2009


CONTENTS
Section 1 Introduction

Section 2 Understanding diabetes

Section 3 Diabetes education

Section 4 Hospitalisation

Section 5 Monitoring diabetes control

Section 6 Footcare

Section 7 Community groups with specific needs

Section 8 Healthy eating and diabetes

Section 9 Maintaining a healthy lifestyle

Section 10 Medication

Section 11 Unstable diabetes

Section 12 Long term complications

Section 13 Pregnancy and diabetes

Section 14 Residential care

Section 15 Resources

Section 16 Reference
SECTION 1
Introduction
Preface
This manual has been developed by a team of health professionals working in the area
of diabetes care.

‘Diabetes – Your Hospital Manual’ was originally an initiative of the staff of The Queen
Elizabeth Hospital Diabetes Centre. The original publication in 1990 was aimed at
documenting in-house hospital policies to assist staff in developing comprehensive and
effective care for people with diabetes during hospitalisation.

Since that time the Manual has been updated to incorporate nationally accepted
guidelines. Diabetes Outreach aims to disseminate this information for use in a range
of hospitals and health care settings particularly in rural and remote areas. The
information contained in this manual should be used in conjunction with current local
policies and protocols.

Users of the manual are welcome to submit any suggestions for its improvement to
Diabetes Outreach.

Should you have any queries about the contents of this manual contact:

Diabetes Outreach
8 Woodville Road,
WOODVILLE SA 5011
Telephone: (08) 8222 6775
Facsimile: (08) 8222 6768

SECTION 1 – INTRODUCTION – REVISED SEPTEMBER 2009


1
Purpose
This manual is designed as a reference for nurses and allied health providers working
in hospital and community settings but can be used by all health care providers who
are working with people with diabetes.

The manual aims to:

1. provide current, accurate information on the management and education of


people with diabetes

2. guide health professionals in the treatment and care of specific problems


associated with diabetes.

An improvement in the quality of diabetes health care and education provided by


health care providers is the desired outcome.

A reference list is provided at the end of each section and a glossary is included at the
end of the manual. Users of the manual are free to photocopy any relevant
information that will assist them in caring for people with diabetes.

The manual is also available online and can be downloaded free of charge at
www.diabetesoutreach.org.au.

Use of this manual


The following steps may be helpful in using this manual:

• be clear about the problem / situation


• select and read the relevant section / s
• look at recommended action / guidelines
• do what is suggested
• evaluate the outcome.

Example:

A person with newly diagnosed diabetes mellitus is in hospital for minor surgery.

• Find the problem / situation - the person has no knowledge of what diabetes is
and needs a basic introduction of diabetes while in hospital.

• Select the right sections - Diabetes education – Section 3


Hospitalisation – Section 4

• Look at recommended action / guidelines together with the individual’s needs,


ability and comprehension.

• Do what is suggested

• Evaluate outcome - has the person a simple understanding of what diabetes is?
Are there any areas that need explaining? (Evaluation may lead to identification
of a new situation / problem which requires further action).

SECTION 1 – INTRODUCTION – REVISED SEPTEMBER 2009


2
Primary health care
Traditionally health care was assessed through measuring, this meant counting
numbers of bed days, numbers of people and numbers of procedures. Its success
was measured by the number of people who came in and out and how much it cost to
get them in and out. Often this did not show whether the overall health of the
community was improved. Today primary health care is concerned with the broader
picture of improving the health of the community in all the complexity that this involves.

The starting point for a primary health care approach is to provide a complete system
of care to address the community’s main health problems – that is, those which are the
most common and which have the most significant impact on the health status of the
community.1

The World Health Organisation defines primary health care as having the following
broad ideals:

• it is the first level of contact for individuals and communities with the health
system
• is located as close as possible to where people live and work
• is universally accessible - no barrier of cost, geography, culture, race, gender or
other barriers
• is based on full participation of the community
• emphasises prevention
• addresses the main health problems of the community it serves
• is the main focus of a country’s health system - not a bottom layer added on.
WHO2

The Declaration of Alma-Ata defined primary health care as: ‘Primary Health Care is
essential health care based on practical, scientifically sound and socially acceptable
methods and technology made universally accessible to individuals and families in the
community through their full participation and at a cost that the community and country
can afford to maintain at every stage of their development in the spirit of self-reliance
and self-determination.’2

How do we define primary health?


Primary health means promoting health and preventing illness (eg complications
associated with diabetes) before it occurs.

Trying to create an environment that makes `healthy choices, easy choices' (access to
healthy food, exercise options etc).

Factors affecting health include physical factors, social status, cultural issues,
economic situation and gender environment.

SECTION 1 – INTRODUCTION – REVISED SEPTEMBER 2009


3
Circles of influence (individual in centre, group / family, community, policies, social /
economic).
Circles of influence

Group/family Community

Individual

Policies Social/Economic

Primary health care goals for diabetes


Each health service will need to assess its situation and work out individual goals. The
following are general goals which you may wish to consider when working with
individuals to establish personal goals.

Promote health

Promoting exercise, high fibre, low saturated fat, low added sugar eating as the
‘normal’ pattern for the health of all Australians.

Prevent illness

Encourage people to find out whether they are at risk of developing type 2 diabetes, eg
do they have a family history, are they overweight or over 40 years.

Minimise disability

For those who have diabetes (any type), have regular checks with the appropriate
health professionals for early detection and prevention of complications.

Equality of access

Ensure equity of access of people with all types of diabetes.

Equity of outcome

Targeting population(s) who are most at risk of developing type 2 diabetes (eg
Aboriginal).

Overcoming isolation

Provide opportunities for people with diabetes to interact and network with others, eg
support groups.

Disease control

Provide information for all people with diabetes about the range of services /
treatments available.
SECTION 1 – INTRODUCTION – REVISED SEPTEMBER 2009
4
The process of evaluation
These are some of the steps to be considered in evaluation:

• formal and informal feedback from the participants


• has the program reached its target audience
• has the implementation followed the planning - was planning adequate - was
implementation adequate
• check each aspect of the program - were there any aspects which indicate a
change of strategy
• did the program meet all its goals
• was the program flexible - did it change to meet people’s needs
• relationships between participants and professionals - was power shared?

‘Evaluating the work of your agency or team is a vital process to prevent it wandering
from its original goals or away from addressing the needs of the community you are
working for. Informal evaluation can be incorporated into the normal work of the
agency or team, for example, through discussion and reflection at weekly staff
meetings. It will be necessary, however, for the agency or team to take time out to
evaluate itself more formally, and to involve the community in this process. This can
be done by setting time aside specifically for evaluation and strategic planning.’3

The health care team


A team of health care professionals is available to assist people with diabetes to deal
with specific problems as they arise. The following health professionals may be
included in the care of people with diabetes.

• Aboriginal health worker • Occupational therapist


• Community health nurse • Ophthalmologist
• Diabetes educator • Optometrist
• Dietitian • Paediatrician
• District nurse • Pharmacist
• Endocrinologist • Physiotherapist
• Exercise Physiologist • Podiatrist
• General nurse • Psychiatrist
• General practitioner • Psychologist
• General practice nurse • Social worker
• Obstetrician • Surgeon

Remember the most important member of the team is the person with diabetes.

Diabetes mellitus is one disorder where most of the care is provided by the individual
themselves. The individual’s knowledge, skills and attitude for behavioural change are
the essential ingredients of optimal self-care.

To improve health and the quality of life, we, the health professionals involved in
diabetes care, have a responsibility to provide ongoing expertise, information and
psychological support to individuals with diabetes.

SECTION 1 – INTRODUCTION – REVISED SEPTEMBER 2009


5
References

1. South Australian Community Health Association and Primary Health Care Training Project (1992)
The changing face of health - A primary health care casebook. South Australian Health
Commission, Adelaide.

2. World Health Organisation (1978) Report of the International Conference on primary health care
- Alma-Ata, USSR. World Health Organisation, Geneva.

3. Wass A (2000) Promoting health: The primary health care approach. Harcourt Australia,
Marrickville.

SECTION 1 – INTRODUCTION – REVISED SEPTEMBER 2009


6
SECTION 2
Understanding diabetes
What is diabetes?
Diabetes mellitus is a condition where high blood glucose levels (hyperglycaemia)
occur. The normal range for blood glucose in a person who does not have diabetes is
between 3 and 8mmol/L. This range is maintained during the individual’s day to day
activities.

Glucose is needed by the body for energy and is obtained from carbohydrate foods
such as starches and sugars. The glucose is transported from the gut through the
portal system to the body. Glucose that is not immediately used is transformed and
stored in the liver. The regulation and storage of glucose is controlled by the hormone
insulin.

Insulin is produced by the beta cells of the pancreas in response to a rise in blood
glucose concentration. The hormone insulin is responsible for the uptake, storage and
use of glucose by the body cells, thus supplying available energy for use in the body.
Without sufficient insulin there will be impaired metabolism, not only of carbohydrates,
but of protein and fats as well.

Classification of diabetes
The different types of diabetes have different causes and clinical presentation. The
common feature for all types of diabetes is hyperglycaemia.

Primary diabetes

Type 1: An absolute deficiency of insulin. The exact trigger is unknown but is an


autoimmune response. Intensive insulin therapy is required for survival.

Type 2: A combination of insulin resistance (a resistance by the cells of


the body to the action of insulin, thereby reducing the effectiveness of insulin) and
insulin deficiency. Type 2 diabetes is a progressive disease that requires ongoing
monitoring. Most people will need to take oral anti-diabetic medication and eventually
many will require insulin.1

Gestational diabetes

Diabetes occurring for the first time during pregnancy and often lasting only for the
duration of the pregnancy. Progression of type 2 diabetes later in life will occur in
5–50% of women with gestational diabetes mellitus (GDM). Around 17% of Australian
women with GDM develop type 2 diabetes within 10 years, and up to 50% within 30
years.2

Secondary diabetes

Diabetes as a result of another disorder, for example: pancreatic disease, endocrine


disorder, drugs, chemicals or other stresses.

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


1
Features of type 1 and type 2 diabetes
Type 1 Type 2
Characteristics
10 – 15% of all people with diabetes 85-90% of all people with diabetes

no insulin produced insulin resistance and insulin deficiency

some family history usually family history

due to damage to beta cells because of age, overweight / overwaist, lifestyle


auto immune response factors

generally occurs in younger people under usually occurs in older people over 40
40 years but may occur at any age years, may occur at any age

Onset
rapid onset (weeks / months) gradual onset, often no symptoms
(months or years)

ketonuria often present (due to lack of ketonuria not present as some insulin
insulin) still being produced

may present with existing chronic


complications

Treatment

requires intensive insulin therapy either by initially life style education, and will
multiple injections or insulin pump require oral medication and/or insulin
therapy after a few years

NB Type 2 diabetes in children

Type 2 diabetes is rapidly increasing in children and adolescents, accounting for


3
approximately 5 percent of diabetes in this age group in Australia.

Type 2 diabetes in children presents in a similar way as in adults eg there is insulin


deficiency and resistance. Often children have a strong family history (present in over
80% of cases) and predominately they are obese. Indigenous and some ethnic groups
are at high risk such as Aboriginal and Torres Strait Islanders. Whilst type 2 diabetes
is often asymptomatic it may present with ketosis and even mild to moderate
ketoacidosis in this group. Type 2 diabetes may have a prolonged asymptomatic
phase and so screening for complications should start at diagnosis. Children are at
risk for macrovascular complications due to the underlying metabolic syndrome
associated with type 2 diabetes.3

The treatment is similar to the approach with adults eg lifestyle and medication.

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


2
Prevalence of diabetes
Results of the AusDiab Study released in April 2001, showed that 1 in 4 Australians
have a problem with glucose metabolism. The study identified that 3.8% of adults (25
years plus) had diagnosed diabetes, 3.8% had undiagnosed diabetes and 16.3% had
either impaired glucose tolerance or impaired fasting glucose.4

Diagnosed 3.8%
Undiagnosed 3.8%
IGT of IFG 16.3%
Total 23.9%

The prevalence of type 2 diabetes rises steeply with age and is estimated at:

25 – 34 years 0.3%
35 – 34 years 2.5%
45 – 54 years 6.2%
55 – 64 years 13.1%
65 – 74 years 18.6%
75 years plus 23.6%

The prevalence of childhood diabetes (type 1) is estimated at:

0-14 years old 22 per 100,000 people


15-24 yrs old 15 per 100,000 people
Over 40 years 5 per 100,000

The latest report published by the Australian Institute of Health and Welfare shows that
5
the rate of type 1 diabetes is increasing by 3% per year.

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


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Clinical presentation
The classic symptoms of diabetes mellitus include:

• polyuria
• polydipsia
• tiredness / lethargy.

The symptoms of diabetes vary from individual to individual and in relation to the level
of hyperglycaemia. Some people with type 2 diabetes may also be asymptomatic.
Symptoms are similar in each type of diabetes, however, intensity and onset varies.

The following terms describe associated symptoms of hyperglycaemia.

Glycosuria – the presence of glucose in the urine. When blood glucose concentration
exceeds the renal threshold of approximately 10mmol/L in a young person (in older
people it can be higher) glucose is excreted in the urine and is detected with a reagent
testing strip.

Polyuria – excessive urination. Glucose is osmotically active and requires water for
excretion. In uncontrolled diabetes, the filtered glucose `pulls’ large quantities of water
with it which leads to increased urine production.

Polydipsia – excessive drinking. Polyuria causes loss of water, resulting in


dehydration. Dehydration triggers thirst in the person in an effort to replace lost water.

Polyphagia – excessive eating of food. Without insulin, glucose is unavailable to the


cells for energy. The body perceives a state of `starvation’ and the appetite is
increased in an effort to gain enough food for energy. The body also loses nutrients
through the urine (glycosuria, ketonuria).

Weight Loss – in type 1 diabetes, protein and fat stores are broken down to be used
for energy. Ketones are produced and excreted in the urine.

Ketonuria – in type 1 diabetes there may be the presence of ketones in the urine or
blood. When there is not enough insulin to utilise the glucose, fat stores are broken
down for energy, ketones are produced. Moderate to large ketones found in urine or
blood may indicate ketoacidosis, a life-threatening emergency situation.

Tiredness – caused by the inability to utilise glucose, resulting in insufficient energy


supply.

Skin and genital infections – hyperglycaemia results in a lowered resistance to


infection, glycosuria results in thrush (monilia / candida infection), pruritus vulvae or
balanitis.

Blurred vision – due to change in the shape of the lens of the eye because of
hyperglycaemia. Occasionally this is the main symptom and may last several weeks
while blood glucose is being stabilised.

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


4
Diagnosis and management
Type 2 diabetes
Risk factors and screening

Testing for undiagnosed type 2 diabetes is recommended for the following high risk
Individuals:6

• people with impaired glucose tolerance or impaired fasting glucose


• Aboriginal and Torres Strait Islanders aged 35 and over
• certain high risk non-English speaking background groups aged 35 and over
(specifically Pacific Islander people, people from the Indian subcontinent or of
Chinese origin)
• people aged 45 and over who have either or both of the following risk factors
- obesity (BMI ≤ 30 )
- hypertension
• all people with clinical cardiovascular disease (myocardial infarction, angina or
stroke)
• women with polycystic ovary syndrome who are obese.

Individuals presenting the following risk factors are also considered to be at high risk of
having undiagnosed type 2 diabetes:

• women with previous gestational diabetes


• people aged 55 and over
• people aged 45 and over who have a first degree relative with type 2 diabetes.

Diagnosis

Diagnosis is based on plasma glucose measurements in conjunction with clinical


assessment.6, 7

Diagnosis is made in one of the following ways but each must be confirmed on a
subsequent day unless unequivocal hyperglycaemia with obvious symptoms are
present.

1. Symptoms of diabetes and a random (non-fasting) plasma glucose >11mmol/L


(random means any time of day regardless of last meal).

2. Fasting plasma glucose >7.0mmol/L.

3. 2-hour plasma glucose >11mmol/L during an oral glucose tolerance test (OGTT).

The OGTT (Appendix 1) is unnecessary to diagnose diabetes in people with an


unequivocally elevated fasting or random plasma glucose. An OGTT should be
performed in a person with an equivocal result. (See Figure 1).

The test is carried out after an overnight fast, following three days of adequate
carbohydrate intake (greater than 150g per day). A 75g load of oral glucose is given
and the diagnosis of diabetes can be made if venous plasma glucose level fasting is
>7.0mmol/L or 2 hour post glucose load is >11mmol/L.

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


5
Figure 1

Glucose levels – venous plasma: mmol/L

F: 5.5-6.9 F: ≥7.0
F or R:<5.5 R: 5.5-11.0 R: ≥11.1

Diabetes unlikely Diabetes uncertain Diabetes likely

Re-test yearly if
high risk Oral glucose tolerance test

3 yearly if
increased risk 2hr glucose levels

<7.8 7.8-11.0 ≥11.1

Diabetes unlikely Diabetes likely

F = Fasting
R = Random Impaired glucose tolerance

A person with type 2 diabetes may first present with long term complications - eg
diabetic retinopathy, neuropathy, coronary artery disease, peripheral vascular disease
and / or cataracts (refer Long term complications – Section 12).

Routine examination may incidentally detect glycosuria and / or hyperglycaemia – eg


during pregnancy or as a result of community screening programs.

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


6
Ongoing management principles for people with type 2 diabetes

A team approach is essential for the successful management of diabetes, with the
active participation of the person with diabetes and if appropriate including family
members.

Ideal management involves:

• active involvement of the person with diabetes and their family members
• appropriate treatment plan
• appropriate nutrition and weight control
• appropriate exercise / activity program
• advice for maintaining a healthy lifestyle eg stress management, avoiding
smoking
• appropriate safe use of pharmaceuticals as required (oral agents and / or
insulin).

The aims of management are to:

• restore the altered metabolism of the person with diabetes and maintain blood
glucose levels within the normal range
• identify and reduce risk factors of diabetes related complications
• prevent or delay progression of the short and long term complications
• empower the person to self manage their own diabetes and restore the individual
with diabetes to as independent a lifestyle as possible
• provide ongoing management, support and resources.

Principles of medical management:

• people with type 2 diabetes usually progress from lifestyle alone, tablets and then
onto insulin8
• type 2 diabetes is a progressive disease which needs progressive increases in
treatment to maintain appropriate HbA1c levels
• oral medications can be combined with insulin.

See Medication - Section 10 for medication pathway in type 2 diabetes.

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


7
Type 1 diabetes
Diagnosis

Type 1 diabetes can be diagnosed if the characteristic symptoms and signs are
present and the fasting venous plasma glucose concentration is greater than or equal
to 7.0mmol/L, and / or the random venous plasma glucose concentration taken at least
2 hours after eating is greater than or equal to 11.1mmol/L. An oral glucose tolerance
test (OGTT) is rarely indicated in diagnosis of type 1 diabetes in childhood and
3
adolescence. A child or adolescent may present with diabetic ketoacidosis (refer
Unstable diabetes – Section 7).

The ‘honeymoon period’ in type 1 diabetes.

The honeymoon period is the time between diagnosis and complete damage to
the beta cells of the pancreas. Initially the person’s pancreas is still producing
some insulin but in decreasing amounts. The person may go from not needing
much insulin to needing some insulin, to being totally dependent on insulin
within a year.

How long the ‘honeymoon period’ lasts varies from person to person but people with
type 1 diabetes will usually be totally dependent on insulin within one year.

Ongoing management principles (refer Children and adolescents – Section 14)

• Children and adolescents with type 1 diabetes should have access to care by a
multidisciplinary team trained in childhood diabetes.
• The older child and the family should be recognised as being part of the
management team.
• Education from a credentialled diabetes educator (where possible) should be part
of the management of type 1 diabetes.
• Education should be adapted to each individual’s age, maturity, stage of
diabetes, lifestyle and culture.
• After the initial period of diagnosis and education (when frequent contact may be
required), the child should be regularly reviewed throughout the year. This should
be no less than 3-4 times per year), including one major annual review (paying
particular attention to growth, blood pressure, puberty, associated conditions,
nutrition and complications) with the multidisciplinary team.
• In rural and remote areas children with diabetes may be successfully cared for by
a local paediatrician / physician with training and experience in paediatric
diabetes, access to resources, support and advice from a tertiary centre diabetes
team.
• The transition from a paediatric to an adult service for the adolescent with
diabetes is often difficult. Transfer to an adult service should be comprehensive
and include a preparation phase and evaluation phase.3

Principles of medical management

• people with type 1 diabetes are dependent on insulin for survival


• insulin must not be stopped under any circumstances
• insulin is not normally used in combination with any other hypoglycaemic agents
• metformin is sometimes used for people with type 1 diabetes who have insulin
resistance but the evidence for its effectiveness is limited.3

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


8
Gestational diabetes
Risk factors and screening
The Australasian Diabetes in Pregnancy Society (ADIPS) recommends that screening
for gestational diabetes (GDM) should be considered in all pregnant women. Risk
factors for GDM include.9
• glycosuria;
• age over 30 years;
• obesity;
• family history of diabetes;
• past history of GDM or glucose intolerance;
• previous adverse pregnancy outcome; and
• belonging to an ethnic group with a high risk for GDM (Australian Indigenous,
Polynesian and South Asian [Indian] groups; Middle Eastern and other Asian
groups).

Diagnosis

GDM is diagnosed by OGTT (refer Pregnancy – Section 13)

Ongoing management principles (refer Pregnancy – Section 13)

• A team approach is recommended for managing women with GDM and, if


necessary a virtual team could be used.
• The large health services teams would usually comprise an obstetrician, diabetes
physician, a diabetes educator (diabetes midwifery educator), dietitian, midwife
and paediatrician. In country areas management by an obstetrician or obstetric
general practitioner knowledgeable in GDM management in collaboration with a
dietitian, diabetes educator or midwife, is acceptable.9
• Insulin therapy is commenced if fasting blood glucose levels exceed 5.5mmol/L
or 2 hour post-prandial levels exceed 7mmol/L on two or more occasions in one
week.
• Women need to receive appropriate education and support throughout their
pregnancy as well as follow up screening and pre-conception counselling.

Follow up annual screening and pre-conception screening

• Women should be screened for diabetes at 6 weeks post-delivery and 12


monthly thereafter.
• Women need to be informed about the risks for type 2 diabetes in the future and
the need for preconception screening (refer Pregnancy – Section 13).

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


9
Appendix 1
The oral glucose tolerance test

Indications
1. To confirm diabetes when fasting blood tests are inconclusive.

2. Screening for gestational diabetes (refer Pregnancy – Section 13).

Considerations
• Recent illness may give false glucose tolerance test results, therefore it is
preferable to perform the test after at least 2 weeks of good health.

• Adequate dietary carbohydrate for the 3 days prior to the test (≏ 150g/day). In
most cases this means that the person should have their usual diet.

• Certain drugs, eg hormones, diuretics or steroids, may influence the results,


therefore it is important to record any such drugs on the request form.

• This test is ordered by a doctor.

Preparation
• The test is performed in the morning, after a fast of at least 8 hours (but not
more than 16 hours).

• Water is permitted throughout this period and during the test.

• The person is advised to rest for 30 minutes before and for the duration of the
test. (Sitting in a chair is sufficient).

• No smoking for at least one hour before the test or during the test.

Glucose (75g) in solution is used eg Glucoscan solution.

The dose for children is 7ml of solution (1.84g of glucose) per kg body weight, up to a
maximum of 285ml (75g).

The dose for adults is 75g of glucose in solution.

Procedure
Ensure appropriate pathology request form is completed by a medical officer.
Collect venous blood sample immediately before glucose drink then at 2 hours after
glucose drink.

Note times for fasting and 2 hr bloods, and label bottles correctly.

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


10
References
1. National Prescribing Service (2008) Managing hyperglycaemia in type 2
diabetes - Volume 56. National Prescribing Service Newsletter. [Cited 18 May
2009]; Available from:
http://www.nps.org.au/health_professionals/publications/nps_news/current/nps_
news_56/managing_hyperglycaemia_in_type_2_diabetes

2. Lee A, Hiscock R, Wein P, Walker S, and Permezel M (2007) Gestational


diabetes mellitus: Clinical predictors and long-term risk of developing type 2
diabetes. Diabetes Care, 30(4): p878–883.

3. Australasian Paediatric Endocrine Group (2005) Clinical practice guidelines:


Type 1 diabetes in children and adolescents. Department of Health and Ageing,
Canberra.

4. Dunstan D, Zimmet P, Welborm T, Sicree R, Armstrong T, Atkins R, and et al


(2001) Australian diabetes obesity and lifestyle study (AusDiab), International
Diabetes Institute, Melbourne.

5. Australian Institute of Health and Welfare (2008) Incidence of type 1 diabetes in


Australia: First results. Cat. no. CVD 42, Australian Institute of Health and
Welfare, Canberra.

6. National Health & Medical Research Council (2001) Part 3: Case detection and
diagnosis. Evidence based guidelines for case detection and diagnosis of type
2 diabetes. December, NHMRC, Canberra.

7. Harris P, Mann L, Marshall P, Phillips P, and Webster C (2008/09) Diabetes


management in general practice: Guidelines for type 2 diabetes. Royal
Australian College of General Practitioners and Diabetes Australia, Canberra.

8. Nathan D, Buse J B, Davidson M B, Ferrannini E, Holman R R, Sherwin R, and


Zinman B (2009) Medical management of hyperglycemia in type 2 diabetes: A
consensus algorithm for the initiation and adjustment of therapy. Diabetes
Care, 32(1): p193-203.

9. Hoffman L, Nolan C, Wilson J D, Oats J J, and Simmons D (1998) Gestational


diabetes mellitus management guidelines. Medical Journal of Australia. 169
p93-97. 18 June 2009. Available from:
http://www.mja.com.au/public/issues/jul20/hoffman/hoffman.html

SECTION 2 – UNDERSTANDING DIABETES – REVISED SEPTEMBER 2009


11
SECTION 3
Diabetes education and support
Introduction
The impact of chronic disease and the growing awareness of the role played by people
with chronic conditions in determining their own health outcomes has led to greater
awareness of the role of self management in chronic disease. Similarly, the need to
support people with chronic conditions to acquire self management skills and the
confidence to apply theses skills in everyday living has also led to the identification and
incorporation of self management support and education in a range of chronic disease
models including the National Chronic Disease Strategy1 and the National Service
Improvement Framework for Diabetes.2

Unlike acute medical conditions, chronic conditions are ongoing, with health outcomes
and quality of life dependent on client self management and decision making, and the
availability of ongoing (versus short term) clinical care and support services. Client-
centred approaches in chronic disease management place the person with the
condition as the ‘expert’ rather than the health professional. This does not negate the
need for expert or best practice clinical management but recognises that the person
with the condition has the absolute power of veto over even the most efficacious
clinical management plan.

Diabetes has been considered as one of the most complex of the chronic diseases,
requiring the person with diabetes to juggle a range of daily clinical and lifestyle tasks
in order to avoid the short and long term complications of diabetes. Diabetes self
management education (DSME) aims to build the person with diabetes as an active
member of their diabetes team and ‘to improve health status by empowering the
person with diabetes to;

• acquire knowledge (what to do)


• acquire skills (how to do it)
• develop confidence and motivation to perform appropriate self care behaviours
(want to do it)
• develop problem solving and coping skills to overcome barriers to self care
(can do it).3

The role of health care providers is to support people with diabetes along this path by
providing self management education and support, enabling them to master the tasks
required for effective self care and to become an active participant in their diabetes
management.

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Goals and outcomes for diabetes education
The report Outcomes and Indicators for Diabetes Education – A National Consensus
4
Position provides a framework for the design and evaluation of diabetes education
programs.

Three overarching goals for diabetes education were identified in this report that
resulted from a review of relevant literature, survey of service providers, extensive
consultation with consumers, service providers and policy makers and a national
stakeholder forum:

• optimal adjustment to living with diabetes


• optimal physical (health) outcomes
• optimal (public and personal) cost effectiveness.

The outcomes associated with the attainment of these goals were identified as:

• knowledge / understanding (including the application of knowledge)


• self management
• self determination
• psychological adjustment
• clinical outcomes
• cost effectiveness.

The above outcomes were defined as the results of diabetes education. Indicator
areas were identified for each outcome. Indicators are defined in the report as the
units of information that can measure progress towards achievement of the result.

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Chronic disease self management and diabetes self
care behaviours
There are two widely accepted models for generic chronic disease self management
5
support. The chronic disease education models arising from Stanford University and
6
the Flinders Human Behaviour & Health Research Unit identify common tasks that a
person needs to achieve in order to successfully manage a chronic condition.

Flinders Human Behaviour & Health


Stanford University
Research Unit
• recognising and responding to • know about the condition and
symptoms various treatment options
• using medications • be actively involved in decision
• managing acute episodes and making in relation to treatment and
emergencies management of the condition
• maintaining good nutrition • follow the treatment plan developed
• maintaining adequate physical with health care providers
activity • monitor symptoms and take
• not smoking appropriate action to manage and
• using relaxation and stress reducing cope with symptoms
techniques • manage the physical, emotional and
• interacting appropriately with health social impact of the condition on
care providers their life
• seeking information and using • adopt a lifestyle that promotes
community resources health and does not worsen
• adapting work and other role symptoms.
functions
• communicating with significant
others
• managing negative emotions and
psychological response to illness

The Stanford Model is underpinned by self efficacy theory which is premised on the
following: belief in one’s ability to perform tasks is a good predictor of motivation and
behaviour; self efficacy can be enhanced through skills mastery, goal attainment,
modelling and social persuasion; improved self efficacy leads to improved behaviour,
motivation, thinking patterns and emotional well being. The Flinders Model also
identifies the Transtheoretical Model as a useful model to guide health professional
interventions which should be characterised by collaborative goal definition; targeting,
goal setting and planning; training and support for individuals to change; active and
sustained follow-up. The Stanford Model focuses on peer leadership and generic skill
development while the Flinders Model is clinician led and is designed to be integrated
with medical management.

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3
The self management tasks identified by these self management models are
congruent with the self care behaviours identified in a technical review undertaken by
American Association of Diabetes Educators (AADE) as being key behaviours for
effective diabetes self management.3

AADE Diabetes Self Care Behaviours


Healthy eating
Being active
Monitoring
Taking medication
Problem solving
Healthy coping
Reducing risks

With permission from the AADE, the Australian Diabetes Educators Association
(ADEA) has adopted the AADE self care behaviours and published them in Diabetes
Self Care – the 7 Steps to Success.7

The self care behaviours provide an easily understood framework and a common
language for people with diabetes and diabetes educators to discuss health behaviours
and their associated risks and benefits.

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Health behaviour and health education theory
Health behaviour and health education theories provide frameworks in which to
consider why knowledge may not be translated into action, why people may or may not
adhere to treatment recommendations and strategies that can be utilised to support
behaviour change. The Outcomes and Indicators Framework identified self
management and self determination as two outcome areas most impacted on by
diabetes education, after knowledge and understanding. The following theories
provide insight into these concepts and practical strategies to achieve these outcomes.

The Health Belief Model8 identifies that in order to adopt a behaviour (eg engage in
self care practices), a person must believe they are at risk of an adverse event (eg
diabetes complications), that the consequences of the event are severe and that the
event can be avoided by a particular treatment or engaging in a particular behaviour.
The likelihood of a person adopting the behaviour depends on how they perceive the
benefits as opposed to the barriers (or costs) of adopting the behaviour.

Self Determination Theory4 describes autonomous motivation versus controlled


motivation – doing something because one wants to do it versus being coerced to do it
(including health professional pressure or pressure to appease a health professional).
Autonomous motivation is associated with greater likelihood of success in adopting
and sustaining a behaviour and is associated with the absence of threats and external
rewards. An autonomous environment offers choice and the opportunity to discuss
and acknowledge feelings.

Self efficacy is one of the five domains of self determination identified in the Outcomes
and Indicators Framework. Self efficacy is also one of the key constructs of Social
Cognitive Theory.8 People develop self efficacy through experiencing success.
Social Cognitive Theory embodies the following strategies for health behaviour
interventions:

• providing opportunities for social support


• promoting capability and mastery through skills training
• modelling positive outcomes of healthy behaviours
• describing outcomes of change that are meaningful to individuals
• promoting individual regulation of goal directed behaviour through providing
opportunities for decision making, self monitoring, goal setting, problem solving
and intrinsic (self) reward
• providing opportunities for observational learning and opportunities to learn from
credible models (e.g., peers)
• supporting self initiated rewards / incentives
• approaching behaviour change in small steps and being specific about the
change
• providing training in problem solving and stress management, including the
opportunity to practice skills in challenging situations.

The Transtheoretical Model8 identifies the various stages of change that individuals
move through in order to adopt and maintain a behaviour: pre-contemplation;
contemplation; preparation; action; and maintenance. Other important concepts of the
Transtheoretical Model are decisional balance (the benefits versus the costs of
changing) and self efficacy (confidence that one can engage in healthy behaviours
across a range of challenging situations versus temptation to engage in unhealthy
behaviours). The Model also clearly identifies that different strategies are required for
each ‘stage of change’ and applying strategies suitable for one stage at another may
be counter productive. Given the range of self care behaviours that people with
diabetes are required to contemplate, it is important to recognise that individuals may
be at different stages of readiness for each one.
SECTION 3 – DIABETES EDUCATION AND SUPPORT - REVISED SEPTEMBER 2009
5
Delivery of diabetes education
9
A Cochrane Review examining the impact of group training in diabetes self care
concluded that group programs impacted favourably on a range of clinical diabetes
outcomes.
10
The NHMRC Patient Education Guideline for Type 2 Diabetes identifies the following:

• Both group and one-to-one diabetes client education provided on a face to face
basis have a positive impact on knowledge, lifestyle change and some aspects of
psychological outcomes.
• Interventions delivered over the longer term and those with regular reinforcement
are more effective than one-off or short term interventions.
• Multidisciplinary team delivery may provide better client outcomes.

Program aims
The overall aim of diabetes education is to support people with diabetes to acquire the
knowledge, skills and confidence to engage in effective diabetes self care practices
and be pro-active members of their diabetes care team.

The specific objectives could be to:

• enhance self efficacy


• facilitate the adoption of self care behaviours
• reduce diabetes related distress.

To be effective, education should be designed to build on the person’s own life skills
and behaviours. It should be sensitive and relevant to the individual’s needs, goals
and their perception of their illness. Changing behaviour will depend on the educator’s
approach to the person’s beliefs and the knowledge the person already has.

People change their behaviour when:

• they believe their illness will affect their lives


• they are confident that they can positively affect the outcome of their illness
• they believe the benefits outweigh the disadvantages of change
• they are confident that they can succeed
• it will help them achieve their own personal goals.

Recommendations and advice given to people should be based on careful


assessment of the individual’s needs and priorities. It is essential to have a broad
based knowledge about emotional, cultural and social circumstances. Achievable
goals need to be negotiated with the individual.

Educational programs should be planned bearing in mind that any illness and / or
admission to hospital can cause regression in an individual’s coping mechanisms and
emotional responses. This can cloud the person’s normal judgment and impede
learning.

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6
Teaching tips
• Use correct but simple terminology.
For example: `glucose’ is preferable to `sugar’. People can then relate
glucose not only to simple sugars but to carbohydrates as well.

• Having ascertained what people already know, work from that to new areas of
information.

• Having ascertained what worries or concerns the person, work to address these
as a priority.

• Work from simple to more complex information.


For example: teach the relationship between diet and blood glucose, before
expecting people to plan a menu.

• Relate what is currently being taught to the learner’s past experiences.


For example: `How did you feel yesterday?’
`I felt weak, I was sweaty and unsteady on my feet.’
`Your blood glucose level may have decreased, maybe
you had a hypo.’

• Encourage active participation in the teaching session.


For example: ask the person to describe how they might explain an aspect of
diabetes self-care to a friend or relative.

• Demonstrate skills - person performs skill with you / person performs skills
independently with your support / supervision.

• Referring to written step by step information that person may refer to if educator
is not present.

• Ask the person to recall information.


For example: `What happens to the glucose concentration in the blood of a
person with diabetes?’

• Repetition and reinforcement of information will aid learning.

• It is important to give positive feedback.


For example: say that they have done well to have retained information from a
previous session. Commend further reading undertaken on diabetes. Reinforce
the positive benefit of asking questions. This will give a sense of achievement,
direction and control.

• Use a variety of teaching methods.


For example: groups
one to one sessions
videos
drawings / diagrams
demonstration practice.

• Leave person with written handouts on subjects covered that will reinforce the
information given or skills taught.

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7
Evaluating teaching effectiveness
The questions the person asks will assist in showing what they have learnt.

Accept the person’s right not to follow any / all of the recommendations at the time of
teaching. They may take these up later.

People have individual health beliefs and values.

For some people, the need to avoid alcohol, cigarettes, fatty foods and excess calories
conflicts with perceived rights for social acceptance, pleasure, gratification and tension
reduction.

Therefore, some people need help in substituting one value for another. A new value
must be equally rewarding if the behaviour is to be changed.

For example: Not smelling of smoke when smoking is stopped.


Wearing new clothing after losing weight.
Feeling better when controlling blood glucose concentrations.
Being able to work better when exercising / reducing alcohol
intake.

Printed text should be provided to reinforce information given and should be specific to
the areas addressed.

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8
Evaluating an education program or service
Evaluation can be formative or summative. Formative evaluation focuses on the
processes of a program eg to find out if improvements or adjustments are needed to
achieve the educational outcomes. Evaluating processes is a way of monitoring the
implementation of the program. The summative evaluation is focused on assessing
what outcomes have been achieved from the program eg long term effects of a
program.

The first phase for evaluating a program or service can be done using a formative
approach as this will inform further adjustments/improvements to the education
program or service.

Formative evaluation

1. Service capacity measures


• total occasions of service

2. Service reach measures:


• number of referrals for education versus prevalence of type 2 diabetes for
a given geographical area
• number of referrals for education of gestational diabetes (GDM) versus
incidence of GDM for region.
3. Efficiency measures:
• number of people attending the initial group program versus numbers
attending further education sessions
• number of people who actually attended versus number booked in
• number referred to other health service providers.

4. Surveys
• can be used at the end of each session to get a general feel for how the
clients felt after the session. See Appendix 1 for an example of a
consumer satisfaction survey.

Summative evaluation

The report Outcomes and Indicators for Diabetes Education – A National Consensus
Position (Outcomes and Indicators Framework 2007) provides a framework for the
design and evaluation of diabetes education programs. Some of the outcomes related
to diabetes education from this report were identified as:
• knowledge / understanding (including the application of knowledge)
• self management
• self determination
• psychological adjustment
• clinical outcomes
Some of the tools that can be used pre and post education to assess outcomes can be
accessed via the Diabetes Outreach website www.diabetesoutreach.org.au.

SECTION 3 – DIABETES EDUCATION AND SUPPORT - REVISED SEPTEMBER 2009


9
Another method for evaluating outcomes can be though the client setting their own
personal goals. Explain that goals focus on:

• Actions – not attitudes (stop feeling worried)


• Something to do or start doing – not something to stop doing
• One action at a time
• Actions that individuals feel are achievable – even if they pose a bit of a
challenge
• Actions that are personally meaningful.

You can explain the SMART goal acronym, giving examples. Goals should be:

• Specific – exactly what will you do? eg I will walk for 30 minutes.
• Measurable – how much / how often are you going to do this? eg three
times a week.
• Achievable – how confident are you that you can do this? On a scale of 1
– 10, confidence should be rated at least 7, otherwise the goal may be
unattainable.
• Realistic – is this something that really can be done?
• Time frame – be specific about the time frame in which you are going to
achieve this eg I will achieve this by the end of next week.

See Appendix 2 for an example of a goal setting sheet.

We would like to acknowledge the contribution by Kaye Neylon to this section of the
Manual (2009) and her work on the 7 steps education and support program.

SECTION 3 – DIABETES EDUCATION AND SUPPORT - REVISED SEPTEMBER 2009


10
Appendix 1
SATISFACTION SURVEY

SERVICE ACCESS Yes No


Were you able to get an appointment as soon as you wanted?

Was the appointment at a venue and time that suited you?

RESPECT FOR YOUR WISHES Yes No


Did the diabetes team member(s) listen to what you had to say?

Were you involved in decisions about your diabetes education plan?

INFORMATION AND EDUCATION Yes No


Did you get as much information about your diabetes and its treatment as
you wanted?

Did the diabetes team member(s) listen to your questions?

Did the diabetes team member(s) explain things to you in a way you could
understand?

EMOTIONAL SUPPORT Yes No


Did you have any concerns that you wanted to discuss but did not?

Did you have confidence and trust in the diabetes team member(s)?

Did the diabetes team member(s) ask about how your living situation might
affect your health?

COORDINATION OF CARE Yes No


Were you clearly told about where and when your appointments would be?

Did you ever feel that members of the diabetes team did not talk to each
other enough about your care or situation?

Did you have any follow-up visits that you felt could have been avoided by
better coordination?

Did you feel the diabetes team member(s) communicated appropriately with
your doctor?

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11
Appendix 2

Being active
The purpose of this module is to:
• describe the relationship between physical activity, diabetes control and risk factors for the development of complications
• discuss physical activity and exercise recommendations for people with type 2 diabetes
• discuss precautions for people with type 2 diabetes engaging in exercise
• assist participants to develop a personal physical activity plan.

Participant learning outcomes


At the completion of this module, participants will be able to:
• identify personal benefits of physical activity and planned exercise in their diabetes management
• identify personal barriers to engaging in physical activity / exercise and use a problem solving approach to overcoming them
• state precautions to be taken by people with type 2 diabetes engaging in exercise.

Goal setting
S: Specific Specific, concrete goals to describe what the aim is.
M: Measurable Make sure there is an inbuilt measure so that it is clear when the goal has been accomplished.
A: Action oriented Make sure there is a description of how the goal will be achieved.
R: Realistic Set achievable and realistic goals that are geared towards success not failure.
T: Time-bound Goals that have a time frame can be measured and reset.

Being Active example


Eg I'm going to start exercising. This does not meet the criteria for a SMART goal
Instead try
‘I'm going to walk for 20 minutes on my lunch break three times a week for the next four weeks.’

This goal clearly states what the person will be doing, when they will be doing, and for how long. It seems realistic and after four weeks it can be evaluated
and changed as required. The aim of the goal is to take small steps that will lead to the larger overarching goal of ‘being active’. If the person wasn’t
reaching their goal then it is important to look at what the barriers are eg using the example above perhaps the person has been skipping their lunch break
because they have too much work to do. Whatever the reason, it's an indication that the goal needs adjusting. The person might decide to walk after
supper for twenty minutes instead. It is important to change the goals so that the person can succeed.

SECTION 3 – DIABETES EDUCATION AND SUPPORT - REVISED SEPTEMBER 2009


12
Being Active – Goal setting record

Date Client goal Barriers identified Confidence Follow up


(scale 1-10)
* Date Goal Achieved Outcome

*Note: if the person does not score 7 (on a scale of 1-10) then they should be encouraged to re-frame their goal

SECTION 3 – DIABETES EDUCATION AND SUPPORT - REVISED SEPTEMBER 2009


13
References
1. National Health Priority Action Council (2006) National chronic disease
strategy, Australian Government Department of Health & Ageing, Canberra.

2. National Health Priority Action Council (2006) National service improvement


framework for diabetes, Australian Government Department of Health &
Ageing, Canberra.

3. Mulcahy Kathryn, Maryniuk Melinda, Peeples Malinda, Peyrot Mark, Tomky


Donna, Weaver Todd, and Yarborough Peggy (2003) Diabetes self-
management education core outcomes measures. The Diabetes Educator,
29(5): p768-803.

4. Eigenmann C and Colagiuri R (2007) Outcomes and indicators for diabetes


education - a national consensus position. Diabetes Australia, Canberra.

5. Stanford University School of Medicine (2009) Chronic disease self-


management program. [Cited 29 April 2009]; Available from:
http://patienteducation.stanford.edu/programs/cdsmp.html

6. Flinders Human Behaviour & Health Research Unit (2006) The 'Flinders Model'
of chronic condition self-management. [Cited 29 April 2009]; Available from:
http://som.flinders.edu.au/FUSA/CCTU/self_management.htm

7. Australian Diabetes Educators Association (2008) Diabetes self care - the 7


steps to success. Australian Diabetes Educators Association, Canberra.

8. Glanz Karen, Rimer B K, and Lewis F M. eds (2002) Health behaviour and
health education. 3rd Edition. John Wiley & Sons, San Francisco.

9. Deakin T A, McShane C E, Cade J E, and Williams R D R R (2005) Group


based training for self-management strategies in people with type 2 diabetes
mellitus (Review). Cochrane Database of Systematic Reviews, (2)

10. National Health & Medical Research Council (2008) NHMRC Patient education
guidelines: DRAFT. NHMRC, Canberra.

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14
SECTION 4
Hospitalisation
People with diabetes can be admitted to hospital for a range of health problems.
Sometimes the admission is related to the chronic complications of diabetes and
sometimes the admission is not caused by diabetes. Examples of related conditions
include coronary artery disease, cerebrovascular accident, renal disease, or vascular
problems. Problems directly related to diabetes requiring hospitalisation include the
acute complications; diabetic ketoacidosis, non-ketotic hyperosmolar collapse / illness
and severe hypoglycaemia. Sometimes people are admitted for the initiation of insulin
therapy in special situations, eg insulin pump insertion, continuous blood glucose
monitoring. Whatever the reason for admission to hospital it is very important to
manage blood glucose for the best outcomes possible.

Section 4 consists of the following topic areas:

1. Admission procedures.
2. Diabetes management principles.
3. Peri-operative care.
4. Management for radiological procedures.
5. Inpatient diabetes management guidelines (where diabetes is a co-morbidity not
primary reason for admission).
6. Managing acute complications in hospital (hypoglycaemia, diabetic ketoacidosis
and hyperglycaemic hyperosmolar state.
7. Insulin pump therapy.

You may like to refer to the glossary and list of abbreviations contained at the back of
this section.

Admission procedure
The nursing assessment indicates the reason for admission, and should be clear if
diabetes is the reason for the admission or a co-morbidity.

Type of diabetes should be documented as either:

• type 1
• type 2
• type 2 diabetes – insulin requiring.

Assessment
Confidentiality of information and the person’s privacy must be maintained.

The interview process may be conducted formally or while admitting the person, ie
during observations, ward orientation or physical assessment.

• Relevant medical history, including hypoglycaemia unawareness, foot problem.


• Physical assessment, comprehensive head to toe assessment.
• Patient education and assessment of knowledge, skills and attitude, and
modification of self care action plans (Appendix 1).
• Discharge plan.

SECTION 4 – HOSPITALISATION – REVISED SEPTEMBER 2009


1
History – specific to diabetes
A comprehensive history provides health care providers with the information
needed to provide adequate care and education. The Queen Elizabeth
Hospital Assessment Standards have been used to underpin the following
1
recommendations.

Specific symptoms:

• altered vision (blurring)


• polyuria
• polydipsia / dry mouth / fruity breath
• polyphagia / abdominal pain
• weight loss / weight gain
• nocturia / frequency / burning on micturition / thrush
• malaise / fatigue
• neuropathic sensations in feet (burning).

Diabetes history:

• family history of diabetes / cardiac history (elevated BP / lipids)


• duration and type of diabetes (self and family members)
• ethnic group
• obstetric history of large babies / gestational diabetes
• current glycaemic control and self-management
• diabetes education – knowledge / skills / attitude – prior learning
• recent surgery or glucocorticosteroids, recent illness.

Identifying risks:

• hypoglycaemia risk (also hypoglycaemia unawareness)


• smoking
• foot risk status
• hyperglycaemia
• hypertension
• hyperlipidaemia
• alcohol intake
• activity levels.

Attitudes / cultural beliefs / socialisation / literacy

• all people with diabetes should have an opportunity to discuss their self
management issues with qualified health professionals.

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2
Physical assessment
Weight (kg) calculate body mass index which is weight in kilograms
and Height (m): divided by height in metres squared. Healthy range is equal to
or less than 25, suitable for use with both men and women from
age 18 years onwards.2
Waist <94cm for men
<80cm for women
Blood pressure lying and standing
Eyes visual aids used
changes in vision noted by person
date of last ophthalmological or optometry review
Feet sensation and circulation (conduct a foot risk assessment)
(see Footcare – Section 6).
skin integrity
interdigital problems (cracked or macerated skin)
abnormal bone structure of feet
date last seen by a podiatrist, if at all
Blood glucose aim for fasting or pre-meal, if random test done note time of last
meal
Urinalysis microalbumin
ketones
nitrites and / or cells / leucocytes
glucose

Self care
• Medications.
• Self administration of insulin.
• Hypoglycaemia action plan.
• Foot care.
• Sick day action plan.

Education (see Diabetes education – Section 3 and Appendix 1)


• Health maintenance knowledge deficits.
• Emergency care.
• Medication therapy.
• Impending procedures / surgery.

Negotiate a management and education plan to address the identified needs with the
individual, listing objectives and expected outcomes.

Referral options
• Diabetes educator.
• Dietitian.
• Or other relevant health professionals as deemed necessary, eg social worker,
psychologist, podiatrist, vascular nurse, eye department, aboriginal health
worker.

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3
Discharge planning
A planned discharge is vital. This should begin on admission to hospital.
Appropriate information for long term care should be supplied to the person with
diabetes and to family members. This will assist the person and family to continue
self-management after discharge.

Ensure the person is registered with the National Diabetes Services Scheme and has
adequate supplies of:

• syringes / pen needles


• monitoring equipment
• medication
• ensure a plan for access to supplies over public holidays and weekend breaks.

Ensure the person is aware of resources for ongoing supplies, eg Diabetes Australia,
National Diabetes Services Scheme (see Resources – Section 15).

Ensure appropriate outpatient appointments have been made, eg doctor, dietitian,


diabetes educator, podiatrist, ophthalmologist / optometrist.

Assess the ability of the person with diabetes and the family to cope at home
and within the community.

Is there a need for extra involvement of family or of community resources?

Are they aware of their long term medical needs, monitoring and liaison with their local
doctor?

Ensure the person is aware of the role of their local doctor. The general practitioner is
often the principal medical professional, in other instances there may be a `shared-
care’ arrangement between specialist, general practitioner and diabetes educator.

Regular follow up visits are encouraged and offer a great opportunity for the general
practitioner to get to know the person and explore the person’s understanding, fears
and concerns about diabetes.

Ensure the person is aware of where to seek assistance / advice for problems
and emergency treatment.

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4
Diabetes management principles
This section has been designed to provide information about the diabetes
management of patients where diabetes mellitus is a co-morbidity and not the primary
reason for admission. For information about acute complications of diabetes see page
18 of this section.

General management principles include:

• Blood glucose levels as close to normal as possible improves in-hospital


morbidity and mortality rates. Aim for target blood glucose levels (BGL)
3
5.0 - 10.0mmol/L.
• Never stop insulin in type 1 diabetes.
• Avoid routine use of sliding scale insulin - this destabilises diabetes in most
patients. Sliding scale insulin should only be used for patients who are fasting
and in limited circumstances.4
• Insulin regimens should target prospective / anticipated blood glucose levels
rather than react retrospectively to previous BGLs.4
• Avoid random use of short acting insulin in response to a single elevated BGL
unless patient is symptomatic, especially overnight. It is better to adjust the
overall regimen to prevent further rises in BGL values.4
• Adjust insulin daily to meet target BGL.
• If at any stage diabetes management is unclear or targets are not being met
contact general practitioner or diabetes specialist (eg endocrinologist) if
appropriate.4

Improving glycaemic control


Oral hypoglycaemic agents (OHA) (see table 1; page 15)
• Oral hypoglycaemic agents which are started or increased during hospitalisation
generally do not act quickly enough to control hyperglycaemia.
• Inpatients who have adequate diabetes control and there are no
contraindications (eg patient is not acutely sick or renal impairment) OHAs can
continue to be used.

Subcutaneous insulin
• Supplementary basal insulin (see table 2; page 15).
• Basal / bolus intensive insulin regimen (see table 3; page 16).
• Changing usual insulin regimen (see table 4; page 17).
• Sliding scale insulin for patients who are fasting (see table 5; page 17).

Intravenous insulin / glucose infusion


In many cases, an intravenous insulin / glucose infusion would be used if patient
requires insulin and is fasted for a prolonged period of time (more than 6 hours) or
patient is very unstable. An insulin / glucose infusion protocol must be followed.
Examples and advice around the use of these protocols can be accessed from
hospitals such as the Royal Adelaide Hospital (RAH), Lyell McEwin Hospital (LMH) and
Flinders Medical Centre (FMC).

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5
Monitoring
Blood glucose
• As a general guide BGL’s should be checked pre-meal (within 30 minutes pre-
meal) and 2100 hours for all patients who are not on IV insulin (0200 BGL should
4
be measured only if overnight hypoglycaemia is suspected).
• The frequency for monitoring BGL needs to be assessed regularly and any
changes documented. If not requiring adjustment to OHAs or insulin therapy
and BGLs in target for 24 hours consider reducing the number of BG tests per
day. If fasting BGL is out of target do more testing that day.
• Notify GP / MO if BGL is greater than 15mmol/L on 2 consecutive readings or
5
any BGL greater than 20mmol/L. (Refer to Unstable diabetes – Section 11 for
further information about hyperglycaemia).

Ketones
• Check for urinary or blood ketones in patients who are on insulin if BGL
persistently >15mmol/L or if the patient is very ill. 4
• If urine ketone levels 3+ or blood ketone levels are above 1.5 or ketoacidosis
suspected, contact the GP / MO or diabetes specialist (eg endocrinologist)
4
immediately.

Special circumstances
Enteral or parenteral nutrition
Patients with diabetes who are commenced on enteral or parenteral nutrition may need
significant adjustments to the type, doses and / or timing of their diabetes treatment.

• GP / MO to assess the most appropriate treatment regimen, preferably at the


commencement of enteral / parenteral feeding.
• Monitor BGLs 4 times per day – more frequently if appropriate.
• Remember to recommence an appropriate insulin / medication regimen when the
feeds are ceased and regular oral intake resumes.4

Patients on glucocorticoids
• Patients with diabetes who are commenced on prednisolone, dexamethasone or
other glucocorticoids will experience elevated BGLs.
• BGLs should be monitored 4 times per day and diabetes treatment intensified to
keep BGL in target.
• Remember to adjust diabetes treatment downwards as dose of steroids are
reduced and ceased.4

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6
Peri-operative care
Optimal blood glucose levels prior, during and after surgery will assist with wound
healing, reduce the risk of post-operative complications and shorten hospitalisation
period. Surgery tends to cause an increase in blood glucose levels. Therefore, an
increase in oral hypoglycaemic doses or insulin may be required for an extended
period eg while the person is under stress and relatively inactive post-operatively.

Pre-op care
Admission the day before surgery may be advisable to thoroughly assess and
establish monitoring and treatment plans in a person who:

• has type 1 (or type 2 diabetes, insulin requiring)


• is not well controlled
• is having major surgery and / or is likely to have nothing by mouth for a
prolonged period pre or post-operatively.

It is important that an anaesthetist be consulted as part of the patients pre-anaesthetic


work-up or that the patient’s management is discussed with the anaesthetist. Advice
regarding insulin regimens can be obtained by contacting an endocrinologist if
necessary (eg by phone if not available in person).

People with type 2 diabetes and on Metformin should have their Metformin ceased 48
hours prior to surgery. Sulphonylureas will need to be withheld on the day of surgery
(long acting sulphonylureas such as Glibenclamide may need previous night’s dose
withheld).

Management is determined by the results of blood glucose monitoring, and whether


the person is eating or not.

* ALL people with diabetes should have their blood glucose level checked within 1
hour prior to going to theatre. Report to the anaesthetist if the level is <5mmol/L or
>10mmol/L.

People with type 1 diabetes are particularly at risk from ketosis. Notify GP / MO if
ketones are present in blood or urine.

Before giving insulin to a person who is fasting make sure there is an IV glucose
infusion in place running at an appropriate rate.

Intra-op care
• The type of IV fluid given will depend on whether the person is receiving insulin
or not. Glucose infusion must be used if patient has received insulin prior to or
during surgery.
• Monitor BGL at least 2 hourly (1 hourly if IV insulin / glucose infusion in situ).

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7
Post-op care
Check blood glucose on arrival in recovery:

• then 4-6 hourly (or 1 hourly for continuous insulin / glucose infusion) for 24 hours
or until stable and eating
• then before meals.

All people with type 1 diabetes require a check for ketones:

• at least 8 hourly
• more frequently if blood glucose >15mmol/L, if the person is vomiting or is
generally unwell.

Before discharge, the person should be advised that their medication dosages should
return to pre-operative doses as they recover and become more active.

Recommence anticipated discharge regimen for at least 24 hours prior to


discharge.

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8
Management for radiological procedures
To minimise problems all people with diabetes should be booked into the earliest
possible appointment time.

The Radiology Department should be informed that the person has diabetes and of
their current medication.

Ensure the GP / MO has discussed the procedure with the person and obtained
consent (if applicable). Medication orders may be modified according to the type of
diabetes and medication, and the type and time of procedure. Reduction in dosages
requires discussion with the GP / MO and the person with diabetes.

Well controlled by diet or oral hypoglycaemic agents


The person should omit the morning dose of tablets if fasting is necessary.

Note: Metformin should be stoped 48 hours prior to preparation and ensure


serum creatinine level assessed before restarting Metformin.

Receiving insulin
If fasting, as per inpatient guidelines. Individual advice is essential based on type
of diabetes and insulin schedules.

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9
Precautionary measures
Blood glucose monitoring equipment should be accessible for use by an accredited
nurse in the Radiology Department.

Blood glucose should be checked before, during and after the procedure, if the person
feels unwell or complains of hypoglycaemic symptoms.

All people with diabetes should bring the following to the Radiology Department as a
precaution:

• quick carbohydrate eg sugar containing soft drink, glucose tablets - in case of a


hypoglycaemic episode
• Radiology Department should have a hypoglycaemia protocol, hypoglycaemia kit
and blood glucose meter on the emergency trolley for treatment of
hypoglycaemia.

Special precautions may be necessary for people having any radio contrast study
(even using low ionic agents). This includes angiography, CT scan with enhancement
intravenous pyelography.

Those at special risk of problems include those with:

• impaired renal function – creatinine clearance less than 30ml per minute.
In elderly people glomerular filtration rate (GFR) may be significantly reduced in
the presence of a marginally increased or normal plasma creatinine.

• dehydration or effective reduction in blood volume


For example, people with congestive cardiac failure, hypotension, septic shock or
intensive diuretic therapy.

• other nephrotoxic drugs or concomitant medications that may contribute


to decreasing GFR
This includes medications such as gentamicin, diuretics, angioconverting enzyme
inhibitors, angiotensin II receptor antagonists, non-steroidal anti-inflammatory
medications, cyclo-oxygenase 2 inhibitors, cyclosporin, vancomycin, tacrolimus,
amphotericin and others.

If radio contrast studies are necessary, the following precautions should be considered
by the GP / MO:

• stopping other medications several days before the procedure (eg diuretics, non-
steroidal anti-inflammatory drugs)
• hydration before, during and after the procedure using intravenous saline.

After the procedure


Once eating / drinking, recommence medications (except for Metformin – ensure
serum creatinine is normal prior to re-starting this).

It may be necessary to reduce the dose of insulin if food intake is reduced. Discuss
medication adjustment with the GP / MO or diabetes educator.

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10
Guidelines for inpatient diabetes
management
The following material is based on the Royal Adelaide Hospital (RAH) Inpatient
Guidelines (2008).4 The guidelines are not to be used for patients who are receiving
enteral or parenteral nutrition. They are not to be used for patients who have been
admitted with unstable diabetes as the primary diagnosis such as diabetic ketoacidosis
(DKA) or hyperglycaemic hyperosmolar state (HHS).

There are 5 guidelines to assist with practice:

1. Patient is eating (figure 1).


2. Patient is not eating or will fast >6 hours after a procedure (figure 2).
3. Patient is not eating but will eat within 6 hours of procedure (figure 3).
4. Hypoglycaemia (figure 4).

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11
Figure 1

Patient is eating

Diabetes target BGL


5-10mmol/L

EATING

3 regular meals
(NOT enteral or parenteral)

BGL in target majority of the time 1. BGL not in target


(within a 24 hour period):
OR
• Continue monitoring BGL
• Continue usual diabetes 2. Intercurrent illness / infection that
medication would benefit from tight control
• GP / MO to adjust doses if
hypoglycaemia occurs

Patient on oral Patient on insulin


hypoglycaemic agent
(OHA) or diet only

1. If BGL > than target for more than 24 hours 1. Increase patient’s usual
make incremental increases of OHA to the insulin dose (table 4)
maximum daily dose if required (table 1) OR 2. If BGL still not in target
2. Add supplementary insulin to OHA (table 2) within 24 hours use basal /
3. If BGL still above target use basal / bolus bolus insulin regimen
intensive insulin regimen (table 3) (table 3)

Recommence anticipated discharge regimen


for diabetes at least 24 hours prior to discharge

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12
Figure 2

Management of a patient who is NOT eating or will fast


for >6 hours after a procedure
1. Patient fasting for >6 hours after a procedure
OR
2. Patient nil orally for >6 hours & NOT on enteral or
parenteral nutrition

Schedule patient first on the list for procedures

Patient on oral Patient on insulin


hypoglycaemic
agent (OHA) or diet
Commence IV 5% glucose at
Withhold OHA on the morning 80-100mls/hr
of the procedure (metformin 48
hours prior)
Give half the usual morning
s/c insulin dose on arrival to
Check BGL prior to procedure unit on day of surgery

Commence s/c sliding scale


(table 5)
If BGL >10.0mmol/L If BGL
<10.0mmol/L
Check BGL 6 hourly #
Monitor BGL four
Commence IV 5%
times per day
glucose 80-100mls/hr Continue s/c sliding scale and
and s/c sliding scale 5% glucose IV until patient is
insulin * (table 5) If BGL eating solid food 3 times a
>10.0mmol/L

When eating regularly: Recommence discharge


• recommence OHA insulin regimen at least 24
OR hours pre-discharge
• basal / bolus if more
intensive treatment
required
* If you wish to use an insulin infusion and require a protocol please contact RAH, LMH or FMC.
# Refer to page 7 of this section for information on pre-op, intra-op and post-op BGL monitoring.

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13
Figure 3

Management of a patient who is FASTING but will eat


within 6 hours of procedure

Patient fasting but will recommence oral diet within 6 hours after a procedure

If patient for procedure, schedule patient first on the list

Patient on oral hypoglycaemic Patient on insulin


agent (OHA) or diet

Commence 5% glucose IV at
Withhold OHA on the morning 80-100ml/hr at 0600 or on
of the procedure (metformin admission to pre op area
48 hours prior)

Give half the usual morning s/c


Check BGL within 1 hour before insulin dose on arrival if day of
and after procedure surgery

After procedure Check post-op BGL.


If BGL >15.0mmol/L: If >10.0mmol/L GP / MO to
1. GP / MO to review and order review and order single dose
4 units of Actrapid of Actrapid (table 5)
2. Check BGL four times per
day.
3. If BGL remains above
target follow (figure 1) Recommence patient’s usual
insulin with the next meal

When eating regularly:


• recommence OHA OR If patient unable to eat or
• basal / bolus if more tolerate diet refer to
intensive treatment required information on patient fasting

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14
Table 1
Oral Hypoglycaemic Agents (OHA)
Name Tablet Strength Maximum daily dose
Metformin 500mg, 850mg, 1000mg 1000mg TDS if CrCI > 90mL/min
1000mg twice daily if CrCI 60-90mL/min
500mg twice daily if CrCI 30-60L/min
Metformin XR 500mg 2000mg night if CrCI>90mL/min
1000mg night if CrCI 30-60mL/min
Cease Metformin if CrCI < 30mL/min
Glibenclamide 5mg 10mg twice daily
Gliclazide MR 30mg 120mg morning
Glimepride 1mg, 2mg, 3mg, 4mg 4mg morning
Glipizide 5mg 20mg twice daily

Table 2

Supplementary basal insulin:

• Supplementary insulin can be added in conjunction with OHA in situations


where a temporary rise in BGL occurs: eg: patient on a short course of
corticosteroids OR patient has an infection

• Add Glargine 10-12 units at breakfast in addition to maximum OHA to provide a


temporary ‘top up’ for a few days. (Dose may need adjustment based on
response).

• Cease this additional dose of insulin when no longer required and/or prior to
discharge.

• Avoid random short acting insulin (particularly overnight) in response to a single


high BGL unless patient is symptomatic as this is more likely to cause
hypoglycaemia.

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15
Table 3

Basal / bolus intensive insulin regimen:

This is an intensive four times a day insulin regimen using short acting insulin with
each main meal and long acting analogue insulin at bed time.

Initial Dose Calculation:


0.3 to 0.5 units/kg as a total daily dose divided over four doses a day
OR
the patient’s previous total daily insulin dose divided over four doses a day.

Use approximately 2/3 of the total daily dose evenly split into 3 bolus doses; 1/3 of
total daily dose as basal bedtime dose
eg. 60kg patient - Total daily insulin dose calculated as 0.5units/kg/day = 30 units.
Split doses as:
Table 4
Breakfast 6 units NovoRapid
Lunch 6 units NovoRapid
Dinner 6 units NovoRapid
2100 12 units Glargine

OR
Patient previously on twice daily insulin of 40 units with breakfast and
25 units with dinner = 65 units daily.

Split doses as:


Breakfast 14 units NovoRapid
Lunch 14 units NovoRapid
Dinner 14 units NovoRapid
2100 24 units Glargine
Example: Based on 24 hour BGL profile: mmol/L
0600Adjustments:
Dose 1100 1600 2100
15.0 patient’s8.0
Review 24 hour BGL2.8 6.0
profile each afternoon and adjust insulin orders
prospectively.
Adjust each dose up or down by 10% of current dose as required.

Current order Adjusted order


Breakfast 6 units NovoRapid 6 units NovoRapid
Lunch 6 units NovoRapid 5 units NovoRapid (decrease)
Dinner 6 units NovoRapid 6 units NovoRapid
2100 12 units Glargine 14 units Glargine (increase)

As the BGL at 0600 was high, the bedtime dose of Glargine is increased to prevent
the next morning’s reading from being high again. As the patient had hypoglycaemic
episode at 1600, the lunch time insulin dose is reduced to prevent a similar
occurrence the next day. The other two doses (breakfast and dinner) were left
unchanged as the blood glucose responses to them (at 1100 and 2100) were in the
target range.

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16
Table 4

Changing usual insulin regimen:

• Review patient’s blood glucose profile over 24 hours.

• Alter insulin dose to prevent prospective blood glucose rise or fall (eg. If the
before breakfast BGL is high then increase the bedtime basal insulin dose to
prevent the next morning reading being high).

• Alter doses by 10% of the current dose.

Table 5

Sliding scale insulin for patients who are fasting - Subcutaneous only

• To be used ONLY in patients that are nil orally or fasting post-operatively.

• Commence 5% glucose infusion.

• Check BGL 6 hourly (not QID: best timing is 0600, 1200, 1800, 2400hrs).

• Administer Actrapid subcutaneously 6 hourly based on the blood glucose


level.

BGL (mmol/L) ACTRAPID insulin dose subcutaneous


0 - 5.0 No insulin
5.1 - 8.0 2 units
8.1 - 12.0 4 units
12.1 - 16.0 6 units
16.1 - 20.0 8 units
> 20.1 12 units and notify medical staff

• Review patient’s BGL daily and increase insulin doses by 1 unit at each level
of the sliding scale if target BGL not achieved.

• Recommence patient’s usual OHA or insulin regimen when oral intake is


adequate and regular.

(The doses above may be used to determine a single stat dose of insulin when that
is required).

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17
Managing acute complications
Further reading about hypoglycaemia, diabetic ketoacidosis and hyperglycaemic
hyperosmolar state can be found in Unstable diabetes – Section 11. The following
information focuses on managing these acute complications in a hospital setting or a
heath service.

Hypoglycaemia
A `hypo’ kit and the hypoglycaemia protocol should be assembled and placed in a
prominent position in every health service, ward or clinical area. The following is an
example of a hypo kit:

Hypoglycaemia Management Kit

Contents
Glucagon 1mg (IU) - currently supplied as GlucaGen Hypokit

Glucose Intravenous Infusion 25g in 50mL (50%)

1 roll of 2.5 cm micropore

1 x 20 mL syringe

1 x 21 G x ¾ inch winged infusion set

3 alcohol wipes

1 x InterLink vial access cannula

Glucose drink – currently supplied as Carbotest (50g per 300mL)

50 mL measure cup

2 x 2 portion Arnott’s biscuits

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18
Figure 4

Treatment of Hypoglycaemia
For patients on insulin or oral hypoglycaemia agents.

Indications: 1. Blood Glucose Level (BGL) less than 4.0mmol/L irrespective of


symptoms.
OR
2. Typical symptoms with moderately low BGL eg. 4.0–5.0mmol/L.

A Safe to Swallow Unsafe to swallow or Fasting Unconscious

(i.e. awake and (i.e. drowsy and / or uncooperative • Place in coma position
co-operative) or dysphagic) • Notify doctor immediately
• Give 1mg glucagon IM
• Notify doctor immediately • Doctor MUST review and
• Give 1mg glucagon IM may give 10 – 20ml IV
• If glucagon therapy is glucose 50%
unsuccessful then doctor
must review and may give IV
glucose
Go to B ↓ When safe to swallow go to B ↓ When safe to swallow go to B ↓

B • Give 100 ml of Carbotest (50g) orally


• Give 2 biscuits

C • Repeat BGL 15 minutes after initiation of treatment


• If BGL is less than 4.0mmol/L OR patient still has symptoms:
- If safe to swallow Repeat B ↑
- If unsafe to swallow Repeat A ↑
• If BGL greater than 4.0mmol/L AND symptoms are no longer present go to D↓

D • Repeat BGL in 1 hour


• If BGL is less than 4.0mmol/L OR patient has symptoms – Repeat B ↑
• If BGL is greater than 4.0mmol/L AND symptoms are no longer present
- Cease hypoglycaemia treatment
- Investigate cause

Important points
• Document events and treatment given.
• Notify doctor.
• Observe pulse and blood pressure with event.
• Post glucagon – vomiting is not uncommon.

If patient is receiving naso-gastric enteral feeding


• Administer 100 ml Carbotest via naso-gastric / enteral tube as per B.
• Recommence feeds at usual regime as per B.

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19
Length of observation
Be aware that the risk of having further hypoglycaemic events is increased in the hours
immediately following a hypo. For example older people on oral hypoglycaemic agents
(sulphonylureas) are at greater risk of recurrent hypoglycaemia and may need
intravenous infusions of dextrose 5%.

Patients should be monitored more closely for the next 12-24 hours. The BGL
frequency will depend on the severity of the hypo as well as the person’s individual risk
factors. If unsure, discuss with senior nursing staff or MO / GP. Observe person for at
least 24 hours and blood glucose levels monitored 2 hourly if needed, up to 12-24
hours depending on severity and duration of episode.

Document hypoglycaemic episode, action taken, outcome, monitoring progress and


possible cause.

Note: some form of fast acting, rapidly absorbed carbohydrate should be left with
the person.

Preventing hypoglycaemia

Identify Cause Education Staff Education

• missed / delayed meals / • check knowledge / • appropriate meals


snacks skills • appropriate snacks
• has vomited / insufficient • recognition • correct medication
intake • treatment • alert medical officer
• over medication • prevention of recurrent low
• increased activity • medical alert BGL’s
• weight loss without • to carry fast acting • accurate monitoring
medication CHO and has near results
• possible self-induced bedside • encourage patient to
• excessive alcohol report symptoms
• fasting for procedure • if patient receiving
• if patient receiving enteral enteral feeding,
feeding-tube blocked or consider IM glucagon
turned off 1mg prescribed as a
• extremes of weather standing order
temperature

For further assistance and education contact diabetes educator or dietitians.

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20
Diabetic ketoacidosis (DKA) and hyperglycaemic
hyperosmolar state (HHS)
The following information outlines the basic principles of managing diabetic
ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in hospital. For
more information about DKA or HHS refer to Unstable diabetes – Section 11. We
highly recommend you consult with a Diabetes Service experienced in managing
hyperglycaemic crises and ensure that there are local treatment protocols in place.

Diagnosis
The process of HHS usually evolves over several days or weeks, whereas the
evolution of an acute DKA episode is much shorter. HHS only occurs in type 2
diabetes. 6 DKA is associated with type 1 diabetes but has been known to occur in
people with type 2 diabetes in the presence of an acute event such as septicaemia,
7
respiratory collapse, myocardial infarction etc.

Clinical presentation
For both DKA and HHS the clinical picture consists usually of polyuria, polydipisa,
polyphagia, weight loss, vomiting, abdominal pain (only in DKA), dehydration,
weakness, altered level of consciousness or mental status, and finally coma. Other
physical findings may be poor skin turgor, Kussmaul respirations (in DKA),
tachycardia, hypotension, alteration in mental status, shock and ultimately coma (more
common in HHS).6

Laboratory tests
• plasma glucose
• blood urea nitrogen / creatinine
• serum ketones
• electrolytes (with calculated anion gap)
• osmolality
• urinalysis
• urine ketones by dipstick
• arterial blood gases
• complete blood count
• ECG
• bacterial cultures if infection suspected.

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21
Treatment
Successful treatment of both DKA and HHS requires correction of:

• dehydration
• hyperglycaemia
• electrolyte imbalances, and
• the identification of co-morbid precipitating events and frequent patient
monitoring is crucial.

Fluid therapy
The initial fluid therapy is aimed at expansion of the intravascular volume and
restoration of renal perfusion. Subsequent choice for fluid replacement depends on
the state of hydration, serum electrolyte levels and urine output.6

Insulin therapy
Unless the DKA is mild, intravenous insulin infusion is required.

Potassium
Even though total body potassium may be depleted, mild to moderate hyperkalaemia is
not uncommon in patients with DKA or HHS. Insulin therapy, correction of acidosis,
and volume expansion decrease serum potassium concentration. Close monitoring of
potassium is needed to identify hypokalaemia. Replacement potassium may be
needed. Refer to your hospital clinical guidelines.

Bicarbonate
Severe acidosis in DKA can lead to a number of adverse vascular effects. The use of
bicarbonate in DKA will depend on the pH level.

Complications
The most common complications of DKA and HHS includes hypoglycaemia from over
administration of insulin, hypokalaemia due to insulin administration and treatment of
acidosis with bicarbonate and hyperglycaemia secondary to interruption /
discontinuation of IV insulin therapy without adequate cover from subcutaneous insulin.
Cerebral oedema is rare but when it occurs it is frequently fatal.6

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22
Insulin pumps in an inpatient setting
Insulin pump therapy during an inpatient stay is possible as long as the person (or a
parent or spouse) and the endocrinologist are consulted and nursing staff are
confident to supervise and document the treatment. Hospital staff are not expected to
be experts in insulin pump therapy. It is important to seek assistance from the
diabetes team who is managing the persons pump therapy. It is essential that contact
be made with the person’s endocrinologist and / or their diabetes educator to develop
a plan for the persons admission and discharge. See Medication – Section 10 for
background information about insulin pump therapy.

Patient needs to be able to fully self manage the insulin pump


OR
MO needs to order alternative treatment if patient unable to self manage
the pump

If the person is unable to self manage the pump (eg simply too unwell, in pain,
impaired cognition or conscious state) it is recommended that the insulin pump is
stopped and replaced by an insulin infusion. The pump should not be removed until
there is another method of insulin replacement eg insulin infusion. If an insulin
infusion is not possible then multiple insulin injections will be required (long acting and
short acting insulin). Transition insulin dosing must be discussed with the patient’s
endocrinologist.

If a patient is self managing the pump it is essential that nurses oversee and record
blood glucose results, insulin doses and carbohydrate (CHO) intake. This includes
checking the bolus doses with the patient before it is administered. Ensure accurate
documentation at all times.

In a hospital setting the pump should not be turned off unless:

• For the treatment of severe hypoglycaemia (less than 2mmol/L). Following


treatment for hypoglycaemia and return to target blood glucose levels, the insulin
pump must be re-commenced.
• Showering and person is not hyperglycaemic. Ensure pump is turned back on
within 60 minutes.

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23
Management of the insulin pump and procedures
• The person should have recent information from their last endocrinologist visit
stating the person’s usual basal rates etc.
• The surgeon or medical practitioner should contact the person’s endocrinologist
well prior to the procedure to get specific advice regarding management of
insulin.
• The insulin pump should not be worn during an X-ray, CT or MRI.
• Ensure a detailed admission and discharge plan is put in place. Contact the
person’s diabetes educator or endocrinologist to develop this. They will give
advice about the management of diabetes during planned procedures. If the
procedure is unplanned (trauma, medical emergency) stop the pump and
commence an insulin infusion.
• If the person is having a general anaesthetic, the insulin pump must be
disconnected / removed and insulin must be administered via insulin infusion or
subcutaneous insulin injections.
• If the person is having a local anaesthetic an assessment of the persons ability to
self manage pre, during and post the procedure must be considered.
• Ensure a new line is put in place the day before the procedure (not the morning
of the procedure).
• Ensure cartridge volume is enough to carry the person through to a suitable time
frame (eg will not run out in the middle of the night).
• In case of pump failure or other emergency obtain contact phone numbers from
the patient including endocrinologist, family member, pump support person,
pump manufacturer. It is also important to write down any instructions that the
patient has been given regarding insulin doses should pump failure occur.

Caring for the insertion site and line change


To reduce the risk of infection and ensure line patency:

• Change the infusion line and site every three days.


• Ensure thorough handwashing before procedure.
• Protect the infusion line from contamination when disconnected.
• Some health services recommend the use of an anti-bacterial agent such as
Solu-I-V or Persist Plus to clean the area prior to insertion of the cannula.
• Document date and time of insertion site and line change in the case notes.

Potential problems to look for


• Subcutaneous site eg infection, allergies, tunnelling.
• Line kinks, leaks, clogs.
• Pump may have mechanical problems.
• There is an accelerated tendency for diabetic ketoacidosis (this can occur
within 3-6 hours of ceasing the pump as the insulin supply stops).

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24
Blood glucose monitoring and insulin pumps
Patients using insulin pump therapy are usually required to test their BGLs at least 6
times a day.

Blood glucose monitoring times can be:

• before breakfast, lunch and dinner (checks the basal rate)


• before bed (checks the basal rate)
• 2 hours after food (checks the meal bolus dose)
• between 2 and 3.00am (to detect overnight hypo / hyperglycaemia)
• test more frequently if the person is unwell.

Medical record documentation


The following table outlines what should be recorded.

What to record Where to record it


Basal rate medication chart
Meal bolus dose or carbohydrate insulin
medication chart
ratio
Correction bolus dose or insulin sensitivity
factor (the amount that 1 unit of insulin medication chart
lowers the individuals BGL in mmol/L)
Blood glucose levels fluid balance chart / diabetes record chart
Carbohydrate intake fluid balance chart / diabetes record chart
Ketonuria fluid balance chart / diabetes record chart

case notes and fluid balance chart /


Hypoglycaemia
diabetes record chart

case notes and fluid balance chart /


Hyperglycaemia
diabetes record chart

SECTION 4 – HOSPITALISATION – REVISED SEPTEMBER 2009


25
Management of hypoglycaemia
Causes of hypoglycaemia on an insulin pump
• The basal rate is too high.
• The carbohydrate:insulin ratio (or meal bolus) or insulin sensitivity factor or
correction bolus doses are too high,
• Accidentally giving too much insulin.
• Overestimated carbohydrate intake.
• Delaying a meal after a bolus dose.

Management of hypoglycaemia
If the person is conscious the hypo is treated as a person who does not have an insulin
pump (hypoglycaemia protocol – figure 4). However if the BGL is less than 2.0mmol/L
then the pump must be suspended / disconnected and hypoglycaemia protocol
followed (figure 4). After 30 minutes of pump suspension – and if the BGL is over
4mmol/L – recommence / connect the pump. If BGL remains less than 4mmol/L,
contact MO as person may need IV glucose.

Monitor
• Investigate cause.
• Document the event.
• After 30 minutes of pump suspension and if the BGL is over 4mmol/L
recommence / connect the pump. If BGL remains less than 4mmol/L, contact
MO.
• It is necessary to review insulin administration rates to ensure that
hypoglycaemia does not recur and blood glucose level remains within target
range.

SECTION 4 – HOSPITALISATION – REVISED SEPTEMBER 2009


26
Hyperglycaemia and pump therapy
The key points in the management of hyperglycaemia are the same for insulin pump
users as for those on insulin injections. However, it is important to realise that patients
on pumps are only using rapid acting insulin and do not have a background reservoir
of long acting insulin. This means that diabetic ketoacidosis can develop rapidly
and must be taken very seriously.8, 9

Potential causes of hyperglycaemia when using an insulin


pump
• Current illness / infection.
• The basal rate is too low.
• The carbohydrate:insulin ratio (meal bolus) or insulin sensitivity factor or
correction boluses are too low.
• Forgetting to give a meal bolus dose.
• Not counting carbohydrates correctly.
• Overdue to resite infusion set.
• No insulin in the cartridge.
• The cartridge is not sitting in the pump correctly.
• Connections are loose or not connected.
• Tubing or connection is leaking or kinked.
• Infusion set has been pulled out.
• Infection at the insertion site.
• The pump is in stop mode.
• The pump has failed (electronically).
• The pump has flat batteries.
• There is air in the cartridge or infusion set.

Current guidelines for the management of hyperglycaemia recommend that the pump
should not be used to correct hyperglycaemia when ketones are present.9-11

If the blood glucose level is greater than 15mmol/L and there are ketones in the urine
or blood but the person does not have DKA the following principles apply.8, 9

• Immediately check for problems with the pump or delivery system and infusion
site.
• Immediately contact the endocrinologist for instructions about insulin
requirements and need for insulin infusion.
• Give correction bolus via syringe.
• Replace the insulin in the pump, and the infusion set and re-site the cannula as
soon as possible.
• Recommence the insulin pump.
• Test the BGL hourly.
• Encourage the person to drink extra low joule fluids.

SECTION 4 – HOSPITALISATION – REVISED SEPTEMBER 2009


27
Abbreviations
MO: medical officer

GP: general practitioner

S/C: subcutaneous

IV: intravenous

BGL: blood glucose level

OHA: oral hypoglycaemic agent

DKA: diabetic ketoacidosis

HHS: hyperglycaemic hyperosmolar state

RAH: Royal Adelaide Hospital

LMH: Lyell McEwin Hospital

FMC: Flinders Medical Centre

Glossary
Basal insulin rate: refers to the continuous (24 hours a day) infusion of rapid acting
insulin. A person’s basal rate is initially calculated using an algorithm by the diabetes
team but over time the person learns to adjust their basal rate as required. It is given
as units/hour eg 0.4/hr = 9.6 units over 24 hours.

Carbohydrate bolus: refers to the dose of rapid acting insulin that is administered
using the bolus feature of the pump when ingesting carbohydrates at meals / snacks.
This is calculated using an algorithm by the diabetes team. The carbohydrate bolus is
given immediately before eating or after eating eg 1 unit for 12 grams of carbohydrate.

Correction bolus: A correction bolus is an amount of insulin that is given to lower


blood glucose levels. A correction bolus is calculated using an algorithm based on the
person’s insulin sensitivity factor. This calculation is usually different for everyone.
This is calculated using the bolus feature of the pump. eg 1 unit of insulin lowers the
BGL by 2.4mmol/L.

A correction bolus may be given at any time but is often combined with the
carbohydrate bolus dose. For example if the BGL was 11mmol/L before meal then a
correction bolus would be needed as well a meal bolus otherwise BGL would still be
high after eating.

Carbohydrate counting: counting carbohydrates is extremely important for people on


insulin pump therapy. Carbohydrates can be counted in grams or exchanges. Most
patients will be taught how to count carbohydrates in grams. There are a number of
resources for assist people with carbohydrate counting. Pump users do not need to
eat snacks if they do not wish to and can vary the timing of their meals and eat to
appetite.

SECTION 4 – HOSPITALISATION – REVISED SEPTEMBER 2009


28
Appendix 1
Patient Identification Label
Your Service Name UR No _____________________________________
DIABETES ASSESSMENT Surname ____________________________________
To be completed by a Registered Nurse on admission. For Given Name _________________________________
explanation of the question material please turn over the
page. If there are any deficits or issues identified in the care DOB ________________ Sex __________________
plan please refer to the appropriate health professional in Doctor ______________________________________
consultation with your patient.
Ward ___________________OPD _______________

1. What type of diabetes does the person have? (each type requires different treatment)
□ type 1 □ type 2 □ gestational □ secondary diabetes (eg steroid induced)

DIABETES ASSESSMENT….Page 1
2. How do they manage/control their diabetes? (different treatment requires different self-care information):
□ diet/lifestyle □ sulphonylureas (eg. glibenclamide, gliclazide, glimepiride, glipizide)

□ metformin □ acarbose □ repaglinide

□ GLP-1 (eg januvia, byetta) □ glitazones □ insulin

b) Does the person understand what their treatment regime is? (eg time to administer, side effects, dose. If
they are on insulin is the administration technique correct? (Refer to Section 10 in Diabetes Manual)
□ yes □ no (please teach) □ carer/nursing home/hostel provides care

c) If on sulphonylureas or insulin is the person aware of risk for hypoglycaemia and how they should prevent and
manage it if it occurs?
□ yes □ no (please teach) □ carer/nursing home/hostel provides care

3. a) Does the person monitor their BGLs (blood glucose levels)? (it is highly recommended that persons on
sulphonylureas or insulin test their BGLs regularly due to potential for hypoglycaemia)
□ yes method __________________ any problems _____________________ □ supplies (NDSS or Chemist)

□ no - person states they do not wish to test (ensure they are aware of signs/symptoms of
hyper/hypoglycaemia)
- diet, metformin or arcabose only (ensure they are aware of signs and symptoms of hyperglycaemia)

□ other nursing home or hostel nursing staff are performing the test

If the person wishes to monitor please provide appropriate education.

b) If the person has type 1 diabetes are they aware of the procedure and action with ketone testing if their
BGLs are above 15mmol/L and / or they are unwell? (Sick day management)
□ yes □ no (please teach) □not applicable □ care/nursing home/hostel provides care

1. Does the person understand the role of a healthy eating plan in diabetes management?
□ yes □ no (please teach) □ care/nursing home/hostel provides care

□ person states they do not wish to receive information

2. Is the person aware of the need for regular checks by LMO or diabetes specialist? (see over page).
Refer to Long-term Management leaflet.
□ yes □ no (recommend visit to LMO after discharge for regular review)

□ care/nursing home/hostel provides care

3. Is there an active foot problem at the moment? (eg callouses, corns, ingrown toenail, infection, signs of
pressure or neuropathy or ulcers) – see Section 6, Diabetes Manual.
□ yes (refer for foot risk assessment )

□ no (recommend yearly risk assessment and appropriate care)

7. Check toe nail cutting is uncomplicated – refer to diabetes resource nurse.

RN Signature: RN Print Name: Date:

SECTION 4 – HOSPITALISATION – REVISED SEPTEMBER 2009


29
DEFINITION OF TYPES OF DIABETES (It is important to ascertain which type of diabetes a person has so that
appropriate treatment/education is provided)

• Type 1: occurs as a result of insulin deficiency following autoimmune destruction of pancreatic beta cells.
Dependant on insulin for survival from diagnosis.
• Type 2: characterised by insulin resistance and insulin deficiency. Usually occurs in people over 40 years. Initially
controlled by healthy eating, exercise, and OHA’s. May eventually need insulin to assist in management.
• Gestational: diabetes detected during pregnancy.
• Secondary: examples include disorders with pancreatic pathology, use of medications (glucocorticoids), liver disease
and other endocrine disorders.

MEDICATION ADMINISTRATION (It is a nurse’s duty of care to ensure the following is taught prior to discharge)

• Action, side effects, timing, dose, availability of medication (eg chemist with script from LMO).
• Insulin: correct technique, correct timing, correct dose and site. Observe and document administration technique.

MONITORING
DIABETES ASSESSMENT….Page 2

• Times to test: before a meal is preferred so that medication can be adjusted accordingly.
• Frequency of testing: depends on their control and how stable.
• Supplies: National Diabetes Supply Scheme is the most cost effective (Diabetes – South Australia U4/159 Sir
Donald Bradman Drive, Hilton – Ph 8234 1977).
• Sharps disposal: sealable hard plastic container or with sharps container through councils. Sharps must not be
thrown in the bin, as household rubbish becomes landfill.
• Quality control meter: recommended monthly with control solutions.

EMERGENCIES (It is a nurses duty of care to ensure the following is taught prior to discharge)

Hypoglycaemia

• Symptoms: sweating, trembling, weakness, confusion, tingling around mouth, headache.


• Causes: delayed or missed meal, exercise or alcohol with minimum carbohydrate intake, medication/s.
• Management: quick acting carbohydrate followed by slowly digested carbohydrate.
• Glucagon injection: teach family or friend or care giver of those at risk, eg patient with type 1 or with type 2 who is
lean and on insulin. They will require education and prescription prior to discharge.
• Advise clients who are at risk to test blood glucose level prior to driving or any dangerous activity (eg climbing a
ladder).
• Encourage patient to have a medic alert bracelet or to carry a medical identification care.

Hyperglycaemia

• Symptoms: thirst, lethargy, polyuria, weight loss, blurred vision, recurrent infection.
• Causes: stress, illness, infection, not enough medication, too much carbohydrate.
• During illness medication should not be stopped as insulin requirements generally go up.
• Symptomatic hyperglycaemia should seek medical advice as soon as possible.

HEALTHY EATING

• Encourage regular meals with even distribution of carbohydrates throughout the day.
• Low fat, high fibre and limiting quickly absorbed carbohydrates.

LONG TERM COMPLICATIONS (PREVENTION)

• Importance of regular GP reviews (3-6 monthly) and within one week of discharge from hospital.
• A measure of HbA1c (average blood glucose level) recommended 3-6 monthly.
• 2 yearly eye checks (more frequently if problems stated), yearly kidney checks, regular BP, cardiovascular, nervous
system and cholesterol level checks.
• Regular flu and pneumonia vaccinations.
• Footcare: daily inspection, treat problems early, avoid excessive heat or cold. Encourage appropriate footwear. Cut
nails following the normal contour of the toe, file sharp edges. See podiatrist if problems occur.

SECTION 4 – HOSPITALISATION – REVISED SEPTEMBER 2009


30
References

1. The Queen Elizabeth Hospital Nursing Department (2000) Nursing history


assessment standard and criteria, Nursing Policy Procedure Manual, The
Queen Elizabeth Hospital, Adelaide.

2. Harris P, Mann L, Marshall P, Phillips P, and Webster C (2008/09) Diabetes


management in general practice: Guidelines for type 2 diabetes. Royal
Australian College of General Practitioners and Diabetes Australia, Canberra.

3. Griesdale D E G, de Souza R J, van Dam R M, Heyland D K, Cook D J,


Malhotra A, Dhaliwa R, Henderson W R, Chittock D R, Finfer S, and Talmor D
(2009) Intensive insulin therapy and mortality among critically ill patients: A
meta-analysis including NICE-SUGAR study data. Canadian Medical
Association, 180(8): p821-827.

4. Royal Adelaide Hospital (2008) Royal Adelaide Hospital consensus based


guidelines: In-patient diabetes management. December, Royal Adelaide
Hospital, Adelaide.

5. Queensland Health (2008) Insulin subcutaneous order and blood glucose


record - adult: Guidelines for use in Queensland Health hospitals, Queensland
Health.

6. American Diabetes Association (2004) Hyperglycemic crises in diabetes.


Diabetes Care, 27(Suppli. 1): pS94-S102.

7. Dunning T (2009) Care of people with diabetes. John Wiley and Sons Ltd,
United Kingdom.

8. Australian Diabetes Educator Association (2006) Guidelines for sick day


management for people with diabetes, ADEA, Canberra.

9. Australasian Paediatric Endocrine Group (2005) Clinical practice guidelines:


Type 1 diabetes in children and adolescents. Department of Health and Ageing,
Canberra.

10. American Diabetes Association (2009) Standards of medical care in diabetes -


2009. Diabetes Care, 32(Suppl 1): pS13-S61.

11. New South Wales Insulin Pump Interest Group (2006) Insulin pump therapy: An
information booklet for diabetes health professionals interested in establishing
an insulin pump therapy service, Diabetes Australia & ADEA, Canberra.

SECTION 4 – HOSPITALISATION – REVISED SEPTEMBER 2009


31
SECTION 5
Monitoring diabetes control
The purpose of monitoring diabetes is to evaluate progress and to adjust therapy.
Monitoring diabetes includes aspects of diet, activity, clinical signs and symptoms as
well as blood glucose and ketones.

Controlling diabetes is important for:

• health and a sense of well being for the individual


• normal growth and development in children and adults
• normal outcomes of pregnancy
• lowering the incidence of illness and hospitalisation
• prevention of long term complications.

Although glucose can be measured in both blood and urine, blood glucose
measurement is preferable for the following reasons:

• blood glucose measurement gives more accurate information about the present
state of the blood glucose
• urine glucose is variable due to changes in renal threshold, therefore blood
glucose levels are usually not less than 10mmol/L before they register in the
urine
• urine glucose monitoring cannot detect hypoglycaemia.

All methods are potentially inaccurate and the reliability of any test also depends
upon the quality of the equipment, basic quality assurance (QA) systems and the
skill and experience of the person performing the test. Only staff trained and
competent in the use of blood glucose meters for blood glucose monitoring
should perform the tests.

People with diabetes should be encouraged to perform their own blood glucose
monitoring if they have access to a meter they can use at home. A health professional
trained and accredited in meter operation should assess the person’s technique before
they perform their own tests in hospital. However, due to the increasing numbers of
meters and various techniques, hospital staff may not be familiar with the person’s
particular meter. Meter company representatives can provide information to assist.

Remember

Many factors may affect the accuracy of test results. Strategies for reliable blood
glucose measurements include:

• obtaining the appropriate sized drop of blood as recommended by the meter


company
• precise timing according to manufacturer’s instructions where relevant
• routine maintenance of equipment and performance of quality control
• correct storage and avoidance of extremes in temperature.

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


1
Blood glucose monitoring for inpatients
Indications
Measuring blood glucose during hospitalisation is appropriate for all patients who have
diabetes. Results will guide management decisions and should inform patient
education.

Blood glucose measurements with hospital meters can only be performed by staff with
current accreditation. Information is available from your diabetes educator or meter
company representative about quality assurance programs.

Universal precautions
Follow universal precautions for all blood glucose monitoring. Remember when
handling body fluids, treat all fluids as potentially infective. Ensure that blood testing
technique does not increase the risk of infection from blood products.

The following guidelines in addition to universal precautions are recommended:

1. Wear disposable gloves when performing or teaching blood glucose monitoring.

2. If possible, do not squeeze the patient’s finger to produce an adequate drop of


blood. Allow the patient to do this.

3. Dispose of all materials that have been contaminated with blood immediately.

4. Dispose of all sharps into sharps container.

5. When teaching, ensure personal lancing device is always left unloaded (dispose
of used lancet immediately after use).

6. Professional use lancing devices must be disposable, single use and have
retractable lancet.

7. Wash your hands before and after procedure.

8. Ensure work area and surfaces are cleaned and all traces of blood removed.

Soap and water is recommended as a safe and effective cleansing agent.


1
Allow to dry.

Blood glucose meters


There are increasing numbers of blood glucose meters now available. Each
manufacturer provides instruction leaflets and quality control recommendations specific
to the meter. The manufacturer’s recommendations must be followed for reliability of
results.

Hospital blood glucose monitoring must be accurate and reliable to guide management
decisions. A hospital accreditation program is essential to ensure accuracy and to
maintain ongoing review of blood glucose monitoring techniques / results performed by
staff.

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


2
Quality assurance
When using a blood glucose meter to test a person’s blood glucose, health
professionals are accountable for the results obtained.

To ensure that each operator is competent in using a blood glucose meter, we need a
method of checking that the equipment and operator performance meet pre-set
standards. This is achieved through the implementation of a quality assurance
program.

Involvement in a quality assurance program is an important part of any blood


glucose monitoring system. The following terms are frequently used when
defining quality assurance and blood glucose monitoring.

Accuracy: agreement between result obtained for the sample and its true value.

Precision: agreement between repeated tests on the same sample.

Acceptability: when a test result lies within acceptable intervals (usually + or - 10% of
true value).

Quality assurance aims to improve management of the person with diabetes by


providing a confident basis to support blood glucose results. This is essential for
accurate adjustment of a patient’s diet and medication.

Recommended hospital standards of practice

Blood glucose meters can only be used by staff members who have successfully
completed an annual meter education and accreditation program.

Staff cannot operate blood glucose meters if accreditation status has lapsed.

Ideally an internal quality control test should be performed:2

• Every 24 hours
• Each time a new bottle of strips is opened
• If the meter is dropped
• When the batteries are changed
• If the BGL is questionable.

Quality control solutions are available for each type of meter and they contain a set
amount of glucose. The test result must be within the range specified for the meter
and strips being used. The test should be documented and records of quality control
records should be kept for 7 years.3

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


3
Components of an accreditation program
Teaching method

The clinical teaching method of explanation and demonstration, complemented by


audio-visual aids, shall be applied in teaching the following:

1. The functional range of the instrument.

2. Detailed functions.

4. Practical procedures of reagent strip, control checks, blood glucose


measurement and cleaning the instrument.

5. The application of results in self care.

Learner participation

Under supervision all participants will have the opportunity to practise reagent strip
control checks, blood glucose measurement and cleaning the instrument.

Evaluation method

1. Theoretical knowledge will be evaluated by means of a staff questionnaire.

2. Staff will be evaluated in the practical procedure of blood glucose


measurement.

Accreditation

Staff should be accredited after successful completion of the program and evaluation
procedures.

Program evaluation

Staff should also evaluate the effectiveness of the program.

Annual re-accreditation

Re-accreditation of technique should occur annually. An audit process can be used for
review of procedure and technique (Appendix 1).

How can operators become accredited

Consult with your regional diabetes educator. In most cases this person is accredited
to conduct accreditation activities. Otherwise, hospital staff can be accredited directly
by meter company representatives. An example of an accreditation tool can be seen
in Appendix 2.

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


4
When to test?
Fasting values reflect overnight blood glucose control and is affected by how
sensitive the liver and body cells are to insulin (insulin resistance). Pre lunch
and pre evening meal blood glucose are affected by factors such as diet,
activity and medication. Fasting and pre-meal testing is recommended as first
line monitoring as other (eg post-prandial) readings will automatically be
elevated if fasting and pre-meal readings are high.

Values at two hours post-prandial would reflect peak glycaemia which is affected by
factors such as the food eaten, gastric emptying, insulin resistance, medications and
illness.

Indications for extra blood glucose monitoring outside of pre-prandial (particularly


before breakfast and evening meal):

• Type 1 diabetes.
• A1c being lower or higher than expected from the existing blood glucose profile
(because of possible hidden hypo or hyperglycaemia).
• Unstable blood glucose, particularly those tending to hypoglycaemia before the
next meal.
• Hypoglycaemia, particularly in those with hypoglycaemic unawareness.

The appropriate times to test will vary with each individual and will often be the result of
a joint decision of the individual and their general practitioner / medical officer /
diabetes educator.

Glucose levels – understanding the numbers


Blood samples are taken under defined conditions and at set times.

Times

Fasting - usually taken after an overnight fast of about 8-12 hours


Random - taken at any time during the day
Pre-prandial - taken directly before meals usually written as `before meals’
Post-prandial - usually taken approximately two hours after a meal.

Samples

Whole Blood - has 10-15% lower glucose values than plasma because the
sample contains blood cells which have low glucose levels
- capillary whole blood samples are taken for ward or self blood
glucose monitoring tests.

Plasma - is obtained by centrifugation of anticoagulated whole


blood and has a 10-15% higher glucose value than
whole blood because there are no cells
- venous plasma is usually tested in laboratories.

Summary

• Fasting and pre-prandial ≤ random or post prandial.


• Whole blood < plasma.
• Venous plasma ≤ capillary plasma.

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


5
Monitoring glucose and ketones when in hospital
4
Aim for target blood glucose levels (BGL) 5.0 - 10.0mmol/L. Blood glucose levels as
close to normal as possible improves in-hospital morbidity and mortality rates. Refer to
Hospitalisation – Section 4 for information about monitoring blood glucose and ketones
in a hospital setting.

Self blood glucose monitoring at home


Self monitoring of blood glucose for people with non-insulin treated diabetes may lead
to improved glycaemic control and it is commonly recommended. However the
5-8
evidence to support this theory remains inconclusive. An AADE systematic review
and a Cochrane review have both concluded that self blood glucose monitoring for
people who are not using insulin may be effective in improving glycaemic control but
further research is needed.6, 7 It is important that health care professionals have an
individualised and targeted approach to SBGM.

Strategies that can be used to enhance the effectiveness of SMBG include the
following.8(p1012)

• Stress the importance of SBGM as data needed by the person for decision
making, not as something done primarily for the benefit of the provider.
• Emphasise that the results are not a judgment of the persons’ self-management
efforts but simply a number they can use to make informed decisions.
• Assist the person to identify blood glucose targets and actions to take to achieve
those targets.
• Identify strategies for overcoming barriers to monitoring.
• Assist the person in dealing with the impact of results.
• Help the person to identify strategies to obtain the support they need for SBGM
from members of their families and health care team.
• Role-play responses to negative comments about the results from members of
their family and health care team.

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


6
Important principles
1. Self blood glucose monitoring in the usual work and home environment can be
helpful assessing day to day glucose control.

2. Self blood glucose monitoring should be used in the management of all pregnant
women with diabetes and all people on insulin therapy.

3. Self blood glucose monitoring is recommended for all people at risk of


hypoglycaemia eg taking sulphonylureas or insulin.

4. People who are diet controlled or on metformin alone can be provided with the
option of blood glucose monitoring. If they choose not to self monitor then it is
important that they are informed of the need for 3 monthly HbA1c tests as this
will be the only measure of control.

5. Quality control solutions are recommended for use by people who self monitor
with a meter, to ensure reliable and accurate results. Support and resources
must be provided to encourage the person to maintain monitoring standards.
Alternatively people may be able to go to their local Diabetes Service Pharmacy
or Diabetes Australia to have their meter quality control checked.

6. Participation by the person has potential to increase self-responsibility therefore


self care.

7. It is important to ensure that the person has the correct technique when using
their meter and that the meter is providing accurate results.

When to test
The targets and frequency of testing will depend on what type of diabetes the person
has, the type of treatment they are on (diet, tablets or insulin) and the intensity of their
regimen. For example a person who is on a basal bolus regimen (4 injections a day)
will need to test at least 3 - 4 times a day whereas a person who is only having a basal
insulin regimen (1 to 2 injections) will be able to test less often. People need to be
able to adjust the times and frequency based on their current situation.

Example: HOME BLOOD GLUCOSE TESTING


DAY FASTING BEFORE BEFORE BEFORE 2-3am
LUNCH DINNER BED
Monday X X
Tuesday X X
Wednesday X X
Thursday X
Friday X X
Saturday X X
Sunday X X

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


7
Remember the following points when working with people who
are monitoring at home

• Monitoring is only meaningful if the person knows what the target is.

• Monitoring is only useful as a self management tool if people can interpret their
results and work out what has caused high / low BGLs so they can take remedial
action to bring BGLs back into target.

• The person needs to understand that how they feel is not an accurate estimate
of BG levels and not good enough evidence on which to base self management
decisions.

• Any self monitoring must be meaningful to the person doing it – that is they are
doing it for a reason or to find out the effect of their diabetes management (food,
activity, medication) and make management decisions.

• Unfortunately some health professionals, no matter how well intentioned, use


‘blaming’ language. High or low BG levels should be just another problem to
solve.

• Reassure that out of target BG levels are manageable – even if it takes a while
to figure out what to do.

Assessment of long term glycaemia


Glycated haemoglobin
Glucose attaches to blood protein. The blood protein that carries oxygen is called
haemoglobin and has a life of about 120 days. Haemoglobin that normally has
glucose attached to it is called glycated (glycos = glucose). The quantity of glycated
haemoglobin is expressed as a percentage of the total haemoglobin.

A regular monitoring schedule for glycated proteins provides information which helps to
assess overall control.

A Glycated Haemoglobin Test is a laboratory test used to check control of blood


glucose levels by reflecting long term diabetes control. Since haemoglobin stays in the
body for some time this measurement reflects all the `highs’ and `lows’ of blood
glucose levels over the past 8-12 weeks. The higher the glycated haemoglobin, the
higher the average blood glucose.9

The test can be done every 3-6 months to check overall control.

Glycated plasma protein (Fructosamine)


Normal proteins, particularly albumin, are also modified by the continual exposure to
blood glucose. The plasma levels of these products are therefore elevated in people
with diabetes.

Since the lifetime of plasma proteins is approximately 2 weeks, measurement of


glycated proteins reflects average plasma glucose levels over the preceding 2 weeks.
Fructosamine is an indirect measure of glycosylated albumin. This type of assay allows
assessment over the short term.

Glycated haemoglobin is the preferred measurement.

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


8
Ketones
Testing for ketones is necessary in people with type 1 diabetes and should be
performed if the person has an infection, is unwell, nauseous or blood glucose values
exceed 15mmol/L. Tests should be performed before meals and at bedtime, with the
10
number of tests decreasing as glucose control improves.

Ketones can indicate impending acidosis. Ensure the medical officer is notified if
ketones are detected in urine or blood.

For more information about the monitoring of ketones and its role in sick day
management see Unstable Diabetes – Section 11 or www.adea.com.au.

Note: Ketone testing is only routinely performed if the person has type 1 diabetes.

Microalbumin
Proteinuria is the hallmark of diabetic nephropathy. The appearance of proteinuria
during the routine review of people with diabetes is common. The time of onset of
proteinuria and the rate of increase is variable. However, once clinical proteinuria
occurs (dip stick positive, >500mg/L) progressive renal damage is likely 11. Initially
intermittent low grade proteinuria occurs (microalbuminuria, 20-200µg/min). A
laboratory microalbuminuria test is recommended to detect early changes in renal
function. Evidence of microalbuminuria usually precedes the macro proteinuria that is
detected with dipstick methods. Microalbuminuria can also be detected using Micral-
Test. This strip test can be used outside the central laboratory and is an
immunological reagent carrier as opposed to a chemical dipstick. It uses a monoclonal
antibody test to give a semi quantitative measurement in the range 0-100mg/L of
albumin in urine.

People with diabetes may develop overt clinical manifestations of renal disease,
generally termed nephropathy. Eventually a proportion of these people will either
require dialysis or kidney transplantation. Microalbumin is also an indicator of blood
vessel disease and therefore a marker for cardiovascular disease.
Monitoring people with diabetes for microalbuminuria is therefore important if a
protocol is to be implemented which can detect and possibly reverse ultimate
renal damage or cardiovascular disease.

Assessment
• Test for microalbuminuria. This can be done using a first morning voided spot
urine or an overnight collection.
• Test urine with ‘multistick’ to ensure the absence of infection. Infections will
reduce the reliability of the result. Retest once the condition has improved.
• If microalbuminuria present, perform up to two additional measurements in the
next 6 weeks. Diagnosis of microalbuminuria is established if 2 of the 3
measurements are abnormal.

Interpretation of results9
Category Timed Urine Sample First Morning Sample
Albumin (ug/min) Albumin: Creatinine
Ratio
Female Male
Normal <20 0-3.5 0-2.5
Microalbuminuria 20-200 3.6-35 2.6-25
Macroalbuminuria >200 >35 >25
SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009
9
What to do
If microalbuminuria only present:

• review diabetes control and improve if necessary


• consider treatment with ACE inhibitor
• consider referral to a physician experienced in the care of diabetic renal disease
• the STENO 2 Study studied inpatients with type 2 diabetes. More active
intervention and improved management of risk factors reduced the incidences of
cardiovascular events and renal failure by approximately 50%.11

If macroalbuminuria:

• quantitate albuminuria by measuring 24 hour urinary protein


• refer to a physician experienced in the care of diabetic renal disease.

If macroalbuminuria and hypertension are present:

• hypertension should be treated actively and BP maintained at lower levels.


(<130/80, <125/75 if proteinuria >1g/d exists) in order to slow the progression of
nephropathy.

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


10
Appendix 1

Blood Glucose Meter Audit


Ward: Date:

Name:

Does the operator Yes No

1. wash hands  
2. ensure all equipment is available  
3. confirm meter cleanliness and function
(date and time)  
4. confirm meter is correctly calibrated  
5. ensure strips have not expired/deteriorated  
6. perform control test  
7. identify the person correctly  
8. give clear and relevant explanation to the person  
9. advise the person of possible discomfort  
10. put on gloves when appropriate  
11. ensure patient’s skin area is clean  
12. correctly prepare finger pricking device
using aseptic technique  
13. correctly choose site for blood sample  
14. correctly load strip into meter (if appropriate)  
15. correctly commence meter operation (as appropriate)  
16. correctly prick finger (use side of finger, not tip)  
17. correctly obtain a drop of blood  
18. correctly ensure accurate timing (if appropriate)  
19. correctly read test result  
20. correctly record result on blood glucose monitoring
record  
21. correctly interpret result and take appropriate action  
22. terminate the procedure suitably  
23. clean, replace, dispose of equipment appropriately  
24. wash hands  

Comments:

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


11
Appendix 2
REPATRIATION GENERAL HOSPITAL

Capillary Blood Glucose


Monitoring Competency
Practical
All nursing staff must be accredited to use the hospital nominated blood glucose meter.

Name: _____________________________________________ Date: ________________

Theory Accreditation complete: YES / NO

Accredited by: ________________________ Designation: _______________________

OBJECTIVE: The Registered/Enrolled nurse will be able to demonstrate the use and
maintenance of the hospital nominated blood glucose meter, according to listed criteria.

The nurse will:


1. Assemble the necessary equipment
2. Ensure sensor electrodes and control solutions are within expiry date.
3. Calibrate the meter. (Nurse to perform calibration)
• State when the sensor should be calibrated.
• The sensor was calibrated with the calibrator.
• Check that the 5 digit lot number on the calibrator, the meter, the electrode
packet and electrode insert sheet correspond
• State where the lot number is recorded.
4. Perform a quality control (Nurse to perform control test).
• States when control checks are performed
• The expiry date on the control solution and electrodes is checked.
• The calibration code and lot number match
• Inserts electrode into meter correctly
• Follows visual prompts on the meter display to proceed to next step.
• Correctly applies control solution to target area of sensor electrode.
• Compares the result to the control range on the electrode insert sheet
• Records the result in Quality Assurance log
• Can state the action to be taken if result is outside the acceptable range.
5. Perform a capillary blood glucose test. (Nurse to perform procedure)
• Procedure explained to patient.
• Universal precautions used due to potential for blood exposure.
• Appropriate site prepared for capillary blood sample.
• Electrode inserted into meter correctly.
• Lancet device was used correctly.
• Blood applied correctly to target area of sensor electrode.
• Follows visual prompts on the meter display to proceed to next step.
• Instruction to patient following collection of blood sample.
• Disposable components of lancet device disposed of correctly.
• The electrode was removed as per infection control guidelines and disposed
into general waste.
• BGL result was documented in patients file.
6. Be able to state:
• The range of the meter
• The meaning of displayed symbols
• Appropriate action to be taken if BGL outside patient’s target range.

Comments: ______________________________________________________________________

_____________________________________________________________________

Reference: Metropolitan hospitals BGM package, updated Sept 08.


SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009
12
References
1. The Queen Elizabeth Hospital (2008) Infection prevention & control &
community based care. The Queen Elizabeth Hospital, Adelaide.

2. Royal Adelaide Hospital, Modbury Hospital, The Queen Elizabeth Hospital, and
Repatriation General Hospital (2009) Quality assurance for blood glucose
meters: Personal communication. Diabetes Outreach, Adelaide.

3. SA Pathology (Flinders Medical Centre) (2009) Record keeping for quality


control: Personal communication. 27 April, Diabetes Outreach, Adelaide.

4. Griesdale D E G, de Souza R J, van Dam R M, Heyland D K, Cook D J,


Malhotra A, Dhaliwa R, Henderson W R, Chittock D R, Finfer S, and Talmor D
(2009) Intensive insulin therapy and mortality among critically ill patients: A
meta-analysis including NICE-SUGAR study data. Canadian Medical
Association, 180(8): p821-827.

5. Farmer A, Wade A, Goyder E, Yudkin P, French D, Craven A, Holman R,


Kinmonth A L, and Neil A (2007) Impact of self monitoring of blood glucose in
the management of patients with non-insulin treated diabetes: open parallel
group randomised trial. British Medical Journal, 335(7611): p132-138.

6. McAndrew L, Schneider S H, Burns E, and Leventhal H (2007) Does patient


blood glucose monitoring improve diabetes control? A systematic review of the
literature. The Diabetes Educator, 33(6): p991-1011.

7. Welschen L M C, Bloemendal E, Nijpels G, Dekker J M, Heine R, Stalman W A


B, and Bouter L M (2005) Self-monitoring of blood glucose in patients with type
2 diabetes mellitus who are not using insulin (Review). Cochrane Database of
Systematic Reviews (2): p1-25.

8. Funnell M M (2007) Self-monitoring of Blood Glucose: A commentary. The


Diabetes Educator, 33 (6): p1012-1014.

9. Harris P, Mann L, London J, Phillips P, and Webster C (2009/10) Diabetes


management in general practice: Guidelines for type 2 diabetes. Diabetes
Australia and Royal Australian College of General Practitioners, Canberra.

10. Australian Diabetes Educator Association (2006) Guidelines for sick day
management for people with diabetes, ADEA, Canberra.

11. Harris P, Mann L, Marshall P, Phillips P, and Webster C (2008/09) Diabetes


management in general practice: Guidelines for type 2 diabetes. Royal
Australian College of General Practitioners and Diabetes Australia, Canberra.

SECTION 5 – MONITORING DIABETES CONTROL – REVISED SEPTEMBER 2009


13
SECTION 6
Foot Care
Background
1
Foot complications are among the most serious and costly diabetes complication.
However, strategies which encompass prevention, patient and staff education,
multidisciplinary treatment of foot ulcers and close monitoring can reduce the rate of
amputations by 49-85%.1

The effects of diabetes and complications of diabetes commonly target the feet. Any
person with diabetes, of whatever age, requires good foot care whether at home, in
hospital or in a nursing home. The feet of a person with diabetes are at risk of damage
due to a combination of small and large vessel disease, nerve damage and mechanical
instabilities in the foot.

Diabetic foot ulcers usually occur as a result of two or more risk factors occurring
together. In particular peripheral neuropathy plays a central role. Statistics show that
anywhere from 19.6%2 and 50%1 of people have at risk feet. All health care providers
can play a role in helping people assess their own level of risk and to understand their
own self care practices.

Poor glycaemic control increases the risk of vascular disease, neuropathy and
3
infection. Hyperglycaemia may lower immune response, increase the risk of infection
and delay healing.

Neuropathy
Peripheral neuropathy, with or without peripheral vascular disease is a major
underlying risk factor in people with diabetes developing a foot ulcer.3 Sensory loss
associated with peripheral neuropathy becomes progressively more common with
increasing duration of diabetes. Neuropathy leads to an insensitive foot. Neuropathy
also sometimes leads to a deformed foot which then causes more pressure on
different parts of the foot, resulting in thickened callus or corns and potential ulcers. If
a person with neuropathy has a minor trauma such as blisters (from ill fitting shoes or
walking barefoot on hot ground) this can be enough to start a chronic ulcer.1 If the
person cannot feel that they have an injury then they will continue to re-injure the area
and will not identify the need to seek help.

Signs and symptoms of peripheral neuropathy:4

• abnormal, decreased or increased sensitivity


• loss of deep tendon reflexes
• loss of vibratory, cutaneous pressure, temperature, or position sense
• heavy callus formation over pressure points
• trophic ulcers
• foot drop
• changes in shape of foot:
- muscle atrophy
- changes in bone and joint.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


1
NHMRC guidelines recommend that ‘people with type 2 diabetes who have peripheral
neuropathy should be identified because they are at risk of foot ulceration and
3
amputation’.

Peripheral vascular disease


The presence of peripheral vascular disease (PVD) becomes progressively more
common with the duration of diabetes.5 PVD is degenerative and hyperglycaemia,
6
smoking, hypertension and hyperlipidaemia are all risk factors. PVD in conjunction
1
with minor trauma may result in a painful, purely ischaemic foot ulcer. However if the
person also has neuropathy then symptoms may be absent. Peripheral vascular
3
disease is associated with a 2 - 4 fold increased risk of amputation. People with
3
diabetes should be assessed regularly for peripheral vascular disease.

Signs and symptoms of peripheral vascular disease


• intermittent claudication (pedal pulses usually absent)
• rest pain
• nocturnal pain
• shiny appearance of skin
• bluish discolouration of skin
• skin cool to touch
• loss of hair on feet and toes
• failure of a wound to respond to appropriate treatment
• delayed venous filling after elevation
• gangrene.

Foot deformity
Foot deformities such as bunions, hammer or claw toes, callus and Charcot foot are
major contributors to increasing foot pressures. Callus develops in response to shear
stresses and usually occur close to a bony prominence. Callus contributes to
increases in foot pressures by acting as a foreign body and predisposes to the
3
formation of ulcers beneath these lesions. Limited joint mobility and bony deformities
or callus in the presence of neuropathy increases the risk of ulceration.3 Similarly
deformity from previous amputation also increases the risk of ulceration (3-fold
increase).

NHMRC guidelines suggest that people with diabetes need regular assessment to
detect foot deformities.3

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


2
Foot risk assessment and management
There are five key elements that underpin foot management.1

• Regular inspection and examination of the feet by health care providers.


• Identification of the foot at risk.
• Education of the person, family and health care providers.
• Appropriate foot wear.
• Treatment of non-ulcerative pathology.

Regular inspection and examination


It is important to realise that absence of symptoms does not mean that a persons feet
are healthy; a person may have neuropathy, PVD, or even an ulcer and not be aware
1
of it. Every person with diabetes should have their feet, shoes and socks examined at
least every 6 months.7

All health care providers should be involved in ensuring that the person with diabetes
has regular inspection and examination of both feet. This involves assessing the
person in a standing and sitting / lying position with their shoes on initially and then
without their shoes. Shoes and socks should be also be inspected. It is through
regular checks and reinforcement of appropriate and relevant self care practices that
the person with diabetes will have a solid understanding of the importance of foot care.
A key aspect of education is to teach those with at risk feet the importance of self care.
The responsibility of the individual with diabetes or of their carer cannot be emphasised
strongly enough. Daily inspections of at risk feet and footwear should be conducted at
home, with particular attention paid to the identification of any problems and early
management of these.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


3
Identification of the foot at risk
It is only through a thorough and systematic history and assessment that the health
professional can determine the level of risk for the individual. This level of risk then
needs to be communicated to the person. An action plan relevant to the level of risk
should be put in place. Determining the level of risk will guide subsequent
management including the type of referrals, frequency of follow up appointments and
types of footwear.

Identifying the foot at risk can be based on the National Association of Diabetes
Centres (NADC) 2004 ‘Basic Foot Screening Checklist’ (Appendix 1). The checklist is
broken up into 7 sections which will be discussed in more detail below.6

Note:
The NHMRC guidelines ‘Diabetes foot problems’ adopts the following definitions to
describe risk categories for diabetes foot problems:

• ‘at risk’ people – neuropathy or peripheral vascular disease or foot deformity

• ‘high risk’ people – foot deformity with neuropathy or peripheral vascular disease
or previous ulcer or previous amputation.3

Section 1
Ask the person if they have experienced previous foot problems, symptoms of
neuropathy or intermittent claudication. Ask about previous foot ulcer or amputation
because this will immediately put the person in an at risk category for another ulcer.3

Neuropathic symptoms can include numbness, tingling, creeping ants, shooting


pains, burning and deep bone ache. Symptoms may be worse at night, may be
present at diagnosis, may worsen with unstable blood glucose and may not
accompany reduced sensation.

Intermittent claudication symptoms can include ‘angina’ of the legs, ischaemic


muscle pain with exercise. Pain often develops after walking a certain distance or
length of time. Note: less than half of people with diabetes and PVD experience
intermittent claudication.3 Presence of palpable pedal pulses is usually a good
predictor of adequate peripheral circulation.3

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


4
Section 2
Look at both feet to identify active problems including PVD and neuropathy.

Active problem Signs and symptoms


Infection • look for redness, warmth, discharge, swelling, pain
• usually accompanied by elevated blood glucose levels
• may spread rapidly - signs visible across the foot or up the leg
• signs may be masked by ischaemia or neuropathy

Ulceration • non-healing wounds may occur anywhere on the foot


• persistent pressure results in tissue breakdown and may be
painless
• look particularly at pressure areas e.g. tops of toes, tips of toes,
ball of the foot, around the heels
• ulcers are often present underneath callus and corns or
between the toes

Corns and • must be regarded as pre-ulcerative, especially in the


callus neuropathic foot
• appear as areas of hard, yellow, thickened skin
• occur at pressure points
• early treatment and pressure relief prevents ulceration

Skin breaks • possible portal for bacteria and therefore infection


• check between toes and around heels
• treat skin which is excessively dry or moist

Nail disorders • thickness


• discoloration
• infection
• check general condition
• provision for basic nail care may be necessary

Deformity • deformed foot is more susceptible to pressure


• corns and calluses are more evident in the irregularly shaped
foot
• special attention to shoe fit is required

Mechanical factors are those related to structural changes, the shape of the foot and
the type of footwear. Small muscle wasting, secondary to neuropathy may develop in
the feet leading to an abnormal posture of the foot. It may be difficult to find a
comfortable, well-fitting shoe.

Assessment of mechanical factors includes observation of gait and shoe wear pattern.
Gait problems may indicate special footwear is necessary. Conditions include hammer
toes, clawfoot, bunions, calluses, partially amputated feet, Charcot feet and other
deformities.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


5
Section 3
Check foot pulses
Indicates arterial blood supply to the feet and healing potential of wounds
Check for both pulses. See diagram below

Section 4
Test both feet for neuropathy
The NHMRC footcare guidelines recommend that all people with diabetes be routinely
assessed with a 10g monofilament to detect loss of protective foot sensation (see
Appendix 2 for instructions).3 The 10g monofilament is clinically reliable and best
practice. However, if this is not available cottonwool can be used in the same way
(note this method is not gold standard). These tests measure nerve supply to the feet
and the persons ability to detect injury to the feet. They are testing for loss of
protective sensation.

There is limited data to support which sites should be tested using the monofilament.
The NHMRC guidelines suggest that testing at two sites (over the first and fifth
3
metatarsal heads) is sufficient to identify loss of protective sensation.

Section 5
Assess footwear
Ensure footwear is of appropriate size, shape and width to accommodate the foot.
Avoid vinyl uppers as these can trap moisture. Poorly fitting shoes can cause blisters
and corns which may ulcerate, especially in the person with sensory loss.6

Section 6
Assess education need
As part of the foot assessment it is important to ascertain what the person understands
about the effects of diabetes on foot health. Asking the person do they know why and
how diabetes can affect their feet and what the associated self care practices are. Are
their feet adequately cared for.

Section 7
Assess self care capacity
The last part of the assessment is an opportunity to assess whether the person is
capable of the level of care that is required for their level of foot risk.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


6
Summary of assessment of feet
The summary of assessment provided by the National Association of Diabetes
6
Centres will help approach the assessment in a logical and systematic way.

Task History Examination


Detect peripheral Ask about symptoms of
10 gram monofilament
neuropathy peripheral neuropathy

Ask about symptoms of


Detect peripheral vascular Check dorsalis pedis and
peripheral vascular
disease posterior tibial pulses
disease

Ask about previous foot Look for signs of scarring,


Previous foot ulcer
ulcers contractures of muscles

Examine foot for


Major foot abnormality Ask about previous injury significant callus, foot
deformities

Examine for foot ulcers,


Detect active foot infection, corns,
problems maceration, fissuring,
anhydrosis, nail problems

At the end of the assessment it is important to document whether or not the foot is at
risk. Using the NADC Action Plan in Appendix 3 can be a useful tool for documenting
your findings and plan. The person is deemed to be at risk if they have any history of
ulceration or amputation, neuropathy, PVD, foot deformity or any other abnormality
that was identified during the assessment.

If the foot is deemed to be ‘at risk’ then further referrals will need to be arranged. The
type and urgency of the referral will depend on the problem identified for example;

Refer to the podiatrist for further assessment if the person has:

• reduced circulation – poor colour, cooler to touch, reduced or absent pulses (if
foot is cold, pallor and pulses are absent consult a general practitioner or medical
officer)
• nerve damage – numb feet, reduced sensation
• abnormal nails – thickened, ingrown
• abnormal foot structure, bunions, hammer toes
• evidence of trauma – calluses, past ulcers.

Further referral to a vascular surgeon may also be necessary for circulatory problems.

Ulceration or significant infection requires URGENT referral to a multidisciplinary team


(see section Multidisciplinary foot care team and /or high risk foot clinics).

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


7
Education
Education is best presented in several sessions using a mixture of methods. The
person with diabetes needs to learn how to recognise potential foot problems and be
aware of the steps they need to take when a problem occurs. Education should be
structured in such a way that it is appropriate for their individual level of risk. For
example we don’t need to tell all people with diabetes that they can never walk
barefoot. This advice needs to be reserved for the person who really is at risk ie those
with a neuropathic foot. If we tell people to do something when they don’t need to,
they may be less likely to take it seriously when it really is important for them to never
walk barefoot. Furthermore it is unfair to expect people to have an increased burden
of self care tasks that are not relevant to their needs.

General foot care principles


Foot care involves daily washing, drying and regular inspecting of the feet (daily for
those deemed at risk). People who are unable to do so should be helped to find the
best way to perform this. Health care providers and carers can supervise this practice
initially and regularly check that the person performs foot care daily. The person may
need help to organise a low, safe seat, plastic bowl, mirror and a mild soap.

Health care providers should assist as appropriate for those who are not able to
manage themselves.

Daily treatment (self care or nursing care)


• Dry skin- Massage a water-based moisturiser such as Sorbolene cream into all
areas of the feet. Wipe off stickiness.

• Moist skin - Commonly found inter-digitally, especially when toe joints are
stiffened. Refresh toe creases with methylated spirits or Povidone-iodine solution
on a cotton bud. It may be necessary to use a tinea solution.

• Minor skin damage - Treated by using the recommended first aid routine below.

First aid for minor skin injuries (small cuts, abrasions etc)

1. Gently wash and dry the foot.

2. Apply antiseptic – eg Povidone-iodine or chlorhexidine solution.

3. Apply a clean non-stick dressing and secure with tape-bandage.

4. Protect with additional padding or bandage if needed.

5. After the daily shower re-dress the foot until healed.

Notify the doctor if there is any deterioration, signs of infection or delay in


healing within 24 hours or immediately if any pus.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


8
Trimming toe nails
Toe nails which are `normal’ in size and shape (absence of thick-gryophotic, crumbly-
8
mycotic, ingrown +/- infection) may be cut by any competent person.

Wash the feet, ensure a seat in a good light and provide a pair of clean, stainless steel
nail clippers. Each person must have their own clippers or clippers need to be cleaned
and sterilised between cuttings.

Trim nails following the natural curve of the toe, being sure not to cut too short. Never
cut down the sides of the nail. If there are sharp edges, file with nail file or emery
board.

The ‘at risk’ foot: recommended care:1

• daily inspection of feet, including areas between the toes (if not possible then
arrangements will need to be made for someone else to be able to do it)
• regular washing of feet with careful drying, especially between the toes (water
temperature always below 37 degrees)
• do not use a heater or a hot water to warm up feet
• avoid walking barefoot when walking indoors or outdoors
• avoid wearing shoes without socks
• daily inspection and palpitation of the inside of the shoes
• do not wear tight shoes or shoes with rough edges and uneven seams
• do not use moisturising creams between the toes
• change socks daily
• wear stockings inside out or seamless
• do not wear tight or knee high socks
• care in cutting nails (see diagram)
• always have corns and calluses removed by a podiatrist
• notify healthcare provider at once if blister, cut, scratch or sore has developed
(action plan)
• ensure regular examinations by podiatrist and other health professionals.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


9
Providing individualised education using an Action Plan

Someone with diabetes and normal sensation, circulation and structure needs the
5
same foot care and footwear as someone without diabetes. However all people with
diabetes need to be well informed about the potential for future problems and the
importance of early diagnosis ie the need for 6 monthly foot checks by their GP,
diabetes educator or podiatrist.

For those people who have one or more risk factors it is recommended that they have
an up to date action plan developed as part of the education process. The action plan
can be used as a tool to link their risk status with self care practices (see Table 1).
EG – Scenario: 55 year old man with neuropathy but who has good blood supply and
no visual impairment or musculoskeletal problems. See table below.

Potential Cause Action


problems

Cut or abrasion skin break Make sure shoes are worn at all times to protect
your feet from damage.

Check the inside of your shoe for rough areas


or objects before you put them on.

Make sure shoes fit well.

Keep feet away from excess heat eg heaters,


hot water bottles, wheat bags, check
temperature with hand before putting feet in
bath.

If damage occurs:

Simple first aid: wash and dry the area and


apply mild antiseptic (eg betadine): cover with a
sterile dressing.

If not healing in 24 hours , worsens, becomes


inflamed or discharges – see doctor straight
away.

Pressure areas excess pressure Check feet daily to see if there area any signs
of pressure or other damage.
eg redness,
blisters Break shoes in slowly.

See podiatrist for footwear advice.

Nails Cut nails following curve of toe, not too short,


and file edges.
Moist areas
between the toes Moisturise the feet but not between the toes.

See doctor if signs of tinea infection.

Inflammation infection See doctor straight away.

eg Redness,
warmth or
swelling
SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009
10
Appropriate footwear
1 3
Inappropriate foot wear is a major cause of ulceration. People
who do not have altered sensation or deformities can select off-
the-shelf footwear. For people with neuropathy and/or PVD extra
care is needed when selecting shoes. Shoes should not be too
1
tight or too loose eg allow 1-2cm longer than the foot. Shoes
should be selected at the end of the day to allow for any swelling
and any new shoe needs to be broken in very slowly eg half an
hour only on the first day and then increase time over next few
days, checking for signs of pressure.
If there are signs of abnormal loading of the foot eg callus, corns,
ulceration then the person will probably need special foot wear
including insoles and orthoses. Consult a podiatrist.

Treatment of non-ulcerative pathology


In an at risk person it is imperative that callus, nail and skin pathology are treated
regularly by a podiatrist. Deformities should be managed using orthoses and
sometimes surgery.1

Tinea is a fungal infection which often targets the feet;9


• symptoms: itching and stinging, reddening, scaly rash, cracking, splitting and
peeling, blisters
• treatment: antifungal creams, seek medical or podiatry advice if person has at
risk feet
• reducing the risk: dry feet thoroughly particularly between the toes, expose the
feet to as much as air as possible, wear cotton socks, wear thongs to swimming
pools and communal showers, clean socks each day, expose shoes in sunshine.

Callus and corns are signs of pressure and the mainstay of treatment is to reduce the
pressure to prevent recurrence.

Corns and calluses should never be cut or removed with commercial remedies which
may ulcerate the skin. Refer to podiatrist.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


11
Foot ulcer management
People presenting with foot ulcers must be managed in relation to the extent of
ulceration and results of investigations. Foot ulcers present a special problem and
require intensive medical, nursing and podiatry assessment and management.
Pressure is often the key issue in ulcer development, and ulcers will not heal unless
pressure on the area is reduced or eliminated. If the ulcer is on a weight bearing or a
frictional area of the foot, podiatry advice should be sought, as wound management
alone is unlikely to allow the area to heal or remain healed.2 Ulcer care stresses the
need for adequate circulation, early antibiotics if clinically indicated, and removal of
debris and pressure.

Principles of ulcer treatment1

1. Relief of pressure and protection of the ulcer eg mechanical off loading.

2. Restoration of skin perfusion eg surgery, cardiovascular risk factor reduction.

3. Treatment of infection eg debridement and antibiotics.

4. Metabolic control and treatment of co morbidity eg BGLs less than 8.0mmol/L,


treat oedema and malnutrition.

5. Local wound care eg wound debridement and control of exudate.

6. Education of patient and relatives eg self care, how to recognise and report
(worsening) signs and symptoms of infection such as fever, changes in wound or
hyperglycaemia.

7. Determining the cause and preventing recurrence.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


12
Foot care in specialist areas
Foot care in the operating theatre
Protect bony protuberances such as ankle bones, heels and `bunions’ with cushioning
materials if the operation requires a body position which will cause prolonged pressure
to the ‘at risk’ areas. Use lambskin boots, protectors, foam, air pillows, etc. Inform the
theatre nurse of the need for pressure relieving devices during the operation and prior
to theatre.

Keep feet warm. A cold foot will automatically close down peripheral circulation. An
ischaemic area, under pressure, may precipitate skin breakdown and subsequent
ulcer. Use cotton or wool socks and sockettes to increase warmth.

Foot care in intensive care / high dependency / recovery


The focus of attention will be on `vital signs’ but there are numerous examples of
people with diabetes who recover from a heart attack or stroke, only to spend months
immobilised with a non-healing foot ulcer. Sensible foot care will avert this risk.

Use cushioning materials, attend pressure areas two hourly with immobilised,
paralysed or unconscious patients, keep the feet warm with socks, wash and
thoroughly dry interdigital areas and treat macerated skin.

Lengthy bed rest often associated with hospital admissions requires careful
assessment and daily observation of feet. Avoid pressure being exerted on toes and
heels.

Multidisciplinary foot care team and high risk foot clinics


It has been shown that the number of amputations can be decreased by the use of a
multidisciplinary foot care team.3 The full team can be built up slowly by introducing
the various disciplines at difference times. This team needs to work across primary
and secondary health services.1 The team commonly includes a physician, podiatrist,
specialist nurse, orthotists and surgeon.3 If this expertise can not be found locally a
virtual clinic can be set up using technology such as digital photos, telephone and
videoconferencing. Strong local networks are also important so that staff can keep up
to date and resources can be used appropriately.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


13
Summary
It must be stressed that optimal care of the feet of a person with diabetes involves a
multidisciplinary team approach. Communication within the team is vital.

Education of the person in the care of their own feet is of prime importance.
Assistance from family or friends is essential where the person has difficulty seeing or
reaching the feet. The older person may require assistance.

Encourage the person to carry out self care as stated in the foot care section on the
previous page.

Regular checks are recommended by GP or diabetes educator and / or podiatrist


depending on the person’s risk factors. Other health professionals should also be
trained in foot risk assessment such as Aboriginal health workers, community nurses,
and nurses working in general practice.

The need for keeping blood glucose as close to normal as possible needs to be
reinforced to the person.

Smoking, high alcohol intake, excess weight should be reduced as part of prevention.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


14
Appendix 1
Basic Foot Screening Checklist
1. Ask the patient neuropathic symptoms Y N
intermittent claudication Y N
previous foot ulcer Y N
amputation Y N

specify SITE _______________________

DATE _______/____/______

2. Look at both feet infection Y N


ulceration Y N
calluses or corns Y N
skin breaks Y N
nail disorders Y N
foot deformity Y N

LEFT RIGHT
3. Check foot Dorsalis pedis Y N Y N
pulses
Posterior tibial Y N Y N

LEFT RIGHT
4. Test for Monofilament Y N Y N
neuropathy detected at sites
marked - o

5. Assess footwear style Good Poor


condition Good Poor
fit Good Poor

6. Assess education need


Does the patient understand the effects of diabetes on foot health? Y N
Can the patient identify appropriate foot care practices? Y N
Are the patient’s feet adequately cared for? Y N

7. Assess self care capacity


Does the patient have impaired vision? Y N
Can the patient reach own feet for safe self care? Y N
Are there other factors influencing ability to safely care for own feet? Y N

All people with diabetes need to have their feet screened with these 7 simple steps
every 12 months or more often if problems are identified

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


15
Appendix 2
Testing for neuropathy with a monofilament
Method:

• Test first at a site with normal sensation - away from feet (eg. hands)

• Apply the monofilament perpendicular to the skin’s surface INSERT (diagram A)

• The approach, skin contact and departure of the monofilament should be


approximately 1 ½ seconds duration

• Apply sufficient force to cause the monofilament to bend INSERT (diagram B)

• Do not allow the monofilament to slide across the skin or make repetitive contact at
the test site

• Ensure person has their eyes closed while you do the test

• Avoid testing areas where there is callus, scar, neucrotic tissue or ulcer

• Press the filament to the skin and ask the person whether he/she feels pressure
(yes/no) and then ask where they can feel the pressure (left foot / right foot).1

• Protective sensation is present at each site if the person correctly answers 2 out of
3 checks 1

• If the person gives 2 out of 3 incorrect answers their protective sensation is absent
and they are considered to be at risk of ulceration 1

A B

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


16
Appendix 3
Action Plan following Basic Foot Screening
DATE OF REFERRAL ____/_____/____

PATIENT NAME

SERVICE PROVIDER ________________________________

Is the foot high risk ?


Yes  No  (re-check in 12 months)

If yes, why ?  history of previous foot ulceration or amputation


 peripheral neuropathy
 peripheral vascular disease
 foot deformity
 other ___________________________________

Action*
Record details of personnel referred to. Where resources are unavailable, indicate
and describe alternative care provision

1. Ulceration or significant infection


• referred to multidisciplinary team :

2. ‘High risk’ foot


• referred to podiatrist and/or
multidisciplinary team :

• referred for medical assessment at


least every 6 months and foot
examination every 3 months :

3. Active foot problem


• referred to podiatrist

4. Symptomatic peripheral vascular disease


• referred to vascular surgeon :

• involving endocrinologist / physician :

5. Symptomatic peripheral neuropathy


• referred to endocrinologist :

6. Foot deformity or abnormality


• referred to podiatrist :

7. Inadequate knowledge or foot care practices


• referred to :
• or education provided  Yes

*The patient’s General Practitioner or Local Medical Officer will usually be


responsible for coordinating the patient’s care and should be informed of
referrals, interventions and progress.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


17
References
1. Apelqvist J, Bakker K, van Houtum W H, and Schaper N C (2008) Practical
guidelines on the management and prevention of the diabetic foot. Diabetes /
Metabolism Research and Reviews, 24(Suppl 1): pS181-S187.

2. Australian Institute of Health and Welfare (2008) Diabetes: Australian facts


2008. Cat. no. CVD 40, Australian Institute of Health and Welfare, Canberra.

3. National Health & Medical Research Council (2005) Part 6: Detection and
prevention of foot problems in type 2 diabetes. March, NHMRC, Canberra.

4. Haire-Joshu D (1996) Management of diabetes mellitus: Perspectives of care


across the life span. Mosby, St Louis.

5. Phillips P and Evans A (2009) The ABCs of footcare in diabetes: teaching


patients their ABCs. Medicine Today, submitted for publication

6. National Association of Diabetes Centres and The Australian Podiatry Council


(2004) National diabetes foot screening project, Training manual, National
Association of Diabetes Centres, Canberra.

7. Harris P, Mann L, Marshall P, Phillips P, and Webster C (2008/09) Diabetes


management in general practice: Guidelines for type 2 diabetes. Royal
Australian College of General Practitioners and Diabetes Australia, Canberra.

8. Australian Podiatry Council and Diabetes Australia (1997) Australian podiatric


guidelines for diabetes.

9. Victorian Department of Human Services (2007) Tinea factsheet, Better Health


Channel, Victorian Department of Human Services Melbourne.

SECTION 6 – FOOTCARE – REVISED SEPTEMBER 2009


18
SECTION 7
Community groups with specific needs
Rural and remote communities
1
In Australia 34% of the population live in either a rural or remote area. The
disadvantages for rural and remote South Australia (SA) occur in two areas.

1. People living outside the metropolitan areas have higher rates of mortality and
2
morbidity than people living in metropolitan areas.
2. Recruitment and retention are problematic for those health professionals with
3
specialist skills.

In addition, South Australian data also highlights that;

• In 2007, SA had 82,500 adults (age 16 years and over) living with diabetes in
4
country areas.
• Comparisons done between metropolitan Adelaide and country SA in 2005 found
the prevalence of diabetes to be significantly higher in country areas – 10.2%
compared to 7.8%, a 2.4% difference.5
• There are 191 children living in country areas who have type 1 diabetes, 29 of
these are on insulin pump therapy.6
• There are 127 young adults between the age of 18 and 25 with type 1 diabetes
living in country SA, with 64 of these on insulin pump therapy.6
• 44% of people with diabetes in SA have high cholesterol levels.7
• Persons living in rural and remote regions generally have worse health, in terms
of mortality, hospitalisation rates and risk factors compared to those living in
8
metropolitan areas.

Caring for people in a rural or remote setting brings with it all the challenges of
distance, isolation and limited access to specialist support services. Strategies such
as developing networks at a local, regional and state-wide level can help to overcome
some of the barriers.

Major rural centres generally have a core range of health professionals eg diabetes
educators, dietitian, podiatrist, physiotherapist, optometrist or ophthalmologist. For
health professionals working in smaller health services within a larger cluster of health
services, virtual teams can be set up to facilitate access to specialist support and
information / education for people with diabetes in their communities.

Rural and remote areas are home to people with all types of diabetes. It is important
that diabetes services in rural and remote areas are cognisant of the fact that they play
an important role in providing and facilitating best practice in diabetes education.

For example, in a rural area there may be people with type 1 diabetes, children and
adolescents with type 1 diabetes and at times some with type 2 diabetes. The
geographical area may also have women with gestational diabetes and women with
pre-existing type 1 or type 2 diabetes who are pregnant. It is important that education
services do not ignore the education and support needs of these groups. If education
services do not have the expertise to provide education in these areas it is essential
that the service facilitate access in some way (eg distance technologies) to ensure
access to education and support for all people living with diabetes in rural and remote
areas.

SECTION 7 – COMMUNITY GROUPS WITH SPECIAL NEEDS – REVISED SEPTEMBER 2009


1
Indigenous communities
Diabetes is a significant cause of excess morbidity and mortality among Aboriginal and
9
Torres Strait Islander people. Type 2 diabetes occurs at a higher rate and at a
younger age than that of non-Indigenous people.10

• South Australia has the most geographically isolated Aboriginal communities in


11
Australia.
• 45% of Aboriginal communities live more than 250kms away from a health
11
service.
• Diabetes shows up some 10 years earlier in Indigenous people than non-
12
Indigenous.
• Diagnosis of diabetes in Indigenous people in 2004-05 were double that of the
non-Indigenous population.12
• In 2006/07 the crude hospitalisation rate for diabetes was 3.3 times higher for
Aboriginal people compared to non Aboriginal people.11
• In 2006/07 the crude hospitalisation rate for renal disease was 8 times higher for
Aboriginal people as compared with non Aboriginal people.11
• Ischemic heart disease and type 2 diabetes are leading causes of premature
mortality in Aboriginal people.11

Many of the complications from diabetes can be prevented with the appropriate
community based primary health care interventions.13 Structured approaches are
needed if outcomes of Indigenous Australians are to be improved. A structured
approach consists of a shift from reactive care to proactive care. Aboriginal health
services require systems of care which ensure early detection and care planning with
clients. Registers and recall systems which are linked to appropriate action are
integral to this process.13

The Strategy for Aboriginal & Torres Strait Islander people;14


• To implement regionally coordinated knowledge management processes.
• To develop collaborative diabetes implementation plans.
• To provide coordinated ongoing workforce development programs.
• To develop and implement effective organisational capacity building initiatives.

In Australia, State funded health services provide services to the whole community. In
some areas the Aboriginal Community Controlled Health Services (ACCHS) are also
providing primary health care services specific to Indigenous communities. Which ever
service is available, it is essential that regional and ACCHS work together to ensure
access and equity of service.

The roles of Aboriginal Health Workers (AHW’s) within the community health teams of
both state funded services and Aboriginal Community Controlled Health services is
integral when working with Aboriginal people with diabetes. Some AHW’s are also
trained as diabetes educators and should provide the majority of education and
support. AHW’s assist with providing culturally appropriate care.

There are many resources available which are specific to Indigenous communities.
• Diabetes Australia – Northern Territory
www.healthylivingnt.org.au
• Diabetes Australia – Victoria
www.diabetesvic.org.au
• Diabetes Australia – New South Wales
www.diabetesnsw.com.au/about_diabetes/indigenous_introduction.asp
• Australian Indigenous Health Information Net
www.healthinfonet.ecu.edu.au/chronic-conditions/diabetes
SECTION 7 – COMMUNITY GROUPS WITH SPECIAL NEEDS – REVISED SEPTEMBER 2009
2
Culturally and linguistically diverse
communities
Many culturally and linguistically diverse (CALD) community groups have a high
prevalence of type 2 diabetes compared with the non-Indigenous Australian-born
population. A combination of genetic, biological, behavioural and environmental risk
factors are thought to be related to this higher incidence.

As people migrate to a country like Australia (western culture) they may start to adopt
some of the lifestyle behaviours eg eating a greater proportion of high-energy dense
foods or reducing exercise levels. Such changes can lead to excess weight gain, thus
increasing their risk for type 2 diabetes.15 Furthermore research highlights that
migrants are at a high risk of diabetes complications due to the many barriers that they
16
face when accessing health services. Barriers include:

• language
• literacy (in English and native language)
• stigmatisation
• lack of access to culturally specific care
• religious beliefs and cultural practices.

It is important to recognise that religious beliefs and / or cultural practices can affect
the person’s ability or desire to self manage. There may be different perceptions of
what actions will have a positive effect on health across various cultures.
16
Diabetes health care should be:

• culturally specific
• incorporate the diet, beliefs and attitudes of the cultural group
• foster increased understanding, interest and participation.

Health professionals need to be aware of special circumstances that could be a risk for
the client eg Muslims wishing to fast during Ramadan. Health professionals will need
to work with clients to ensure that safety is maintained during this period.17, 18

Culturally specific resources can help with these situations and Diabetes Australia
does provide a national Multilingual Internet Resource for consumers and health
professionals.19

In Australia organisations such as the Migrant Resource Centre can be invaluable


when working with people from CALD backgrounds.

SECTION 7 – COMMUNITY GROUPS WITH SPECIAL NEEDS – REVISED SEPTEMBER 2009


3
Children and adolescents
Type 1 diabetes is one of the most common diseases of childhood and adolescence.
Results for the period 2000–2006 on the incidence of type 1 diabetes show the rate is
increasing in Australia at almost 3% per year.20 Type 1 diabetes in children and
adolescents is a serious, life-long disease that causes a major health, social and
20, 21
economic burden for individuals with the disease, their families and the community.
21
There is also an increasing prevalence of type 2 diabetes in children but at present
there are considerably less children with type 2 than type 1 diabetes.

Current guidelines recommend that children and adolescents should have access to
21
care by a multidisciplinary team trained in childhood and adolescent diabetes. In
rural and remote areas the local team should work in a shared care arrangement with
the appropriate tertiary level diabetes service.

Children
Children with type 1 diabetes require insulin from diagnosis and insulin requirements
will change as they grow into adulthood. It is becoming more common for children to
be on an insulin pump or on multiple dose injections (MDI) from a very young age.

In children with type 2 diabetes, lifestyle education remains the foundation of


management. All education should be done as a whole of family approach.

Adolescence
The management of diabetes during adolescence can be difficult for a myriad of
reasons. Firstly, puberty is associated with insulin resistance and so many young
people require more insulin than what is usually needed for their weight. Other issues
such as alcohol and illicit drug use, dating, sex, contraception, driving, employment,
study and sport must be discussed in a non judgmental way.

All children and adolescents in school or child care must have a care plan that has
been developed in consultation with the paediatric service, parents and school staff.
For more information, visit www.decs.sa.gov.au (Department of Education and
Children’s Services).

Transition to adult services


Young adults with diabetes pose a challenge because they fall outside the focus of the
paediatric and the adult clinics. Many of these young adults are at risk of ‘falling
through the gaps’ which puts them at high risk of acute and long term complications.22

Young people with diabetes need support to stay connected to their diabetes health
professionals. Resources such as www.realitycheck.org.au can be invaluable for
young people as the website is written by young adults who have type 1 diabetes. The
website has many stories and real life accounts of what it is like to live with type 1
diabetes 24/7.

SECTION 7 – COMMUNITY GROUPS WITH SPECIAL NEEDS – REVISED SEPTEMBER 2009


4
People with mental health / illness issues
Individuals who live with psychotic disorders and other mental illness have a higher
23
prevalence of type 2 diabetes as compared with the rest of the population. This
higher prevalence relates to the illness itself, poor dietary habits, lack of exercise and
the direct or indirect effects of antipsychotic and other psychotropic medications.23, 24 A
25
diagnosis of diabetes has also been shown to double the odds of depression.
Conversely a diagnosis of depression can double the risk of developing type 2
diabetes. Depression can also increase the chance of developing complications. It is
important to provide people with the appropriate supports and resources. BeyondBlue
has a fact sheet called ‘Depression and diabetes’ at www.beyondblue.org.au and
SANE Australia has also produced a resource called ‘The SANE guide to good mental
health’. For more information, visit the website at www.sane.org.

Medications used in mental illness


Second generation antipsychotic (SGA) medications are widely used in conditions such
as schizophrenia, bipolar disorder, dementia and psychotic depression. The use of
SGA medications have been associated with reports of dramatic weight gain, type 2
diabetes and changes in lipid profiles.26 It is for this reason that all people taking
antipsychotic medication should be regularly screened for diabetes and its associated
risk factors.23

There is also a possibility of diabetic ketoacidosis in clients taking SGA medication and
clients need to be assessed for and aware of the signs and symptoms of
hyperglycaemia.26

Education and support


People who live with a mental illness need ongoing support and education. Diabetes
knowledge has been demonstrated to be lower in populations with mental illness as
compared to the general population.27 Frequent repetition of important information is
beneficial for all people with diabetes but it is critical for clients with a psychotic illness.

Health professionals who care for clients with mental illness should encourage healthy
nutrition and activity as these can improve metabolic parameters even when there is
no weight loss.23

SECTION 7 – COMMUNITY GROUPS WITH SPECIAL NEEDS – REVISED SEPTEMBER 2009


5
References

1. Australian Institute of Health and Welfare (2008) Australia's health no.11. [Cited
9 February 2008]; Available from:
http://www.aihw.gov.au/publications/index.cfm/title/10585

2. Australian Institute of Health and Welfare (2005) Diabetes-related deaths in


Australia, 2001 - 2003. Bulletin. Issue 32, December, Australian Institute of
Health and Welfare, Canberra.

3. Lowe S and O'Kane A (2003) Workforce report for South Australia. Services for
Australian Rural and Remote Allied Health Inc, Canberra.

4. Population Research and Outcomes Studies Unit (2007) South Australian


diabetes prevalence for those 16 years and over from 2002/03 to 2006/7.
Request ID 200712653, December, Government of South Australia, Adelaide.

5. Population Research & Outcomes Studies Unit (2006) Diabetes in rural and
metropolitan areas. DiabInfo. July, Government of South Australia, Adelaide.

6. National Diabetes Services Scheme (2008) NDSS SA registrants: type1


diabetes 0-18 yrs and 19-25 yrs. 31st October 2008, Diabetes Australia Ltd,
Canberra.

7. Population Research and Outcomes Studies Unit (2005) Prevalence of


diabetes in the SA health regions. Government of South Australia, Adelaide.

8. Australian Institute of Health and Welfare (2006) Rural, regional and remote
health - Mortality trends 1992-2003. AIHW Cat. No. PHE71, Australian Institute
of Health and Welfare, Canberra.

9. Couzos S and Murray R (2003) Aboriginal primary health care: An evidence


based approach. Oxford University Press, Oxford.

10. De Courten M, Hodge A, Dowse G, King I, Vickery J, and Zimmet P (1998)


Review of the epidemiology, aetiology, pathogenesis and preventability of
diabetes in Aboriginal and Torres Strait Islander populations. Commonwealth
Department of Health and Family Services, Canberra.

11. SA Health (2008) South Australia: Our health and health services. Government
of South Australia, Adelaide.

12. Australian Bureau of Statistics and Australian Institute of Health and Welfare
(2008) The health and welfare of Australia's Aboriginal and Torres Strait
Islander peoples. ABS Catalogue No. 4704.0, AIHW Catalogue No. IHW 21,
Commonwealth of Australia, Canberra.

13. McDermont R A, Tulip F, and Schmidt B (2004) Diabetes care in remote


northern Australian Indigenous communities. Medical Journal of Australia,
180(17 May): p512-516.

14. South Australian Aboriginal Health Partnership (2005) Aboriginal health -


everybodys business, Diabetes; A South Australian strategy for Aboriginal and
Torres Strait Islander people 2005 - 2010. South Australian Department of
Health, Adelaide.

SECTION 7 – COMMUNITY GROUPS WITH SPECIAL NEEDS – REVISED SEPTEMBER 2009


6
15. Thow A and Waters A (2005) Diabetes in culturally and linguistically diverse
Australians. Australian Institute of Health and Welfare, Canberra.

16. von Hofe B, Thomas M, and Coligiuri R (2002) A systematic review of issues
impacting on health care for culturally diverse groups using diabetes as a
model. Australian Centre for Diabetes Strategies & Multicultural Health Unit,
Sydney.

17. Burden M (2001) Culturally sensitive care: Managing diabetes during Ramadan.
British Journal of Community Nursing, 6(11): p581-585.

18. Naeem A (2003) The role of culture and religion in the management of
diabetes: a study of Kashmiri men in Leeds. The Journal of The Royal Society
for the Promotion of Health, 123(2): p110-116.

19. Diabetes Australia (2002-2005) Multilingual internet resource. [Cited 16 June


2009]; Available from:
http://www.diabetesaustralia.com.au/Resources/Multilingual/

20. Australian Institute of Health and Welfare (2008) Incidence of type 1 diabetes in
Australia 2000–2006. Australian Government, Canberra Cat. no. CVD 42.

21. Australasian Paediatric Endocrine Group (2005) Clinical practice guidelines:


Type 1 diabetes in children and adolescents. Department of Health and Ageing,
Canberra.

22. Weissbert-Benchell J, Wolpert H, and Anderson B J (2007) Transitioning from


pediatric to adult care. Diabetes Care, 30(10): p2441-2446.

23. Lambert T and Chapman L (2004) Diabetes, psychotic disorders and


antipsychotic therapy: a consensus statement. Medical Journal of Australia,
181(10): p544-549.

24. Sokal J, Messias E, Dickerson F, Kreyenbuhl J, Brown C, Goldberg R, and


Dixon L (2004) Comorbidity of medical illnesses among adults with serious
mental illness who are receiving community psychiatric services. The Journal of
Nervous and Mental Disease, 192(6): p421-427.

25. Anderson R, Freedland K, Clouse R, and Lustman P (2001) The prevalence of


comorbid depression in adults with depression. Diabetes Care, 24(6): p1069-
1079.

26. American Diabetes Association (2004) Consensus development conference on


antipsychotic drugs and obesity and diabetes. Diabetes Care, 27(2): p596-602.

27. Dickerson F, Goldberg R, Brown C, Kreyenbuhl J, Wohlheiter K, Fang L,


Medoff D, and Dixon L (2005) Diabetes knowledge among persons with serious
mental illness and type 2 diabetes. Psychosomatics, 46(5): p418-424.

SECTION 7 – COMMUNITY GROUPS WITH SPECIAL NEEDS – REVISED SEPTEMBER 2009


7
SECTION 8
Healthy eating and diabetes
Aims of the diabetes nutritional guidelines
1
The main aims of these guidelines are to:

• Achieve and maintain:

- Blood glucose levels in the normal range or as close to normal as is safely


possible
- A lipid and lipoprotein profile that reduces the risk of vascular disease
- Blood pressure levels in the normal range or as close to normal as is safely
possible

• To prevent, or at least slow, the rate of development of the chronic complications


of diabetes by modifying nutrient intake and lifestyle.

• To address individual nutrition needs, taking into account personal and cultural
preferences and willingness to change.

• To maintain the pleasure of eating by only limiting food choices when indicated
by scientific evidence.

Education for healthy eating


A separate kit `Healthy eating & diabetes kit’,2 has been designed for use by doctors,
dietitians, practice nurses and diabetes educators and will be especially useful for
people with type 2 diabetes.

Purpose of kit
1. To provide a means of making a preliminary dietary assessment.
2. To provide initial dietary advice, to help the person start making necessary
changes in their diet prior to more `in depth’ dietary education later.
3. To promote continuity of dietary education between doctor, diabetes educator
and dietitian.

This kit, in conjunction with the Diabetes Manual, will assist in providing information for
nutrition education and can be obtained from The Queen Elizabeth Hospital Diabetes
Centre. Further information may be required for people with type 1 diabetes.

SECTION 8 – HEALTHY EATING AND DIABETES – REVISED SEPTEMBER 2009


1
When to refer to a dietitian
The nutrition management component of diabetes care includes both general nutrition
education and medical nutrition therapy (MNT). General nutrition education covers a
range of nutrition topics required by all people with diabetes and may be delivered by
both dietitians and qualified diabetes educators. Diabetes educators who work with
dietitians as part of a multidisciplinary team should provide general nutrition education
as agreed between team members.

MNT builds on general nutrition education and is an individualised and comprehensive


clinical intervention. MNT should only be delivered by dietitians (preferably Accredited
Practising Dietitians). The Australian Diabetes Educators Association (ADEA) and the
Dietitians Association of Australia (DAA) have released a joint statement that
recommends that all people with diabetes should have access to a dietitian for MNT in
order to achieve optimal nutritional management as part of their diabetes care.3

All people with newly diagnosed diabetes should have access to dietary education
preferably with a dietitian. If resources for dietetic services are limited then the
following client groups should take priority in seeing a dietitian:

• all people with type 1 diabetes requiring nutrition education / review


• all women with gestational diabetes or diabetes during pregnancy
• all people with specific life-stage nutrition requirements or who are potentially
nutritionally compromised
• all people with co-morbidities impacting on their diabetes management or
nutritional requirements.

A dietitian referral is indicated in the following situations:

• weight issues (ie underweight or overweight or unexplained weight gain / loss)


• frequent hypo or hyper glycaemia
• inadequate blood glucose management
• elevated blood lipids
• elevated blood pressure
• change in diabetes management (ie oral hypoglycaemic agents or insulin
therapy)
• commencement of insulin therapy
• commencement of insulin pump therapy
• other nutritional issues eg renal nutrition modifications, coeliac disease, food
allergy / intolerance.

If a health professional is unsure of nutrition referral criteria or referral process, they


should discuss with the dietitian.

SECTION 8 – HEALTHY EATING AND DIABETES – REVISED SEPTEMBER 2009


2
Include a variety of foods each day
Healthy eating is the cornerstone for diabetes management. There is no
“special diet” for diabetes. A healthy eating plan, based on a variety of foods
from the five food groups, is recommended for the whole population. We
should ‘eat most’ of wholegrain breads and cereals, followed by vegetables and
legumes and fruit. Milk and milk products, meat and meat alternatives should
be included in smaller amounts each day.
The following table outlines good food choices and approximate serves
required from each food group (for adults):
Healthy Food Choices from the Five Food Groups
Breads and Cereals 1 serve =
 4-5 serves daily 1 slice bread, 1/2 roll, 1 muffin, 1 crumpet, 3 large
crispbreads,
 preferably choose wholegrain, high breakfast cereals, eg 1/4 cup raw oats, 3/4 cup cooked
fibre varieties porridge, 1 1/2 Weetbix, 1 cup Puffed Wheat, 12 mini-
wheats, 3/4 cup Guardian, 1/3 cup All-Bran, 1/4 cup
rice bran, oat bran, or barley bran.
1/2 cup cooked noodles, spaghetti or macaroni,
1/2 cup raw barley or 1/3 cup cooked rice (choose
Basmati or Doongara rice), 1/3 cup bulgur (cracked
wheat)
Vegetables 1 serve =
 Aim for 5 serves each day 1 medium potato, 1/2 cup sweet potato, 1/3 cup sweet
corn (or 1 cob), 1/2 cup cooked (dried) beans, peas
Starchy and lentils
eat in moderation, 1-2 serves daily
Serves do not apply for non-starchy vegetables – they
Non-starchy are unrestricted
eat plenty asparagus beetroot broccoli
fresh, frozen and canned varieties cabbage capsicum carrot
are suitable cauliflower celery cucumber
choose the low salt tinned varieties eggplant green beans lettuce
mushrooms onions peas
pumpkin spinach tomato
turnip zucchini
Fruit Any fruits are suitable 1 serve =
 eat in moderation, 2-3 serves, 1 apple, 2 apricots, 1 banana, 1 cup berries,
spaced over the day 15-20 grapes, 1 orange, 1 peach, 1 pear, 2 slices
 fresh, unsweetened canned or dried pineapple, 1 tablespoon sultanas, 6 dried apricot
(not glace) varieties are suitable halves, 3/4 cup tinned fruit drained,120ml
unsweetened fruit juice (limit to 1 glass a day)
Milk products 1 serve =
 3-4 serves daily 300ml milk – fresh, evaporated, dried, UHT,
200g yoghurt – natural or diet,
 preferably use low fat or skim 300ml buttermilk, soy milk (with added calcium)
varieties 40g hard cheese, 100g ricotta or cottage cheese
Protein foods 1 serve =
 1 serve daily 120g lean meats such as beef, lamb, pork, rabbit,
kangaroo
 use non-fat cooking methods 100g poultry without skin – chicken, turkey
eg baking on a rack, boiling, grilling, 80-120g fresh or canned fish, seafood
micro-waving, steaming 1/2 cup cooked (dried) peas, beans and lentils
2 small eggs
Fat – a small amount
Use small amounts only, around Best choices are polyunsaturated or mono-unsaturated
1 tablespoon a day. Limit frying. margarines and oils eg sunflower, sunola, macadamia,
canola, olive. Avocados, nuts and seeds are high in
good fats; use in small amounts. Avoid or limit
saturated and trans fats eg butter, lard, dripping,
cream, coconut milk/cream, palm oil (used to make
many commercial biscuits / pastries / chocolates).
SECTION 8 – HEALTHY EATING AND DIABETES – REVISED SEPTEMBER 2009
3
Importance of weight management
Weight management is an important component of a healthy lifestyle. Being
overweight or obese increases the risk of developing type 2 diabetes. Excess
weight is associated with insulin resistance (and hence poorer diabetes
control), increased risk of cardiovascular disease, stroke, joint problems and
some types of cancer. Although being overweight or obese is not a risk factor
for type 1 diabetes, a healthy weight is encouraged for all Australians.

If overweight or obese, even a modest weight loss of 5 to 10% of body weight


can improve glycaemic control in type 2 diabetes, lipids, blood pressure and
quality of life. A healthy weight is determined by calculating the Body Mass
Index (BMI)*. However, it may be more useful (and more realistic) to set small
but specific weight loss goals with the person. For example, for someone with
an overall weight loss goal of 10kg, you might encourage smaller monthly goals
of 1kg for the next 10 months.

Waist circumference measurements are another useful tool for assessing risk
of chronic disease. Excess weight around the waist / abdomen is associated
with insulin resistance and a higher risk for chronic disease. A waist
measurement of greater than 94cm for men or 80cm for women is an indicator
of the internal fat deposits, which coat the heart, kidneys, liver and pancreas.
Measurements of more than 102cms for men and 88cm for women greatly
increase the risk of chronic disease.

Use the following tips for taking waist measurements:

• measure directly against the skin


• ask the person to breathe out normally
• make sure the tape is snug without compressing the skin
• measure halfway between the lowest rib and the top of the hipbone,
roughly in line with the belly button.
Refer to the Australian Better Health Initiative ‘Measure-Up’ campaign website
http://www.measureup.gov.au.

Weight loss requires either a reduction in energy (calorie / kilojoule) intake


(through changes in eating habits) or an increase in energy output (by
increasing physical activity), or both. A Cochrane Review found that people
who combined exercise with dietary change lost more weight compared to
those who used diet alone.4 Furthermore, exercise is associated with improved
cardiovascular disease risk factors even if no weight is lost.5 “Eat less, walk
more” is an important and simple message for a healthy lifestyle.

* 2
Body Mass Index (BMI) is calculated as weight (kg) divided by height (m) . Ideal range =
2 2 2
20–24.9kgm ; underweight = <20kgm ; overweight = 25–29.9kgm ; obese class 1 = 30–
2 2 2
34.9kgm ; obese class 2 = 35– 39.9kgm ; obese class 3 >40kgm .

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What is carbohydrate?
Carbohydrate is one of the main nutrients in foods. Carbohydrate comes from
foods containing sugars or starches, eg:

• breads, cereals, grains


• starchy vegetables eg potato, sweet potato, corn
• legumes
• fruit (contains a sugar called fructose)
• milk and yoghurt (contains lactose, a milk sugar)
• foods with added sugars such as table sugar, soft drinks, cakes, biscuits,
lollies (these are higher energy, non-nutritional choices and should be
limited to occasionally).

All carbohydrate foods are eventually digested to glucose. The glucose is


absorbed into the bloodstream and is the body’s main source of energy.
Carbohydrate should contribute approximately 50% of the total energy intake
(range from 45% to 65%). In type 2 diabetes, it is usually recommended that
carbohydrate intake be evenly distributed across the day, to help regulate blood
glucose levels. For people using rapid acting insulin, their insulin doses should
be matched to carbohydrate intake. For people using fixed daily insulin doses,
carbohydrate intake should be kept consistent on a day-to-day basis (specific
advice can be provided by a dietitian).

Carbohydrate foods that can assist in improving blood glucose levels are those
that are low in fat, high in fibre and are broken down slowly to glucose (low
Glycaemic Index, GI). Examples of such foods are wholegrain breads and
cereals, legumes (eg baked beans), most fruit, low fat milk and low fat yoghurt.
See next section for more information on GI.

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The glycaemic index
The Glycaemic Index (GI) is a ranking of carbohydrate foods from 0–100,
according to the rate at which the carbohydrate in the food is digested and
6
absorbed into the bloodstream as glucose. Carbohydrate foods that break
down slowly release glucose gradually into the bloodstream and have a low GI.
Examples of low GI carbohydrate foods are most wholegrain breads (eg Tip
Top 9 Grain and Burgen Mixed Grain), legumes, oats, milk and most fruit.
Carbohydrate foods that break down quickly produce a faster and higher rise in
blood glucose levels and have a high GI. Examples of high GI carbohydrate
foods are regular sliced white bread, Rice Bubbles and jellybeans.

Including low GI foods in the diet may have a number of benefits:

• they can assist with the management of diabetes as they may produce
lower blood glucose levels
• they can help to improve satiety (ie make you feel fuller for longer) thereby
assisting in appetite control
• they may help to reduce the incidence of hypoglycaemia for those on
insulin or sulphonylurea medications.

However, GI alone should not determine food choices.

Other factors that need to be considered include:

• the overall nutrient content of the food, especially the fat content of foods
(eg chocolate has a low GI but is high in fat)
• the amount of food eaten (eg a large amount of food that is low in GI will
still likely have a large impact on BGLs).
At least one low GI food per meal is recommended. See table 1.

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Table 1
GI of Various Foods
Low GI (55 and under) Medium GI (56-69) High GI (70 and above)
Breakfast Cereals Breakfast Cereals Breakfast Cereals
Rice bran & oat bran, Kelloggs All- Sanitarium Weet-Bix, Sanitarium Puffed wheat,
Bran, Kelloggs Guardian, porridge Uncle Tobys Vita Brits, Kelloggs Rice Bubbles,
(made from rolled oats), Burgen Kelloggs Just Right, Kelloggs Sultana Bran,
Muesli, Kelloggs Sustain, Kelloggs Kelloggs Mini Wheats Kelloggs Bran Flakes,
Komplete (plain) Kelloggs Cornflakes,
Kelloggs Blackcurrant Mini
Breads & cereals Breads & Cereals Wheats, Kelloggs Coco
Many whole grain/multi grain Rye wholemeal & light Pops, Shredded Wheat
breads (such as Tip Top 9 Grain, rye bread, wholemeal
Burgen Mixed Grain, Bakers bread, pita bread (white), Breads & Cereals
Delight Cape Seed), Bakers Bakers Delight Apricot Many types of white bread
Delight Lo GI white bread, Delight Log, crumpet, (eg Tip Top Sunblest white
Wonder White Low GI bread, croissant*, Basmati white bread, Bakers Delight
Buttercup Fruit and Spice loaf, rice (boiled), Sunrice Tiger Loaf, regular white
Tip Top Fruit Loaf, pearl barley, Arborio risotto rice sliced bread), English
pasta (durum wheat), fresh rice (boiled), wild rice,
muffin, bagel (white),
Sunrice medium grain baguette, Jasmine rice,
noodles (boiled), Maggi 2 minute brown rice, buckwheat glutinous rice, tapioca
instant noodles (low fat), cracked noodles, dried rice
wheat (Bulgur), buckwheat, noodles boiled, gnocchi Biscuits
Doongara Clever Rice, Long grain cooked, couscous, Water crackers, Sao
white Mahatma rice, semolina polenta (plain)*
Morning Coffee biscuits,
Biscuits Biscuits Ricegrowers Puffed Rice
Ryvita crispbread (Pumpkin Ryvita crispbread Cakes
Seeds and Oats/ Sunflower (Original Rye/ Sesame
Seeds and Oats), Arnotts Snack Rye), Vegetables
Right Fruit Slice Shredded Wheatmeal, Potatoes, broad beans
Milk Arrowroot biscuits
Vegetables Fruit
Sweet corn, sweet potato (baked) Dairy Products Watermelon, lychees
Ice cream* (regular) (canned in syrup, drained)
Legumes & Pulses
Lentils, red kidney beans, butter Fruit
beans, cannellini beans, split peas, Sultanas, pineapple, Drinks
chick peas, baked beans rockmelon, apricots, Sports drinks (eg
cherries (dark), pawpaw, Gatorade), Lucozade
Dairy Products raisins
Low fat varieties of yoghurt, milk, soy
Sugars
milk, custard, Fruche
Sugars glucose, jelly beans
Fruit Sugar (sucrose)
grapefruit, dried apricots & apples,
pears, apples, plums, peaches,
banana (average), oranges, grapes,
prunes pitted, mango, kiwifruit,
nectarine, strawberries

Juices
Fruit juices (apple, orange,
pineapple, grapefruit)
* These are foods high in fat. Use them occasionally.

For more information, see http://www.glycemicindex.com.

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Carbohydrate serves / exchanges
The recommended intake of carbohydrate foods will vary from person to
person; depending on many factors such as weight, height, age, exercise /
activity levels, diabetes medications and insulin. A dietitian will be able to
advise on how much is individually appropriate. A general recommendation for
most adults is 9–15 serves of carbohydrate foods spread evenly over the day,
depending on activity levels. People with type 1 diabetes will need more
specific guidelines on carbohydrate intake and are advised to seek
individualised dietetic input. One serve of carbohydrate contains approximately
15 grams of carbohydrate (another word for a carbohydrate serve is an
exchange).

Example serves (exchanges) of carbohydrate foods are listed below.

One carbohydrate serve (exchange) is equal to:


Amount Food
BREADS AND CEREALS
1 slice Bread eg wholegrain
1/2 roll Bread roll (medium)
3/4 cup Cooked porridge (use 1/4 cup raw oats)
1 1/2 cup Good Start, Weet-Bix, Vitabrits, Bran Bix, Lite Bix
1/4 cup Muesli
1/2 – 3/4 cup Other cereals (eg Weeties, Sustain, Bran Flakes)
1/3 cup Cooked rice eg Basmati, Doongara
1/2 cup Cooked pasta, noodles
3 large Crispbread (preferably wholegrain), eg Ryvita, Cruskits,
Vita Wheats, rice cakes
1 1/2 tblspns (dry) Barley, millet, cracked wheat, burghul
STARCHY VEGETABLES
1 medium Potato
1/2 cup Mashed potato or sweet potato
1/3 cup Sweetcorn or 1/2 cob of corn
1/2 cup Cooked lentils or legumes eg Baked Beans
FRUIT
1 medium Apple, orange, pear, peach, grapefruit, nectarine, banana
2-3 small Plums, apricots, mandarins, kiwi fruit, dates, prunes
1 cup Strawberries, blackberries
1 tablespoon Sultanas
15 - 20 Grapes
MILK PRODUCTS
300ml Skim or low fat milk
300ml Reduced fat soy milk (preferably with added calcium)
200g Low fat, natural yoghurt or artificially sweetened diet yoghurt
100g Light fruit yogurt

Dietitians can usually provide more comprehensive exchange lists.


Carbohydrate counters are also available at many bookstores.

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What about fat?
Fats in the diet are essential for good health. However too much fat in the diet
can contribute to weight gain and saturated fat can increase the risk of other
health problems (such as heart disease). Dietary fats have over double the
energy (calories / kilojoules) content of carbohydrate and protein. In addition,
dietary fat is readily converted to and stored as body fat.

Australians consume too much fat with many having over 40% of total energy
intake. An intake of 30% or less is recommended, with a focus on lowering
saturated fat intake.

Saturated fat is often referred to as the ‘bad’ fat as it raises blood LDL
cholesterol levels. Saturated fat mainly comes from animal products and some
plant oils (mainly palm and coconut oil) (refer to table below). Unsaturated fats
(either poly or mono-unsaturated) are known as ‘good’ fats as they may help to
improve blood cholesterol levels if they replace saturated fats in the diet.

The following table indicates different sources of fat.


Saturated Monounsaturated Polyunsaturated
Fats Oils/Margarines Oils/Margarines
 Butter, lard, Copha, cooking  Canola  Sunflower, safflower
margarine  Olive  Corn
 Ghee, dripping, dairy blends,  Macadamia  Soybean, sesame
vegetable shortening  Sunola  Cottonseed
 Cream, sour cream  Peanut  Grapeseed

Meat/meat products Vegetables Nuts & Seeds


 Fatty meat (untrimmed chops,  Avocado  Walnuts
poultry skin, chicken wings, fatty  Olives  Pine nuts
mince)  Brazil nuts
 Smallgoods, sausages, saveloys, Nuts & Seeds  Sesame seeds
fritz, salami, bacon, mettwurst  Almonds  Sunflower seeds
 Full fat dairy products (full cream  Peanuts  Linseeds
milk, cheese, cream cheese, full  Cashews
fat yoghurt, regular ice cream)  Hazel nuts Spreads
 Pate  Macadamia  Tahini
 Pecans
Plant sources Fish/Seafood
 Coconut oil/cream/milk Spreads  (choose fresh fish or
 Palm oil (used commercially in  Peanut paste canned in
fast food/take away and  Almond spread water/brine)
cakes/biscuits)  sardines, mackerel
 Toasted breakfast cereal eg  Salmon, tuna, mullet
muesli  Calamari
 Gem fish
Takeaway foods  Blue eye cod
 Commercial
cakes/pastries/biscuits
 Deep fried or battered foods
 Pies, pasties, sausage rolls
 Pastries – shortcrust and puff
pastry
 Potato crisps, hot chips

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Trans fats are another type of fat that have a similar effect on blood cholesterol
levels as saturated fats and should be limited. Trans fats are found in many
high fat animal products (such as fatty meats, full cream dairy) as well as some
types of margarine. Trans fats can form in the processing of a liquid oil into a
solid (ie margarine processing). Most margarines in Australia are now low in
trans fats. Look for margarines containing less than 1% trans fat (less than 1
gram of trans fat per 100 grams).

The following fat checklist may be useful.

Avoid or Limit These Foods Suitable Alternatives


High in Fat Alternatives
Mayonnaise, oily dressings, cream sauces, Low joule dressings and light mayonnaise,
fatty gravies, sour cream. vinegar, lemon juice, low joule Gravox, plain
low fat yoghurt, soy sauce, fish sauces and
stock.

Fat on meat, chicken skin, fatty meats - eg Trim fat from meat, remove chicken skin,
sausages, fritz, bacon, salami, deep-fried use lean cuts of meat, cook without fat or
foods, pies, pasties. use an oil spray.

Snack foods - eg nuts, crisps, hot chips, Limit quantity of snacks. Try crisp, raw
prawn crackers. vegetables, fruit, pretzels, or plain popcorn
instead.

Large amounts of margarine, butter, oil, Limit to 1 tablespoon per day of added fats,
cream, peanut butter, dripping, lard, ghee, preferably poly or monounsaturated
coconut cream. margarine or oil.

Full fat (regular) dairy products eg full Use reduced or low fat cheese.
cream milk and cheese, full cream yoghurt.

Protein
Protein is a nutrient essential for the body’s growth and repair, as well as having
other important functions in the body. Foods that are rich in protein include
cheese, eggs, fish / seafood, meat and poultry. These foods do not contain
carbohydrate and do not directly affect blood glucose levels. Milk and yoghurt
are rich in both protein and carbohydrate, and will affect blood glucose levels.
These foods need to be considered in the daily carbohydrate requirements.

Protein foods may be high in fat and saturated fat. Small serves of low fat
protein foods should be included each day, for example skinless chicken, lean
beef or meat trimmed of fat, fish, boiled or poached eggs and low fat dairy
products. Legumes and pulses are also good sources of protein. Refer to
’Good Food Choices’ table on page 3 of this section for serve sizes.

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A word about fibre
Dietary fibre is the part of plant food that cannot be digested by the body. Fibre
is important for good health and has many important roles:

• prevention and treatment of constipation


• contribution to weight management by creating a feeling of fullness in the
gut
• soluble fibre (found in fruit, oats, legumes) may help to reduce blood
cholesterol
• soluble fibre can slow down digestion and may help to manage blood
glucose levels.

Foods that are high in fibre include:

• wholegrain breads and cereals


• oats, porridge and brans
• fruit and vegetables (especially with edible skins)
• legumes, such as lentils, red kidney beans and baked beans
• nuts and seeds.

How much salt do we need?


Salt consists of sodium and chloride. Excess sodium can cause the body to
retain fluid, which may lead to high blood pressure, heart disease and kidney
disease. The amount of sodium needed for body functions is small and is
provided by the sodium that occurs naturally in foods such as meat, fish, milk,
eggs and vegetables. The recommended intake for sodium is 1600mg/day to
reduce risk of chronic disease or an upper limit of 2300mg/day for adults. The
average Australian consumes up to 4600mg/day, with most of the salt
contribution from processed foods. Remember that there is a period of
adjustment in taste when reducing salt and so be patient.

Ways to reduce salt:

• avoid adding salt to cooking and at the table (create flavour with garlic,
onion, spices and herbs)
• choose ‘No Added Salt’, ‘Low Salt’ or ‘Salt Reduced’ products (remember
these still contain some sodium)
• limit commercially prepared food, takeaways and avoid salty snack foods
(eg crisps and salted nuts)
• steam or microwave your vegetables without adding salt
• cook pasta, rice and potatoes without salt
• check food labels for lower salt products (less than 120mg sodium per
100g is a low salt product; up to 400mg sodium per 100g is a moderate
salt product).

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Alcohol and diabetes
Alcohol has an accepted place in our society today and can be a pleasant indulgence if
enjoyed in moderation. However, excessive drinking of alcohol is harmful and can lead
to health and social problems.

For people with diabetes, alcohol also needs to be limited because:

• Alcohol is high in kilojoules / calories and can contribute to excess weight.


Achieving a healthy weight is very important in managing diabetes.
• Alcohol can react with many medications, including some diabetes tablets and
insulin, to cause unpleasant side effects.
• Alcohol can increase the risk of hypoglycaemia (low blood glucose levels) for
people on insulin therapy or taking sulphonylurea medications. The ‘hypo’ can be
delayed.
• If the alcoholic drink contains carbohydrate, eg regular beer, diet beer, sweet
wines and liqueurs, the blood glucose level can rise too high (hyperglycaemia).

Guidelines for sensible drinking


1. The Australian Alcohol Guidelines recommend no more than two standard drinks
on any day.7

A standard drink is: 285ml schooner of regular beer


425ml light beer
30ml nip of spirits
100ml wine
60ml glass of fortified wine (eg sherry)

2. Drinking without eating can increase the risk of `hypo’ for people on insulin or
sulphonylurea medications. It is recommended to have some carbohydrate food
such as wholegrain bread, crackers or the usual meal when drinking alcohol and
to keep a closer check on blood glucose levels.

3. Lower calorie choices are:

• dry wines, eg riesling, dry sherry, dry reds, brut champagnes


• spirits mixed with water or diet drinks, eg whisky, brandy, gin, rum, vodka,
dry vermouth
• light beer.

Cooking with alcohol


Dry wines and spirits can be used in cooking. The heat will evaporate most of the
alcohol, leaving the flavour behind.

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Special considerations
Nutrition standards in your health service
As a health service it is important to demonstrate to colleagues and the wider
community healthy options for food provision in your service. To assist health services
in providing nutritionally appropriate options for events (eg community education,
meetings, focus groups, open days) the SA Health has developed a policy on ‘Healthy
8
food and drink choices for staff and visitors in SA health services’. See
http://www.publications.health.sa.gov.au/fs/22/.

Pregnancy
Diabetes in pregnancy can be gestational diabetes or pre-existing type 1 or type 2
diabetes (see Pregnancy – Section 13). General healthy eating guidelines apply for
women with diabetes who are pregnant or planning pregnancy. Adequate glycaemic
control and a healthy weight can optimise outcomes for both the mother and baby.
Pre-pregnancy medical counselling and review for women with diabetes should occur.

Women planning to become pregnant should take a folic acid supplement of 500mcg
for at least one month before pregnancy and the for the first three months, to reduce
the risk of neural tube defects in the child. Pregnant women with pre-existing type 1
diabetes or type 2 diabetes have higher folic acid supplement requirements; 5mg
supplementation per day is recommended.

The management of type 1 diabetes in pregnancy is challenging. Prompt referral to a


specialist dietitian is essential.

Pregnant women with diabetes mellitus need to pay particular attention to the amount
and type of carbohydrate that they eat. Usually women are advised to eat several
small meals throughout the day. Every meal and snack should contain carbohydrate
and should be eaten at consistent intervals each day. Low glycaemic index
carbohydrates can help to manage blood glucose levels.

The aims of healthy eating during pregnancy are to:

1. achieve or maintain normal blood glucose levels (or as close to normal as


possible)
2. provide a healthy eating plan which meets the increased nutritional demands of
pregnancy
3. achieve an appropriate weight gain during the pregnancy.

Post-pregnancy the mother should be encouraged to breastfeed (if possible). Women


with gestational diabetes should be followed up post-partum to assess for type 2
diabetes.

A dietitian can provide specific advice and support for women with diabetes throughout
their pregnancy and beyond.

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Hospitalisation and convalescence
During hospital admissions some people with diabetes have altered nutritional needs
as a result of their presenting illness, for example, someone with type 1 diabetes
undergoing major surgery might have special nutritional needs as a result of their
operation. Others may be chronically unwell, for example, may suffer from chronic
renal failure or chronic obstructive airways disease. In these cases the dietary
recommendations are determined by assessing the total clinical situation and not only
the diabetes. A dietitian referral would be appropriate.

Nutrition for children with diabetes


Most of the diabetes that occurs in children is type 1 diabetes. However, the incidence
of type 2 diabetes in children and adolescents is growing. Children need to eat foods
that meet their nutritional needs for growth and development.

Children with type 2 diabetes are often overweight or obese. A healthy eating plan that
limits fats (particularly saturated fats) and limits foods / drinks high in added sugars is
recommended. Regular physical activity is also important. Support and advice that
encourages healthy lifestyle changes should involve the whole family.

Similarly, although children with type 1 diabetes do not have to follow a special
‘diabetes diet’, they may need to pay more attention to when they eat and how much.
Insulin needs to be balanced with carbohydrate intake and activity levels to help
manage blood glucose levels.

Referral to a dietitian is essential for children with diabetes and their families.

Summary
1. General healthy eating guidelines apply for people with and without diabetes.

2. A dietitian can provide advice on developing individualised nutrition plans where


a person has special requirements.

3. For people using rapid acting insulin their insulin doses should be matched to
carbohydrate intake.

4. For type 2 diabetes, regular, small to moderate sized meals including


carbohydrate should be spread over the day. Meals should be based on
wholegrain breads and cereals, vegetables, legumes and fruit with smaller
serves of lean meats and dairy foods. Foods with a lower glycaemic index can
help to regulate blood glucose levels.

5. Exercise should be encouraged daily. For people on insulin therapy,


adjustments to insulin may be required for exercise (see Healthy lifestyle –
Section 9).

6. Healthy eating is the cornerstone for type 2 diabetes management.

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References
1. American Diabetes Association (2008) Position statement: Nutrition
recommendations and interventions for diabetes. Diabetes Care, 31(S1): pS61-
S78.

2. The Queen Elizabeth Hospital Diabetes Centre (2007) Healthy eating and
diabetes kit, The Queen Elizabeth Hospital Diabetes Centre, Woodville, South
Australia.

3. Australian Diabetes Educators Association and Dietitians Association of


Australia (2005) Joint statement on the role of accredited practising dietitians
and diabetes educators in the delivery of nutrition and diabetes self
management education services for people with diabetes. Canberra.

4. Norris S L, Zhang X, Avenell A, Gregg E, Brown T, Schmid C H, and Lau J


(2005) Long-term non-pharmacological weight loss interventions for adults with
type 2 diabetes mellitus. The Cochrane Database of Systematic Reviews. DOI:
Art. No.: CD004095. DOI: 10.1002/14651858.CD004095.pub2. Available from:
http://www.cochrane.org/reviews/en/ab004095.html

5. Shaw K A, Gennat H C, O'Rourke P, and Del Mar C (2006) Exercise for


overweight or obesity. The Cochrane Database of Systematic Reviews. DOI:
Art. No.: CD003817. DOI: 10.1002/14651858.CD003817.pub3. Available from:
http://www.cochrane.org/reviews/en/ab003817.html

6. Brand-Miller J and Foster-Powell K (2008) The new glucose revolution: The low
GI shoppers guide to GI values, 2008. Hachette Australia, Sydney.

7. National Health & Medical Research Council (2009) Australian guidelines: To


reduce health risks from drinking alcohol. Commonwealth of Australia,
Canberra.

8. Government of South Australia and SA Health (2009) Healthy food and drink
choices for staff and visitors in SA health facilities, SA Health, Adelaide.

SECTION 8 – HEALTHY EATING AND DIABETES – REVISED SEPTEMBER 2009


15
SECTION 9
Maintaining a healthy lifestyle
It is important for health professionals to appreciate that altering one’s lifestyle on a
permanent basis is usually very difficult.

People need encouragement and support to accept responsibility and recognise the
importance and consequences of their own lifestyle behaviour. It is extremely difficult
for an individual if they do not have adequate support from health care professionals,
family and friends. Healthy lifestyle changes need to be maintained over a long period
of time and therefore people will need continual support.

In discussing lifestyle changes it is important to consider the individual’s history,


culture, gender, where they live and their access to services, religious beliefs, financial
status and psychological state.

Stress
Stress is made up of many things and is caused by a range of different events or
circumstances. Different people experience different aspects and identify with different
definitions. The current consensus on accepted definition of stress is ‘a condition or
feeling experienced when a person perceives that demands exceed the personal and
social resources the individual is able to mobilize’. If a person feels that at this point in
time there is simply too much to handle, they will experience stress. How much an
individual can manage will vary at different times.

Stress occurs when the body automatically reacts to a difficult situation which may be
physical (eg illness or injury), or psychological (eg financial or relationship problems).
Underpinning this reaction is ‘fight or flight’ and the release of a range of hormones,
such as adrenalin. The autonomic nervous system is activated and it is important that
the person is able to counteract the potential damage caused by too much stress,
through regular activity, rest and relaxation to achieve balance.

Health care professionals should ensure that assessment of stress is an integral part
of the assessment process and that stress management strategies are part of the
education plan. The reaction to stress can be very individual and what affects one
person may not affect another. Similarly what one individual can handle will vary from
time to time.

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Potential emotional / psychological stressors may include:

• health problems
• personal trauma
• financial problems
• marital problems
• family problems
• pressure from study / work
• life crises, eg death, accident.

Some people experience stress in relation to things that have not and may never,
happen. We call this ‘worrying’. Worry can lead to high levels of stress and in such
cases, assessment of these issues and appropriate referral for counselling is
important.

The person with any lifelong condition such as diabetes has additional stressors
to deal with.

For example:

• simply coping with diagnosis: the person may feel anger, denial or grief following
the diagnosis of diabetes – this can come and go over time and is not
necessarily a linear process
• coping with the difficulty of changing lifestyle
• coping with new information and learning new skills
• the need, in many cases, to decrease weight, especially when some find eating a
way of coping with stress
• the need for lifelong daily care
• pain inflicted by prescribed treatments (eg blood glucose monitoring)
• the expense of equipment
• the impact on relationships
• diabetes specific stress, such as hypoglycaemia and needle phobia
• managing social situations
• worry about complications
• coping with understanding the health system.

How stress affects diabetes1


In people with diabetes, stress can alter blood glucose levels. It can do this in two
ways. First, people under stress may not take good care of themselves and their
diabetes as this is not their priority at that time. Second, stress hormones such as
adrenalin, cortisol and those produced when the person is unwell, may alter blood
glucose levels directly.

While most people’s glucose levels go up with emotional / psychological stress, others
may notice their glucose levels can go down. For some people with diabetes,
managing stress with relaxation therapy seems to help. It can be helpful for the person
to become aware of what happens to their diabetes when under stress and how to
manage the stress in order to have less impact. Physical stress, such as illness or
injury, can cause blood glucose levels to go up and down in people with either type of
diabetes.

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Dealing with stress2
People deal with stress in different ways.

Stress is usually caused by the reaction people have to what happens to them. Often
the reactions are out of proportion to the event, such as in ‘road rage’ for example. If
they are able to change their thinking and how they react to certain situations, then
these problems may become less stressful.

Some people however may react with damaging behaviour to cope with stress. For
example they may:

• eat more
• turn to taking drugs, alcohol and / or cigarettes
• stop taking responsibility for their own care
• cause added stress for their loved ones.

Healthy eating is a part of managing stress. A healthy diet can assist the body to
function at an optimum level and better handle stress. Refer to Section 8 for
information on healthy eating for people with diabetes. Exercise is also critical in stress
management.

Reducing and managing stress


It is not within the scope of this manual to deal adequately with suggestions for
reducing stress, however the following may assist:

• encourage regular exercise – this is the body’s natural way of reducing stress as
it uses up excess adrenalin and other stress hormones and encourages rest and
relaxation response in the body
• encourage the use of relaxation techniques – guided CD’s can be very helpful,
particularly if the person has not practised relaxation before and finds it hard to
relax
• encourage the person to find something that assists them in relaxation – it might
be walking, singing, swimming, talking to a friend, listening to music
• encourage the use of community resources, eg to stop smoking and / or reduce
alcohol intake
• encourage the person to make connections with other people with diabetes and
someone in their personal network, a family member or friend
• if necessary, consult with the health service social worker/counsellor, clinical
psychologist or general practitioner
• discuss with the medical officer a referral for professional counselling / treatment
– cognitive behavioural therapy (CBT) techniques such as ‘thought stopping’ and
‘positive visualisation’ can be helpful
• if a person shows signs of depression, discuss the option of referral for follow-up
with GP and referral for counselling.

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3
Screening tools
There are a number of diabetes specific tools that can be helpful in gauging a person’s
stress levels and mental health status. For example:

The WHO-5 Wellbeing scale


3
This scale is a measure of general well being. (See Appendix 1).

WHO (Five) score of below 50 indicates low mood but not necessarily depression. A
score of 28 or below indicates likely depression and warrants further assessment eg a
diagnostic interview with appropriate health professional.
4
The Problem Areas In Diabetes (PAID) scale
The PAID scale was originally developed by the Joslin Diabetes Centre in 1995 (see
Appendix 2). The PAID scale can be used to identify areas that are causing the
person distress and help focus problem solving activities so they reflect the particular
area causing concern. The person and the health professional can then explore
options for overcoming the problem.

To calculate a score you need to add them up and then multiply by 1.25 (score range
is from 0 – 100). People scoring 40 or more on the PAID scale may be experiencing
‘emotional burn out’ and warrant further individual assessment and possible
intervention. An extremely low score (0 – 10) combined with poor glycaemic control
may indicate denial. Denial is a normal part of life for many people with diabetes at
times, but persistent denial can be detrimental and needs addressing.

Diabetes Distress Scale (DDS)5


The authors of the PAID scale have recognised that the scale has some limitations eg
some items may have been covered too briefly. Given their concerns, they have
developed and validated an additional measure called the DDS. The scale has 17
items. You can use the DDS2 as an initial screener (see Appendix 3). If this is
positive (score ≥ 6 or average ≥ 3) you can then proceed to DDS17 (see Appendix 4).
Any items scoring ≥ 3 indicates an area of distress and the responses can be used to
begin a conversation about specific areas of their diabetes care.

The DDS and the PAID scale are not substitutes for depression screening.

Kessler Pyschological Scale (K10)6


The Kessler psychological scale consists of 10 questions that can detect depression
and other related psychological disorders.

You can go to http://www.beyondblue.org.au/index.aspx?link_id=89.678 and fill out the


form online. Once the person has submitted their answers the program will generate a
score. This screening tool only provides a rough guide and further steps are required
to obtain a full diagnosis of depression.

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4
Alternatively or in addition to the scales, you can use a series of open ended questions
to determine the person’s general wellbeing and concerns. Examples are:

• How are you feeling about your diabetes at the moment?


• Do you feel diabetes is a comfortable part of your life, or not? Maybe it is a bit of
both?
• What has been helpful for you in managing your diabetes?
• Do you ever feel sad, low or blue?
• Do you ever feel diabetes is overwhelming?
• Do you think you have the right amount of focus on your diabetes, or not? If not,
do you need to focus more or less on it?
• Are there any other problems or concerns in your life that make it difficult to
manage your diabetes?
• Do you have any support?
• What would you like to see change about your diabetes management at the
moment – anything at all?

These are just suggestions. Simply asking a person how they are feeling and what is
on their mind can unearth a lot of useful information – you just need to listen and allow
them the space to be heard. Questionnaires from the book ‘Diabetes Burnout’ by
William Polonsky contain a number of exercises around identifying stress and the
impact on diabetes; looking at areas of diabetes that are causing stress; and
assessing diabetes burnout.

Consider referral to medical practitioner, psychologist, social worker if signs of


psychological distress. It is critical that you do not leave a person with a low score on a
scale without appropriate discussion and follow up. Aim to leave them with some hope
in regards to seeking support, rather than a low score which leaves them feeling
hopeless.

Helpful websites
Australian Psychological Society www.psychology.org.au
Australian Association of Social Workers www.aasw.asn.au
Diabetes Counselling Online www.diabetescounselling.com.au
Beyond Blue www.beyondblue.org.au
Black Dog Institute www.blackdoginstitute.org.au

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5
Exercise
Exercise and physical fitness are an essential part of good health for everyone, not
only for people with diabetes. The diabetes health care team needs to assess and
clearly articulate each individual’s risks and benefits of an exercise program. These
benefits and risks will depend on the type of diabetes, presence of existing diabetes
complications or any other co morbid conditions that could affect the person’s ability to
exercise comfortably and safely. The person needs to understand the recommended
levels of intensity that is safe for their level of fitness and risk profile. Where
appropriate management plans / action plans should be provided which details
7
symptoms that could indicate cardiac problems.

Benefits
• assisting in the utilisation of glucose, thereby enhancing glycaemic control
• regulating appetite and aiding in weight control
• improving cardiovascular fitness
• increasing ‘feel good’ chemicals in the brain
• helping to reduce stress.

Risks
Overall the benefits of exercise outweigh the risks.7 There is a low prevalence of
musculoskeletal injuries in people who are walking, gardening or cycling. The risk of a
major cardiovascular event has been cited as 1 for every 117,000 hours of activity for
people with cardiovascular disease.7

Hypoglycaemia in people with diabetes who are on some oral hypoglycaemic agents
and / or insulin can occur during and post exercise. It is important for people to be
aware of what precautions they need to take to avoid hypoglycaemia when exercising.
They also need a hypoglycaemia action plan which details strategies for treating
hypoglycaemia when exercising.

Assessment
Before increasing usual activity or exercise levels it is recommended that the person
undergoes a medical assessment.8 The medical history and physical examination
should include signs and symptoms of:

• cardiovascular disease
• eye disease
• kidney disease
• foot problems
• nervous system.
Those most at risk include:8

• age > 35 years


• age > 25 years and
• type 2 diabetes > 10 years’ duration
• type 1 diabetes > 15 years’ duration
• presence of any additional risk factor for coronary heart disease eg family
history, smoking, hypertension, hyperlipidaemia
• presence of microvascular disease eg proliferative retinopathy or nephropathy
• peripheral vascular disease
• autonomic neuropathy.

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6
Preparing for exercise
7, 8
Advise people to:

• Include a proper warm up and cool down component.


• Aim for 30 minutes or more of moderate intensity physical activity (see below) on
most days of the week. This can be accumulated in short bouts eg 10 minutes at
a time.
• Wear well fitting, comfortable footwear. Lace-up jogger shoes are
recommended.
• Limit weight bearing exercise if they have peripheral neuropathy as this could
lead to ulceration and fractures (see Footcare – Section 6).
• Be aware of the effect of exercise in poorly controlled diabetes (BGLs
>15mmol/L) as it may further increase the blood glucose level. Special measures
should be taken to ensure blood glucose levels are controlled before the
increased activity. This should be discussed with the GP / MO.
• Use a medic alert system eg bracelet or shoe tag.
• Ensure proper hydration as dehydration can adversely affect BGL and heart
function.
• Consider low to moderate weight training using light weights and high repetitions.
• Avoid high resistance exercise using weights if they are an older person or have
long standing diabetes.

Levels of intensity of physical activity7


Low intensity physical activity elicits a slight increase in breathing rate and is relative
for a given person (eg strolling < 3km/h on level firm ground, tidying the house,
leisurely stationary cycling < 50 watts and social lawn bowls).

Moderate intensity physical activity elicits a moderate noticeable increase in depth and
rate of breathing, while still allowing comfortable talking and is relative for a given
person (eg purposeful walking 3-6km/h on level firm ground, water aerobics, cycling for
pleasure < 16km/h and cleaning the house).

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7
Specific issues for people with type 2 diabetes
A Cochrane review on the benefits of exercise for people with diabetes identified that
exercise improves blood glucose control and that this effect is evident even without
weight loss.9 A regular exercise program is therefore as important for the person with
diabetes as healthy eating and medication.

A high percentage of people with type 2 diabetes are overweight and this may often be
2
due to lack of activity. People should be encouraged to undertake regular daily
exercise and to manage weight.

Education should include the risks and benefits of exercising, and some of the
following behaviours can be encouraged.

• Walking to the shops, or a friend’s house etc instead of driving.


• Using the stairs instead of elevators.
• Setting aside a special time each day to walk the dog, walk around the
neighbourhood.
• Performing daily household activities with vigour!

Choose active hobbies, eg bowls, tennis, swimming.

For people on OHAs or insulin the following points are made:

• If any planned exercise is vigorous and prolonged, it may be necessary to reduce


hypoglycaemic medication or insulin, or increase carbohydrate (such as fruit juice
or glucose) intake prior to the activity to prevent hypoglycaemia.
• It is advisable to monitor blood glucose levels both before, during and after
prolonged exercise.
• For people treated with insulin whose diabetes is stable, some extra
carbohydrate can be taken before exercising. Alternatively, exercise should be
undertaken after a meal.
• During particularly strenuous and prolonged exercise such as squash, football,
swimming or cycling, it is advisable to take extra carbohydrate during the
exercise.
• For some individuals on insulin, particularly before prolonged strenuous exercise,
the insulin dose may also need to be reduced, eg by 2 to 4 units. Since
individual requirements vary, this should be discussed with the GP or diabetes
educator.

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8
Specific issues for people with type 1 diabetes
In type 1 diabetes vigorous exercise can cause major disturbances in blood glucose
10
including hypoglycaemia and hyperglycaemia. In type 1 diabetes the pancreas does
not produce insulin and therefore can not regulate insulin levels in response to
exercise. There may also be deficiencies in the release of counterregulatory
hormones. These hormones are responsible for facilitating the release of glucose from
the liver. The glycaemic response will depend on the type, intensity and duration of the
activity. It is also dependent on how much insulin is circulating and glucose counter
10
regulatory hormone levels. Individuals with type 1 diabetes need to carefully plan
exercise programs in conjunction with their health care team. It is important for them
to understand how to balance their exercise, diet and insulin.
8, 10
General guidelines are:

1. Check BGL before exercising


a. avoid exercise if BGL > 15mmol/L and ketones are present
b. use caution if exercising and levels are above 15mmol/L and no ketones
present
c. eat carbohydrate food if levels are less than 5mmol/L.

2. Monitor blood glucose before and after exercise (depending on duration may
need to monitor during)
a. identify when changes in insulin or carbohydrate intake are required
b. learn about the glycaemic responses to different types of exercise
c. monitor BGL after exercise and if necessary check overnight
(hypoglycaemia can occur many hours after the exercise is finished.)

3. Food intake
a. eat extra carbohydrate as required
b. ensure that fast and long acting carbohydrates are easily accessible during
and after exercise.

Managing intense or prolonged exercise in people with type 1 diabetes is complex and
requires specialist advice. For further information refer to the article by Riddell.10

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9
Activity for the person in hospital
If possible and depending on the reason for admission, encourage the person to walk
around the ward and hospital grounds.

If the person has limited mobility, encourage circulation and breathing exercises.
These should be performed once or twice daily for 5 to 10 minutes (if appropriate).

• Consult with GP / MO prior to commencing any exercise program.


• Consult with physiotherapist for appropriate exercises.
• Teach patient the exercises and evaluate progress.

Suggested exercise for people with limited mobility


Head exercises
• Turn head from side to side as far as possible.
• Tilt head forward as far as possible.
• Tilt head as far as possible towards shoulder keeping shoulder still.

Shoulder exercises
• Lie flat on back, arm at side, palm facing body.
• Keep elbow straight and lift arm until hand points to the ceiling.
• Continue to move the arm back until it rests n the bed next to the head. The arm
may be bent at the elbow if the headboard or the bed will not permit the arm to
be carried all the way back.
• Return to the starting position, rest, then repeat the exercise.

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10
Elbow exercises
• Bend elbow so that palm reaches towards the shoulder.
• Straighten elbow turning palm away from shoulder.
• Rest the elbow on a table and turn the palm to face the shoulder, then away from
the shoulder.
• Your exercises can be extended by adding a light weight (held in your hand) to
provide some resistance.

Hand and wrist exercises


• (a) Bend the hand at the wrist forward and back as far as possible.
• (b) Holding arm still, move hand to the right, then to the left.
• (c) With elbows at their side and arm bent, turn hand as though turning a door
knob.
• Spread fingers apart. Start with fingers straight. Close fingers into a fist and
straighten again.
• (d)Touch tip of thumb with each finger in turn.
• (e) Grip hand sized piece of sponge or small ball and squeeze. Open, grip and
repeat.

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11
Hip exercises
• Lying flat on back, with legs straight, move foot as far as possible to the side,
return leg to original position.
• Lying on back with legs straight, raise and lower legs one at a time slowly, first
straight and then with knee bent.

Knee exercises
• Over the edge slowly straighten the leg at the knee and then slowly return to
original position.
• Sitting upright on a bed with legs straight and back well supported slide foot as
far as possible back toward buttocks, bending at the knee. Then slide foot back
to original position. Repeat with other leg.

Ankle exercises
• Slowly bend foot up and down at the ankle.
• Slowly turn feet inwards and then outwards.
• Sitting on the edge of bed, move ankle or foot through circular motion.

Back exercises
• Lying with knees bent, lift hips up from the bed.
• Roll both knees from side to side, but keep shoulders flat on the bed.
• Sit on a chair, feet on the floor. Turn head and shoulders taking arms first round
to the left and then round to the right.

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12
Alcohol
People with diabetes need to be aware of the effects of alcohol on blood glucose levels
and weight. The types and amounts of alcohol suitable should also be discussed.
Precautions to take when consuming alcohol are also considered important topics to
cover.

People are advised to discuss the use of alcohol with their GP or diabetes educator.
Alcohol can react adversely with medication.

Excessive alcohol contributes to weight gain, increasing triglycerides and increasing


blood pressure.

Alcohol can cause fluctuations in blood glucose levels. The intake of alcohol may also
affect the behaviour and mental state of the individual. The person may fail to
recognise and treat the early symptoms of hypoglycaemia. There may also be some
confusion as to whether excessive alcohol has been consumed, or whether in fact the
person is hypoglycaemic as the symptoms are often similar.

Effect of alcohol on blood glucose concentration


Alcohol can initially increase blood glucose, however there is damage in the over-
consumption of alcohol as it can significantly lower the blood glucose concentration.
Alcohol hinders the activity of the liver in producing and releasing glucose into the
blood and may therefore increase the risk of hypoglycaemia.

Alcohol taken without food can induce hypoglycaemia therefore it is recommended that
alcohol always be taken in moderation and with food.

The carbohydrate in sweet wine and beer tends to initially raise blood glucose levels.
Dry wines and spirits, are preferable to liqueurs, port and sweet wines. If a mixer is
consumed with spirits, a low calorie mixer or soda water should be used.

The following advice should be given to people with diabetes regarding the use of
alcohol.

It is best to limit alcohol, but if alcohol is consumed don’t forget to:

• check with your doctor first (discuss any interaction with medications)
• don’t drink on an empty stomach
• avoid drinking in excess (no more than 2 standard serves [20 grams] is recommended
each day)
• choose low alcohol drinks
• choose dry wines and spirits
• choose light beer
• choose sugar-free mixers such as soda or low joule mixers
• avoid or limit all alcohol if you are trying to lose weight
• pregnant women should not drink alcohol because of the risks to the foetus
• it is not advisable to drive after drinking alcohol
• wear diabetes identification.

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13
Smoking
The damaging effects of smoking on blood vessels are well-known. The increased
tendency for blood vessels to become damaged in people with diabetes is also known.
A person with diabetes who smokes will greatly increase the risk of blood vessel
11
damage and the complications of diabetes.

The resulting vascular disease, particularly in the legs, kidneys and eyes and cardiac
disease, reduce the quality of life for the individual and may even be fatal. Cigarette
11
smoking is the most important modifiable cause of premature death.

Health professionals must be aware of the difficulty encountered in giving up smoking.


Assist, support and encourage the person in their decision to stop smoking.

A useful framework might be:11

• Ask – ensure that every person is asked if they smoke. Those who do smoke
can be asked at each visit.
• Assess – for current smokers assess their interest in quitting.
• Advise – provide information about how important it is for them to quit.
• Assist – help people set a ‘quit date’ and provide information and resources
about how to prepare. Some people may like to seek specific counselling, others
may want medication to assist them.
• Arrange – ensure adequate follow up is arranged eg phone call or appointment

For further information and resources go to www.quitsa.org.au

Insurance and legal obligations


Travel insurance
Some insurance companies may not provide overseas travel insurance for people with
a pre-existing chronic illness or have very strict acceptance criteria. Diabetes is
classified as a pre-existing, chronic illness in insurance terms.

If a person with diabetes is planning to travel overseas it will be important for them to
seek advice about insurance before purchasing their tickets. It may be helpful to
discuss the best options for travel insurance with Diabetes Australia or their travel
agent.

Life insurance or superannuation


It is important that the person also inform their life insurance company or
superannuation fund that they have diabetes. An insurance broker or Diabetes
Australia could assist if further information is required. The Insurance Ombudsman
can also provide advice. Visit www.insuranceombudsman.com.au or phone 1300 780
808.

Motor vehicle licences


All people with diabetes are required to notify the Registrar of Motor Vehicles that they
have diabetes if they need either oral medication or insulin.

It is an offence to drive without such notification and heavy penalties could be


incurred. In addition insurance cover may be invalidated due to lack of notification.

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14
Appendix 1

WHO (Five) Well-Being Index (1998 version)


Please indicate for each of the five statements which is closest to how you have been
feeling over the last two weeks.
Notice that higher numbers mean better well-being.

Example: If you have felt cheerful and in good spirits more than half of the time during
the last two weeks, put a tick in the box with the number 3 in the upper right corner.

Over the last two All of the Most of More than Less than Some of At no time
weeks time the time half of the half of the the time
time time

1 I have felt cheerful


and in good spirits 5 4 3 2 1 0

2 I have felt calm


and relaxed 5 4 3 2 1 0

3 I have felt active


and vigorous 5 4 3 2 1 0

4 I woke up feeling
fresh and rested 5 4 3 2 1 0

5 My daily life has


been filled with
things that interest 5 4 3 2 1 0
me

Scoring:
The raw score is calculated by totalling the figures of the five answers. The raw score
ranges from 0 to 25, 0 representing worst possible and 25 representing best possible
quality of life.

To obtain a percentage score ranging from 0 to 100, the raw score is multiplied by 4. A
percentage score of 0 represents worst possible, whereas a score of 100 represents
best possible quality of life.

Interpretation:
It is recommended to administer the Major Depression (ICD-10) Inventory if the raw
score is below 13 or if the patient has answered 0 to 1 to any of the five items. A score
below 13 indicates poor wellbeing and is an indication for testing for depression under
ICD-10.

Monitoring change:
In order to monitor possible changes in wellbeing, the percentage score is used. A
10% difference indicates a significant change.

(ref. John Ware, 1995).

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15
Appendix 2
Problem Areas In Diabetes (PAID) Questionnaire

INSTRUCTIONS: Which of the following diabetes issues are currently a problem for you?
Circle the number that gives the best answer for you. Please provide an answer for each question.
Somewhat
Not a Minor Moderate Serious
serious
problem problem problem problem
problem
0 1 2 3 4

1. Not having clear and concrete goals for your diabetes


0 1 2 3 4
care?

2. Feeling discouraged with your diabetes treatment plan? 0 1 2 3 4

3. Feeling scared when you think about living with diabetes? 0 1 2 3 4

4. Uncomfortable social situations related to your diabetes


0 1 2 3 4
care (e.g., people telling you what to eat)?

5. Feelings of deprivation regarding food and meals? 0 1 2 3 4

6. Feeling depressed when you think about living with


0 1 2 3 4
diabetes?

7. Not knowing if your mood or feelings are related to your


0 1 2 3 4
diabetes?

8. Feeling overwhelmed by your diabetes? 0 1 2 3 4

9. Worrying about low blood sugar reactions? 0 1 2 3 4

10. Feeling angry when you think about living with diabetes? 0 1 2 3 4

11. Feeling constantly concerned about food and eating? 0 1 2 3 4

12. Worrying about the future and the possibility of serious


0 1 2 3 4
complications?

13. Feelings of guilt or anxiety when you get off track with
0 1 2 3 4
your diabetes management?

14. Not "accepting" your diabetes? 0 1 2 3 4

15. Feeling unsatisfied with your diabetes physician? 0 1 2 3 4

16. Feeling that diabetes is taking up too much of your


0 1 2 3 4
mental and physical energy every day?

17. Feeling alone with your diabetes? 0 1 2 3 4

18. Feeling that your friends and family are not supportive of
0 1 2 3 4
your diabetes management efforts?

19. Coping with complications of diabetes? 0 1 2 3 4

20. Feeling "burned out" by the constant effort needed to


0 1 2 3 4
manage diabetes?

© 1999 Joslin Diabetes Center

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16
Appendix 3
The 2-item Diabetes Distress Scale (DDS2)

Directions. Living with diabetes can sometimes be tough. There may be many
problems and hassles concerning diabetes and they can vary greatly in severity.
Problems may range from minor hassles to major life difficulties. Listed below are 17
potential problems that people with diabetes may experience. Consider the degree to
which each of the items may have distressed or bothered you DURING THE PAST
MONTH and circle the appropriate number.

Please note that we are asking you to indicate the degree to which each item may be
bothering you in your life, NOT whether the item is merely true for you. If you feel that
a particular item is not a bother or a problem for you, you would circle “1.” If it is very
bothersome to you, you might circle “6.”

Problems Not a Moderate Serious


problem problem problem

1.Feeling overwhelmed by the demands of


1 2 3 4 5 6
living with diabetes.

2. Feeling that I am often failing with my


1 2 3 4 5 6
diabetes regimen.

Fisher L, Glasgow R E, Mullan J T, Skaff M M, and Polonsky W H (2008) Development of a brief


diabetes distress screening instrument. Annals of Family Medicine, 6(3): p246-252.

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17
Appendix 4
Diabetes Distress Scale (DDS17)

Directions. Living with diabetes can sometimes be tough. There may be many
problems and hassles concerning diabetes and they can vary greatly in severity.
Problems may range from minor hassles to major life difficulties. Listed below are 17
potential problems that people with diabetes may experience. Consider the degree to
which each of the items may have distressed or bothered you DURING THE PAST
MONTH and circle the appropriate number.
Please note that we are asking you to indicate the degree to which each item may be
bothering you in your life, NOT whether the item is merely true for you. If you feel that
a particular item is not a bother or a problem for you, you would circle “1.” If it is very
bothersome to you, you might circle “6.”

Problems Not a Moderate Serious Office


problem problem problem use
only
1. Feeling that diabetes is taking up too much
1 2 3 4 5 6 [A]
of my mental and physical energy every day
2. Feeling that my doctor doesn’t know
1 2 3 4 5 6 [B]
enough about diabetes and diabetes care.
3. Feeling angry, scared and / or depressed
1 2 3 4 5 6 [A]
when I think about living with diabetes.
4. Feeling that my doctor doesn’t give me
clear enough directions on how to manage 1 2 3 4 5 6 [B]
my diabetes.
5. Feeling that I am not testing my blood
1 2 3 4 5 6 [C]
sugars frequently enough.
6. Feeling that I am often failing with my
1 2 3 4 5 6 [C]
diabetes regimen.
7. Feeling that friends or family are not
supportive enough of my self-care efforts (eg
planning activities that conflict with my 1 2 3 4 5 6 [D]
schedule, encouraging me to eat the “wrong”
foods).
8. Feeling that diabetes controls my life. 1 2 3 4 5 6 [A]
9. Feeling that my doctor doesn’t take my
1 2 3 4 5 6 [B]
concerns seriously enough.
10. Not feeling confident in my day-to-day
1 2 3 4 5 6 [C]
ability to manage diabetes.
11. Feeling that I will end up with serious
1 2 3 4 5 6 [A]
long-term complications, no matter what I do.
12. Feeling that I am not sticking closely
1 2 3 4 5 6 [C]
enough to a good meal plan.
13. Feeling that friends or family don’t
appreciate how difficult living with diabetes 1 2 3 4 5 6 [D]
can be.
14. Feeling overwhelmed by the demands of
1 2 3 4 5 6 [A]
living with diabetes.
15. Feeling that I don’t have a doctor who I
1 2 3 4 5 6 [B]
can see regularly about diabetes.
16. Not feeling motivated to keep up with my
1 2 3 4 5 6 [C]
diabetes self-management.
17. Feeling that friends or family don’t give
1 2 3 4 5 6 [D]
me the emotional support that I would like.

Fisher L, Glasgow R E, Mullan J T, Skaff M M, and Polonsky W H (2008) Development of a brief


diabetes distress screening instrument. Annals of Family Medicine, 6(3): p246-252.

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18
References

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from: http://www.diabetes.org/type-2-diabetes/stress.jsp

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4. Polonsky W H, Anderson B J, Lohrer P A, Welch G, Jacobson A M, Aponte J


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5. Fisher L, Glasgow R E, Mullan J T, Skaff M M, and Polonsky W H (2008)


Development of a brief diabetes distress screening instrument. Annals of
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6. BeyondBlue (2009) Depression checklist: Kessler psychological distress scale


(K10). [Cited 15 June 2009]; Available from:
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9. Thomas D E, Elliott E J, and Naughton G A (2006) Exercise for type 2 diabetes


mellitus. Cochrane Database of Systematic Reviews DOI: Art. No.:
CD002968. DOI: 10.1002/14651858.CD002968.pub2. Available from:
http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME

10. Riddell M C and Perkins B A (2006) Type 1 diabetes and vigorous exercise:
Applications of exercise physiology to patient management. Canadian Journal
of Diabetes, 30(1): p63-71.

11. American Diabetes Association (2004) Smoking and diabetes: Position


statement. Diabetes Care, 27(S1): pS74-75.

SECTION 9 – MAINTAINING A HEALTHY LIFESTYLE – REVISED SEPTEMBER 2009


19
SECTION 10
Medication
Therapeutic approaches vary for type 1 and type 2 diabetes. In this section we will
outline the oral medications which are used in type 2 diabetes and insulin therapy
which is used in both type 1 and type 2 diabetes.

It is important to point out that whilst hyperglycaemia is an extremely important part of


managing diabetes, other metabolic abnormalities such as dyslipidaemia, hypertension
and hypercoagulability are also extremely important in reducing microvascular and
macrovascular complications.

The aim of this section is to provide basic information about each of the diabetes
medications. We recommend you refer to the MIMS Annual for specific details
including interactions between various medications.1

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1
Oral hypoglycaemic agents
Type 2 diabetes is a progressive disease that is characterised by worsening glycaemia
2
and additional medications are required over time if treatment goals are to be met.
The landmark UKPDS demonstrated that 50% of people with type 2 diabetes will end
up on insulin within 7 years.3 However, lifestyle factors such as increasing activity,
losing weight and a healthy eating plan remain an important part of self care.

The groups of oral hypoglycaemic agents available are:

• biguanides
• sulphonylureas
• meglitinides
• glitizones
• alpha-glucosidase inhibitors
• glucagon-like peptide 1 agents.

Note: medication will not substitute for healthy eating, weight reduction and / or
exercise and the benefits of these need to be reinforced. Attention to healthy lifestyle is
important as an adjunct to medication.

The algorithm by Nathan et al (Figure 1) is dependent on aiming for a HbA1c of less


than 7% and the changing of treatments when the target is not being met. It is
important that people with type 2 diabetes and their health professionals understand
that type 2 diabetes is a progressive disease and consequently requires the addition of
glucose lowering medications over time.2 The algorithm shows 2 tiers of treatment
which are based on how well validated the therapies are.

Note: this algorithm is a consensus guideline and some differences may be seen in
the way it is used in an Australian context eg metformin is sometimes not commenced
until there has been a trial of lifestyle.

Tier 1: preferred choice based on current evidence


• Step 1 – lifestyle intervention and metformin
Supporting the person to make lifestyle improvements is integral across the
continuum of type 2 diabetes. However for most individuals, lifestyle
interventions alone fail to achieve or maintain metabolic goals. Consensus is
that metformin should be started at diagnosis alongside lifestyle interventions
(unless metformin is contraindicated).

• Step 2 – addition of a second medication


If maximum tolerated dose of oral hypoglycaemic agent (eg metformin) fails then
a second medication needs to be added. This could be insulin or a
sulphonylurea depending on the person’s level of glycaemia.

• Step 3 – further adjustment


Treatment is intensified in order to achieve HbA1c targets (eg less than 7%).
This may require a basal bolus insulin regime.

Tier 2: less well validated therapies


• In some situations the 2nd tier algorithm may be warranted – eg when
hypoglycaemia is particularly undesirable, then the addition of a glitazone or
exenatide may be added instead of insulin.

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2
Figure 1

Tier 1: Well-validated core therapies


Figure 2
At diagnosis: Lifestyle + Metformin Lifestyle + Metformin
Lifestyle + +
+ Basal insulin Intensive insulin
Metformin

Lifestyle + Metformin
+
Sulphonylurea

Step 1 Step 2 Step 3

Tier 2: Less well validated therapies


Lifestyle + Metformin
+
Lifestyle + Metformin Glitazone
+ +
Glitazone Sulphonylurea

Lifestyle + Metformin
+
Basal insulin
Lifestyle + Metformin
+
Glitazone

Adapted from Nathan D, Buse J B, Davidson M B, Ferrannini E, Holman R R, Sherwin R, and


Zinman B (2009) Medical management of hyperglycaemia in type 2 diabetes: A consensus
algorithm for the initiation and adjustment of therapy. Diabetes Care, 32(1), p193-203.

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


3
Dosing schedule for oral hypoglycaemic agents4
Daily Dose Approx Frequency of
Drug Name Brand Names Tablet Size
Range Duration Admin/day
Biguanides
Metformin (c,e) Diabex Range from 0.5-3g 12h 2-3
Diaformin 500mg, 850mg,
Formet 1g
Genrx metformin
Glucohexal
Glucohexal 1000
Glucomet
Glucophage
Metforbell
Metformin
(Genepharm)
Metformin ER* Diabex XR 0.5g 0.5-2g 24h 1
Diaformin XR 0.5g
Metex XR 0.5g
Metformin XR 0.5g
Sulphonylureas
Glibenclamide (b) Daonil 5mg 2.5-20mg 18-24h 1-2
Glimel 5mg
Gliclazide (b) Diamicron 80mg 40-320mg 18-24h 1-2
Genrx gliclazide 80mg
Glyade 80mg
Mellihexal 80mg
Nidem 80mg
Gliclazide ER* Diamicron MR 30mg 30-120mg 24h 1
Oziclide MR 30mg
Glimepiride (b) Amaryl 1, 2, 3, 4mg 1-4mg daily >24h 1
Aylide
Diapride
Dimirel
Glimepiride Sandoz
Glipizide (b) Melizide 5mg 2.5-40mg 16-24h 1-2
Minidiab
Meglitinides
Repaglinide (g) NovoNorm 0.5, 1, 2mg 1.5-16mg 2-3h 1-3
Glitazones
Pioglitazone Actos 15, 30, 45mg 15-45mg 24h 1
(d,e,f)
Rosiglitazone Avandia 4, 8mg 4-8mg 24h 1-2
(d,e,f)
Alpha-glucosidase inhibitors
Acarbose (a) Glucobay 50mg, 50-600mg in 3h 1-3
100mg divided doses
Incretin Enhancers and Mimetics
Sitagliptin (f,h) Januvia 100mg 100mg >24h 1
Exenatide (g) Byetta Twice daily non-insulin hypoglycaemic agent. Inject 5mcg bd
subcutaneously one hour before two main meals and at least 6
hours apart. After one month increase to 10mcg bd.
Combination products
Metformin / Glucovance 250 / 1.25mg Up to 18-24h 2-3
Glibenclamide 500 / 2.5mg 2000/20mg
(b,c,e) 500 / 5.0mg
Metformin / Avandamet 500 / 2mg Up to 12-24h 2
Rosiglitazone 500 / 4mg 2000/8mg
(c,d,e,f) 1000 / 2mg
1000/4mg
Metformin / Janumet 500 / 50mg Up to >24h 2
Sitagliptan 850 / 50mg 2000/100mg
(c,e,f,h) 1000 / 50mg

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4
*ER = Extended Release

(a) Care renal, gastrointestinal disease. (e) Care renal, liver and cardiovascular
(b) Sulphonylurea disease.
(c) Metformin (f) Authority required
(d) Glitazone (g) Private script
(h) Care, renal insufficiency

Note: oral agents need to be used with special care in the elderly.

Ensure that patient is aware of the name, dose, dosing time, action and side effects of
their medication.

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5
Biguanides
Metformin is a biguanide oral hypoglycaemic agent. It is the only agent available in this
class. The major effect of metformin is to decrease hepatic glucose output and lower
fasting glycaemia. Typically meformin used on its own will lower HbA1c by
2
approximately 1.5% and does not cause hypoglycaemia. The most common side
effects are gastrointestinal. Metformin therapy is usually weight neutral or can assist
with weight loss. This is in contrast to most of the other oral hypoglycaemia agents
which tend to be associated with weight gain. The UKPDS also demonstrated a
beneficial effect of metformin therapy on cardiovascular outcomes.5 It is for these
reasons that metformin is usually the first medication started in type 2 diabetes.

Action
• Reduces hepatic glucose production.
• Increases peripheral utilisation of glucose in muscle and fat tissues.
• Decreases intestinal absorption of glucose.
• Decreases insulin requirements for glucose disposal.

Contraindications
• Hypersensitivity to metformin.
• Severe renal impairment (creatinine clearance <30ml/min).
• Ketoacidosis.
• Respiratory failure.
• Severe infection or trauma; substitute with insulin treatment.
• Severe dehydration.
• Alcohol abuse.

Precautions
• Mild to moderate renal impairment – reduce dose.
Consider the following dosages based on creatinine clearance:
• 60–90mL/minute, 2g/day in divided doses
• 30–60mL/minute, 1g/day once daily or in divided doses.
• Severe hepatic disease.
• Acute congestive heart failure, recent MI, moderate to severe heart failure.
• Conditions which may be associated with tissue hypoxia eg Gangrene.
• Conditions predisposing to lactic acidosis eg metabolic acidosis.
• The very old (eg >85 years).
• Surgery or patients receiving parenteral iodinated radiograph contrast media
(see ‘Important Considerations’ below).
• Pregnancy.

Side effects
Gastrointestinal side effects are common with metformin and transient. In most
patients they are dose related and can be minimised by dose reduction or gradual
dose escalation. Metformin should be taken with or after meals to minimise
gastrointestinal side effects.

Common
• Gastrointestinal disturbances eg nausea, vomiting, anorexia, abdominal pain,
diarrhoea.
• Metallic taste.
• Low vitamin B12 levels.

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6
Infrequent and rare
• Rash.
• Lactic acidosis is a rare but serious adverse effect of metformin. It is fatal in
about 50% of cases when it occurs. Symptoms include severe anorexia, nausea,
vomiting, abdominal pain, cramps, malaise, unexplained weight loss, slow heart
beat, lethargy or sleepiness, dizziness. The risk is higher in some patients with
contraindications (see above list) and when metformin is used in higher doses.
Patients should notify their doctor immediately if these symptoms occur.

Important considerations
• Metformin may need to be stopped prior to (48 hours) and after surgery or contrast media
(iodinated) – depending on renal function and volume of contrast. Always confirm with
medical staff or local hospital protocols.6
• Metformin should also be used with caution in any severe illness in which tissue
oxygenation is potentially reduced (acute respiratory failure, MI, cardiac failure
etc).
• Hypoglycaemia is uncommon in patients taking metformin alone, but may occur
when it is used in combination with other hypoglycaemic agents or insulin.

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7
Sulphonylureas
Sulphonylurea agents reduce glycaemia by enhancing insulin secretion, with efficacy
similar to that of metformin (approximately 1.5% reduction in HbA1c). The major side
effect are hypoglycaemia and weight gain.2

Action
• Increase pancreatic insulin secretion.
• May improve insulin sensitivity in peripheral tissue and decrease hepatic glucose
output.

Contraindications
• In pregnancy, due to possible teratogenic effects.
• In major surgery, due to possible hypoglycaemic effects.
• Hypersensitivity to sulphonylureas.
• Type 1 diabetes.
• Ketoacidosis.
• Severe renal impairment. (Please consult with GP/MO if concerned).

7
Severe hepatic impairment.

Precautions
• Mild to moderate renal impairment.
• Elderly people (use agent with lowest risk of hypoglycaemia – see ‘Important
Considerations’ below).
• Severe infection, trauma or other conditions where sulphonylureas are unlikely to
control blood glucose; substitute with insulin treatment.

Side effects
Common
• Hypoglycaemia.
• Weight gain.
• Transient visual disturbances eg. Blurred or double vision.

Infrequent and rare


• Gastrointestinal effects eg nausea, diarrhoea, heartburn, anorexia.
• Metallic taste.
• Dermatological reactions eg rash, photosensitivity, exfoliative dermatitis (rare).
• Blood disorders eg thrombocytopenia, agranulocytosis, aplastic anaemia,
haemolytic anaemia (rare).
• Hepatotoxicity (rare).

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8
Important considerations
• Ensure that patient is aware of the symptoms of hypoglycaemia so that they can
recognise, treat and take measures to prevent it.
• Sulphonylureas should be taken with or immediately before meals to minimise
the risk of hypoglycaemia.
• The risk of hypoglycaemia is greatest with glibenclamide, therefore its use should
be avoided in the elderly, those with renal and / or hepatic impairment. The risk is
lowest with gliclazide and glipizide.
• Exceeding the maximum dose may achieve little benefit. Substitution with, or
addition of, another sulphonylurea does not usually improve glucose control.
• Combination therapy with another class of hypoglycaemic agent or insulin may
be more appropriate.

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9
Meglitinides
Repaglinide is a member of the meglitinide family of oral hypoglycaemic agents. It is
also known as a prandial glucose regulator. It is the only agent available in this class.
As this medication is only available on a private script, it is not frequently used.

Action
• Transiently increases pancreatic insulin secretion (similar to sulphonylureas but
acts at a different binding site).

Contraindications
• Hypersensitivity to repaglinide.
• Type 1 diabetes.
• Ketoacidosis.
• Children under 12 years.
• Pregnancy and lactation.
• In major surgery, due to possible hypoglycaemic effects.

Precautions
• Impaired renal function.
• Impaired hepatic function.
• Hypoglycaemia.
• Severe infection, trauma or other conditions where meglitinides are unlikely to
control blood glucose; substitute with insulin treatment.

Side effects
Common
• Hypoglycaemia.
• Gastrointestinal disturbances eg nausea, abdominal pain, dyspepsia,
constipation and diarrhoea.

Infrequent and rare


• Rash.
• Transient visual disturbances eg blurred vision (rare).8
• Increase in liver enzymes.

Important considerations
• Repaglinide has a short duration of action and rapid onset of action. It should
therefore be taken immediately before meals.
• The dose of repaglinide should be missed if a meal is skipped. If a meal is added
then a dose should be added. It has the principle of ‘One meal – one dose, no
meal – no dose’.
• Ensure that patient is aware of the symptoms of hypoglycaemia so that they can
recognise, treat and take measures to prevent it.

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10
Glitazones
Glitazones or PPAR-γ (peroxisome proliferator receptor activator) agonists increase the risk of
oedema and heart failure and current National Prescribing Service guidelines recommend
starting insulin as a third agent rather than commencing a glitazone.9 Insulin has a better long
term safety profile. Glitazones double the risk of heart failure. Also, rosiglitazone may
increase risk of MI in patients with IHD, therefore it is contraindicated (see contraindications).9

Action
• Increase the sensitivity of peripheral tissues to insulin.
• Decrease hepatic glucose output.

Contraindications
• Hypersensitivity to the drug.
• Ketoacidosis.
• Heart failure NYHA Class III and IV.
• Moderate to severe hepatic impairment and where ALT >2.5 times the upper limit
of normal.
• Type 1 diabetes.
• Known ischaemic heart disease (IHD)
• Rosiglitazone is contraindicated in patients IHD, particularly those taking
nitrates as it has been shown to increase the risk of myocardial
ischaemia.10 Pioglitazone does not appear to carry the same risk.

Precautions
• Patients with oedema or mild heart failure, due to risk of fluid retention.
• Anovulatory premenopausal women with insulin resistance as ovulation may
resume, therefore consider contraception.

Side effects
Common
• Oedema.
• Weight gain.
• Headache.
• Arthralgia.
• Dizziness.
• Decrease in haemoglobin and haematocrit.
• Increase in total and HDL cholesterol (rosiglitazione).

Infrequent and rare


• Elevated liver enzymes.
• Hepatocellular injury.
• Heart failure.
• Pulmonary oedema.
• Increased risk of peripheral fractures in women.4, 7

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11
Important considerations
• Glitazones can be taken with or without food.
• Hypoglycaemia may occur when it is used with other hypoglycaemic agents or
insulin.
• Monitor liver enzymes at the start of the treatment. Stop treatment if ALT rises
above 3 times the upper limit of normal or if the patient has jaundice.
• Doses should not be increased before 8 weeks have elapsed; in most trials it has
taken between 8 and 18 weeks for full glycaemic response to be seen at any
10 7
given dose. Stop treatment if no effect after 6 months.
• Advise patients to report signs and symptoms of hepatic dysfunction eg nausea,
vomiting, abdominal pain, fatigue, anorexia, dark urine.
• Advise patients to report any weight gain, swollen feet or ankles and
breathlessness.
• Ensure that patient is aware of the name, dose, dosing time, action and side
effects of their medication.

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12
Alpha–glucosidase inhibitors
Acarbose is an alpha-glucosidase inhibitor. It is the only agent available in this class.
Alpha-glucosidase inhibitors are not widely used in Australia largely due to the
common side effect of increased flatulence. They are also less effective in reducing
HbA1c as compared to metformin and sulphonylureas.

Action
• Inhibits the alpha-glucosidase enzymes in the small intestine, which break down
carbohydrates such as starch and sucrose. This action delays the absorption of
carbohydrates and thus decreases the sharp, post-prandial rise in blood glucose
that occurs after meals.
• Acarbose does not affect the absorption of simple sugars eg glucose and
fructose.

Contraindications
• Inflammatory bowel disease.
• Partial intestinal obstruction (or predisposition).
• Gastrointestinal disorders associated with malabsorption.
• Conditions aggravated by formation of intestinal gas eg hernias.
• Severe renal impairment.
• Hypersensitivity to acarbose.
• Pregnancy.
• Patients <18 years.

Precautions
• Ingestion of large amounts of food containing carbohydrate (including sucrose)
can lead to gastrointestinal symptoms (flatulence, large amounts of bloating or
diarrhoea) during treatment, due to carbohydrate fermentation in the colon. The
symptoms are dose dependent and unlikely to be alleviated by taking an
antacid.7 However, they can be reduced by starting patients on low dose and
increasing gradually.
• May elevate serum transaminase levels. Decrease dosage if transaminases are
elevated and stop treatment if elevations persist.

Side effects
Common
• Gastrointestinal disturbances eg flatulence, abdominal pain and distension,
diarrhoea, dyspepsia, nausea.

Infrequent and rare


• Elevation of ALT and AST.
• Hepatitis and / or jaundice.
• Rash and erythema multiforme.
• Anaemia.
• Ileus.
• Oedema.

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13
Important considerations
• Acarbose should be taken directly before meals or with the first few mouthfuls of
food or it will not work.
• Hypoglycaemia may occur when it is used with other hypoglycaemic agents or
insulin.
• If hypoglycaemia occurs, give glucose but not sucrose because of delayed
absorption of sucrose.

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14
Incretin enhancers and mimetics
Glucagon-like peptide-1 (GLP1) and glucose-dependent insulinotropic peptide (GIP,
formerly known as gastric inhibitory peptide) are naturally occurring incretin hormones
produced in the small intestine. GLP-1 and GIP stimulate glucose-dependent insulin
secretion from the pancreas. GLP-1 also inhibits glucagon secretion in a glucose
dependent manner, and slows gastric emptying which further delays glucose
absorption. Incretin enhancers and mimetics reduce the fasting and post prandial
glucose4 and are similarly effective to the other oral hypoglycaemic agents. These
medications are very new and long term safety data is not yet available.

Enhancers (sitagliptin)
Action
Sitagliptan is currently the only agent available in this group. The incretin ‘enhancers’
are oral medications and slow the breakdown of endogenous GLP-1 They increase
glucose-dependent insulin secretion and reduce glucagon production.7

Contraindications
• Hypersensitivity to sitagliptin.
• Breastfeeding.
• Type 1 diabetes.
• Diabetic ketoacidosis.11

Precautions
• Renal impairment – consider dosage reduction for creatinine clearance <50
7
ml/min.

11
Age <18 – safety and efficacy have not be proven in this group.
• Pregnancy.

Side effects
Common
• Upper respiratory tract symptoms.
• Headache.
• Nausea.

Infrequent and rare


• Hypersensitivity reactions e.g. anaphylaxis, angioedema.
• Stevens-Johnson syndrome.5

Important considerations
• Not associated with weight gain.
• Do not cause hypoglycaemia unless used with a sulphonylurea or meglitinide.

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15
Mimetics (exenatide) 7, 12

Action
Exenatide is currently the only agent available in this group. It is an injected medication
(given subcutaneously) which binds to the GLP-1 receptor to enhance insulin secretion
and suppress inappropriate glucagon secretion. It also delays gastric emptying, which
reduces the rate of glucose absorption, and decreases appetite.

Contraindications
• Hypersensitivity to exenatide.
• Type 1 diabetes.
• Diabetic ketoacidosis.
• Severe gastrointestinal disease eg gastroparesis, dumping syndrome.
• History of pancreatitis with exenatide.
• Severe renal impairment.
• Pregnancy.
• Breastfeeding.

Precautions
• Renal impairment – consider dosage reduction for creatinine clearance
11
<30ml/min.
• Age <18 – safety and efficacy have not be proven in this group.

Side effects
Common
• Gastrointestinal disturbances eg nausea and vomiting (occurs in up to 50% of
patients but usually improves with continued treatment), diarrhoea, dyspepsia,
GORD, abdominal pain.
• Headache, dizziness, feeling jittery.
• Injection site reactions.

Infrequent and rare


• Constipation.
• Taste disturbance.
• Pancreatitis.
• Altered renal function including acute or worsening chronic renal failure.
• Increased serum creatinine concentration.

Important considerations
• Used as an adjunct to metformin and / or a sulphonylurea.
• May aid weight loss in patients with BMI >25.
• Hypoglycaemia is unlikely unless used with a sulphonylurea or meglitinide.
• Less frequent blood glucose monitoring is required with exenatide than with
insulin.

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16
Drugs associated with hypoglycaemia
Drugs Explanatory notes
ACE inhibitors (eg. captopril, Risk is increased when used with insulin,
enalapril, fosinopril, lisinopril, sulphonylureas or repaglinide. The
perindopril, quinapril, ramipril, combination is not contraindicated and
trandalopril) commonly used.
Alcohol Increased risk of hypoglycaemia. When taken
with sulphonylureas it may cause disulfiram
like reaction. Taking it with metformin can
cause or increase the risk of lactic acidosis.
Aspirin (high doses only) and High doses of aspirin and salicylates can
salicylates eg diflunisal, mesalazine, have hypoglycaemic effects. Low dose aspirin
olsalazine, sulphasalazine is commonly used in patients with diabetes.
Clonidine May mask the hypoglycaemic warning
symptoms, particularly tachycardia,
palpitations and sweating.
Beta blockers (eg atenolol, May increase severity and incidence of
bisoprolol, carvedilol, metoprolol, hypoglycaemia. Also mask some
pindolol, propranolol, sotalol) hypoglycaemic warning symptoms. They are
not contraindicated in diabetes patients.
NSAIDs (eg diclofenac, ibuprofen, May cause hypoglycaemia by increasing the
indomethacin, naproxen, amount of sulphonylurea in the blood.
ketoprofen, etc)
Perhexiline May cause hypoglycaemia especially in
patients taking insulin, sulphonylureas or
repaglinide. Monitor blood glucose levels
closely. If hypoglycaemia occurs it usually
occurs in early treatment.
Quinine, hydroxychloroquine Quinine may cause hypoglycaemia when
used to treat malaria, and possibly leg
cramps. Hypoglycaemia may occur with
hydroxychloroquine therapy. Monitor blood
glucose levels closely.
Quinolone antibiotics (in particular May cause hypoglycaemia especially in
gatifloxacin) combination with hypoglycaemic agents.
Monitor blood glucose levels closely.
Selective serotonin reuptake May decrease the awareness of
inhibitors (SSRIs) hypoglycaemic symptoms.
Sulfonamides (eg. May cause hypoglycaemia by increasing the
sulfamethoxazole, co-trimoxazole ie amount of sulphonylurea in the blood.
Septrin, Bactrim)

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17
Drugs associated with hyperglycaemia
Drug Explanatory notes
Antipsychotics Chlorpromazine is associated with
hyperglycaemia especially in doses >100mg
daily. Reports of hyperglycaemia and diabetes
with atypical antipsychotics (eg olanzapine,
clozapine, quetiapine).
Corticosteroids (eg prednisolone, Increases risk of hyperglycaemia in people who
dexamethasone, etc) don’t have diabetes, and worsens control in
people with diabetes.
Diuretics especially thiazides Impair diabetes control by raising blood
glucose levels especially in high doses. Less
likely with low doses.
Glucosamine Caution in patients with diabetes. May increase
blood glucose levels.
Lithium May cause hyperglycaemia.
Nicotinic acid May cause hyperglycaemia.
Phenytoin Hyperglycaemia very occasionally reported;
may occur in overdose/long-term high dose
treatment.
Quinolone antibiotics (in particular May cause hyperglycaemia. Monitor blood
gatifloxacin) glucose levels closely.
Sugar containing pharmaceuticals Patients should be warned of some products
eg syrups, elixirs that contain significant amounts of sugar.
Sympathomimetics (eg Hyperglycaemia has been reported.
pseudoephedrine, phenylephrine,
salbutamol)
Adapted from DATIS Review of Management of Type 2 Diabetes Mellitus in General Practice,
updated 2008. This is not an exhaustive list of all the drugs that have been associated with
hyperglycaemia. Please refer to MIMS Annual for specific drugs or drug interactions that may
predispose to hypoglycaemia or hyperglycaemia.

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18
Insulin
Insulin is a hormone which is secreted by the β cells of the Islets of Langerhans in the
pancreas.

It is normally released in response to an increased blood glucose concentration. Many


other factors are also involved in its regulation.

Insulin levels increase after a meal and fall as the glucose levels fall to maintain blood
glucose levels within a normal range.

Action
• Enhances cellular uptake of glucose.
• Inhibits hepatic glucose production.
• Stimulates glycogen formation and storage in the liver.
• Promotes protein synthesis and storage of fat.

Insulin therapy should therefore aim to mimic these actions and maintain blood
glucose levels to as near normal as possible.

Indications
• Type 1 diabetes.
• Type 2 diabetes inadequately controlled with diet, exercise and oral
hypoglycaemic agents and in conditions where oral hypoglycaemic agents
cannot be used eg pregnancy, surgery, trauma.

Types of insulin
Insulin is derived from:

• Human insulins – molecular structure identical to human insulin and obtained by


recombinant DNA technology.
• Insulin analogues – molecular structure similar to human insulin and obtained by
recombinant DNA technology.
• Bovine source – purified bovine insulin.

Human insulin is usually absorbed faster than bovine insulin, however it often has a
shorter duration.

There are numerous insulin preparations in Australia. The insulins are manufactured
by a number of companies, who produce brands that are of similar insulin type and
duration of action. For example Actrapid® and Humulin R® are both short acting or
soluble insulins (refer to table on comparative information for insulins). Insulins of
different brands are not interchangeable and it is not recommended that they be mixed
together.

The type of insulin chosen and the insulin schedule should be based on the individual’s
needs and lifestyle. The medical officer will discuss the appropriate schedule with the
person.

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19
Insulins available
Insulins can be categorised into four groups according to their duration of action.

• Ultra short acting – insulin lispro, insulin aspart, and insulin glulisine are
soluble, ultra-short acting insulins. They are identical to human insulins except
for some molecular structural changes in the insulin chain. As a result, they have
more rapid onset of action, which allows them to be given immediately before
meals.

• Short acting – also called regular, neutral and soluble insulin. This insulin is
clear and short acting.

• Intermediate acting – cloudy insulin (Isophane). Has prolonged duration of


action. The mixed / biphasic insulins also fall into this category. They comprise a
combination of ultra-short acting or short acting insulin, in varying proportion, with
an intermediate acting insulin.

• Long acting – Insulin analogue with a protracted action. It is a clear insulin. It


provides a constant basal insulin over 24 hours and is given once daily. Long
acting insulin analogues cannot be mixed with other insulins before
administration.

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20
Comparative information for insulins4
Type Brand Name Manufacturer Nature
Ultra short acting
(peak at 1hr, last 3.5-4.5hrs)
Insulin lispro Humalog + Lilly Analogue
Insulin aspart Novo Rapid + Novo Nordisk Analogue
Insulin glulisine Apidra + Sanofi-Aventis Analogue
Short acting
(peak at 2-5hrs, last 6-8hrs)
Neutral Actrapid Novo Nordisk Human
Humulin R Lilly Human
Hypurin Neutral Aspen Bovine

Intermediate acting
(12-24hrs) Humulin NPH Lilly Human
Isophane Protaphane Novo Nordisk Human
Hypurin Isophane Aspen Bovine

Long acting Levemir Novo Nordisk Analogue


Insulin detemir (up to 24 hrs) Lantus Aventis Analogue
Insulin glargine (24 hrs)

Pre-mixed insulins
Lilly Analogue
Lispro 25% Humalog Mix 25 +
Lispro protamine 75%
Lilly Analogue
Lispro 50% Humalog Mix 50 +
Lispro protamine 50%
Novo Nordisk Analogue
Insulin aspart 30% NovoMix 30 +
Insulin aspart protamine 70%
Lilly Human
Neutral 30% Humulin 30/70 Novo Nordisk Human
Isophane 70% Mixtard 30/70

Novo Nordisk Human


Neutral 50% Mixtard 50/50
Isophane 50%
The pharmacokinetics of the different insulins are patient dependent. An empirical approach to
dosage together with a ‘go slow’ policy will result in the smoothest fine tuning of management.
Some of these insulins are available as injection devices, pen injectors, disposable insulin pens,
cartridges and vials.

+ Very quick acting. Should be given immediately before eating.

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21
Insulin initiation and stabilisation in the community
These days most people start insulin without going to hospital. This is better because:

• diabetes can be stabilised around the person’s normal day to day routine
• they miss less work or school
• family and personal time is not disrupted.
The person, their doctor and diabetes educator can work together to decide on the
best insulin treatment. To assist, ADEA has guidelines to guide practice and
13
standards in this area.
The ADEA guidelines for initiating insulin in the ambulatory setting state ‘Australian
insulin dose changes are authorised in writing by the prescribing medical officer.’
Titration of insulin by nurses must only be done if there is an appropriate insulin
titration form that has been endorsed by the health service.

Type 2 diabetes
A simple and safe way to initiate insulin is to add bed-time basal (isophane or
analogue) insulin to oral antidiabetic agents.

Table 1: Stepwise guide for initiating and adjusting insulin14

Step 1 ADD 10 units isophane insulin at bedtime.

CONTINUE metformin, a sulphonylurea or both (at the same dosage, but no


greater than the maximum recommended dose)

• If evening blood glucose level is high then use 10 units morning


isophane insulin.
• If both morning and pre-evening meal blood glucose levels are
high then consider using twice daily isophane.

Step 2 ADJUST Insulin therapy gradually every 3-4 days according to fasting blood
glucose (FBG) level until target FBG is reached (usually 4.0-6.0 mmol/L)

Mean FBG (mmol/L) Adjustment to insulin dose


> 10 Increase by 8 units
8-10 Increase by 6 units
6-8 Increase by 2 units
4-6 No change
<4 Decrease by 2-4 units

Step 3 CHECK overall blood glucose control by measuring HbA1c 3-6 monthly.

Step 4 If FBG and evening blood glucose are on target but HbA1c is not, look for
hidden ‘hypers’ – blood glucose peaks that occur during the day, often
before lunch or after dinner.
Options to correct hidden ‘hypers’ include:
• changing preceding meal size or composition
• increasing activity after meals
• adding acarbose
• adding a meal-time rapid acting insulin.

Continuing oral antidiabetic agents minimises the risk of weight gain and
hypoglycaemia.
SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009
22
Type 1 diabetes
Insulin therapy in type 1 diabetes is needed for survival.

The choice of insulin types and regimen has to be guided by a variety of factors,
15
including:

• Age of the patient.


• Lifestyle factors.
• Patient and family preferences and management skills.
• Metabolic targets.
• Duration of diabetes.
• Experience of the health care team.
• Affordability and sustainability.
• Associated complications, including hypoglycaemia.

The insulin regimen needs to aim to:

• Provide appropriate basal insulin requirements to cover the needs across 24


hours.
• Provide sufficient insulin levels when needed to cover food intake.
• Have adequate provision for adjustment and correction when needed.
• Minimise blood glucose fluctuation and risk of hypoglycaemia and
hyperglycaemia.
• Achieve short-term and long-term metabolic targets.

Most adolescents and adults with type 1 diabetes will be on a four injections per
day (basal-bolus) regimen.
With main meals, with intermediate-acting insulin given in the evening or in the
morning and evening, or with glargine given once daily (morning or evening).

Insulin pump therapy (continuous subcutaneous insulin infusion – CSII).


The pump contains a ultra short-acting insulin analogue only and is programmed to
deliver basal rates to match the person’s needs. To cover meals and correct
hyperglycaemia, bolus doses are activated by the patient.

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


23
Insulin administration in hospital
Insulin can be administered only by injection. Insulin is destroyed if taken orally and
therefore is not absorbed if given via this route.

As an inpatient, the registered nurse assigned to care for the person is responsible for:

• checking the medication sheet order (question any discrepancy with the medical
officer)
• checking the correct insulin type, dose and time of administration has been
documented
• checking blood glucose level prior to administering the insulin
• checking that the injection is given and supervising person’s self-administration
(if able), people are encouraged to continue to maintain their self-care while in
hospital
• supervising and assessing injection technique and site
• use a new needle each time
• prime the needle
• insulin currently in use must not be refrigerated
• mix insulin gently (rock and roll)
• count to ten after injection before removing the needle
• rotate injection sites on the abdomen – keep the needle steady
• consulting the diabetes educator if necessary
• people commencing insulin need to be educated about identification, treatment
and prevention of hypoglycaemic episodes
• documenting action taken and subsequent progress.

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24
Important points on insulin
The medical officer is responsible for ordering and documenting the insulin dose while
the person is in hospital. However, there are some important points about insulin and
dosage to bear in mind.

• Insulin type and dosages will vary from person to person. People with type 1
diabetes will have different insulin requirements than those with type 2 diabetes
or gestational diabetes. Dosage and effect will vary from time to time for the
same person.

• When the person with type 1 diabetes is nauseated or unwell and not eating, as
close to usual dose of insulin should be maintained. Food intake needs to be
substituted with liquid carbohydrates such as soups, fruit juice or lemonade.


®
Some people with type 1 diabetes receiving short acting insulin (eg Actrapid or
Humulin R®) require mid-meal snacks and supper.

• People who receive intermediate / long acting insulin without other insulins, do
not generally need snacks unless otherwise indicated.

• When using insulin glargine or detemir it is most important to remember:


• these insulins are clear and therefore may be confused with the quick
acting insulins – mark them clearly as long acting.
• they cannot be mixed in a syringe with any other insulin.

• If on a twice daily intermediate acting insulin, 2/3 of the dose is usually given in
the morning, with 1/3 of the dose before the evening meal.

• If person has P.E.G. feed, please check that the time / action profile of the
prescribed insulin coincides with the time-action profile of the feed.

• People who are receiving insulin therapy and are unable to eat, may be able to
tolerate oral carbohydrate drinks. If not, please contact the medical officer for
review of insulin therapy / IVT.

• Ultra short and short acting insulins are soluble insulins and are the only type
that can be given intravenously.

• Long acting insulin analogues cannot be mixed with any other insulin and must
be injected separately.

• All preparations are standardised to a single strength (100units/mL) and are


suitable for subcutaneous injection.

• When preparing people for surgery see Hospitalisation – Section 4.

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


25
Important points on administration timing
• Short acting insulins are to be given 20–30 minutes before a meal so that insulin
absorption matches the absorption of food. A meal, sufficient carbohydrate
intake or IV dextrose must be given within 30 minutes.
• Ultra short acting insulins should be given immediately before or soon after
meals.
• Following administration, the insulin action cannot be stopped. The insulin dose
must therefore be correct and balanced with the amount of carbohydrate in the
meal.
• If the insulin injection is missed or delayed consult the medical officer. Some
dose adjustment may be necessary.

Side effects
• Hypoglycaemia.
• Weight gain.
• Local reactions – lipodystrophy, lipoatrophy, erythema, pruritis, allergic reactions.

Storage of insulins
• Unopened insulin should be stored in the refrigerator.
• Do not freeze insulin.

o
Once opened insulin can be stored at room temperature (not exceeding 30 C) for
28 to 30 days (depending on the product) as indicated on the label. Please
check product information enclosed with the insulin.
• In hospital, use a one vial or cartridge / one patient policy. Label and date the
vial / cartridge when opening them.16
• Store the insulin you are using out of the fridge and away from direct sunlight.
• Ideally, while in hospital, the person should be encouraged to continue self-care
insulin administration. In this case, identify a suitable storage place and store it
at room temperature.
• Discard insulin if it is discoloured, has changed in appearance in any way or the
expiry date has been reached.
• Insulin is damaged by heat and must not be kept in the car or where the
temperature exceeds 30oC.
• If travelling, spare insulin can be kept in a cool bag or vacuum flask.

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


26
Important points on injection sites
• Insulin is administered by subcutaneous injection and is absorbed into the
capillaries.
• The absorption rate varies with different injection sites. It is most even from the
abdomen, intermediate from the buttocks and arm, and slowest from the
unexercised thigh.
• The preferred site for subcutaneous injection is the abdomen avoiding a 5cm
radius around the umbilicus (see Figure 2 below).
Figure 2

• If the abdomen is unsuitable, for example, in a person who has had abdominal
surgery, then the buttocks or thigh can be used.
• Do not use the same spot in the chosen site every time. Move the site around to
avoid discomfort and to make sure that the insulin is absorbed evenly. This will
also decrease the risk of lipohypertrophy and / or lipoatrophy.
• Assess injection sites and condition of skin. Check for any swelling, hard
nodules, indentations, inflammation or pain.
• There is no need to swab the skin with alcohol before injection of insulin.

Insulin variability
The rate of onset, maximum effect and duration of effect will vary between patients.
Variables that may influence the actions of insulin include:

• injection site
• local injection site reactions (eg. scars)
• depth of injection
• local massage
• temperature
• exercise
• insulin mixing.

Factors affecting absorption rate

Insulin absorption rate is accelerated by:

• high temperature such as sauna, hot showers


• massage around the injection site (do not massage following administration)
• depth of injection (should only be given subcutaneously)
• injecting into exercising limbs.
Absorption rate can be delayed by:

• cool temperatures at injection site


• smoking
• lipohypertrophy or scarring at injection site.

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


27
How to draw up insulin (cartridge or vial)
1. Wash and dry hands. Clean the top of the cartridge
or vial with an alcohol swab.

2. Gently rotate cartridge / vial to thoroughly mix insulin


(do not shake the bottle).

3. Take syringe from packet and remove cap, being


careful not to touch the needle top.

4. Skip 4 & 5 when using cartridges. Withdraw the


plunger to measure the same amount of air equal
to the dose required.

5. With the vial upright inject the air into the insulin vial.

6. With the cartridge / vial inverted withdraw the amount


of insulin required.

7. Remove the syringe from the cartridge / vial.

8. Tap the syringe barrel to send any air bubbles up.

9. Expel any air bubbles.

10. Check the syringe contains the CORRECT dose.

11. Inject insulin.

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


28
Giving the injection
1. Ensure injection site is clean. There is no need to
use alcohol swabs on the injection site.

2. “Pinch up” an area of abdomen and gently hold


between fingers.

3. Don’t squeeze skin tightly.

4. Inject the needle at a 90° angle and inject insulin


dose. Count 10 seconds then withdraw the
needle. Do NOT massage the area.

5. Dispose of the syringe safely as per hospital policy for `sharps’ disposal.

Rule of Ten’s is a simple way to help people on insulin self-


inject in a consistent way each time.

Mix insulin before every injection – 10 rocks / 10 rolls

Inject insulin and count 10 seconds before removing the needle.

Giving insulin via an insulin pen device


Insulin pen device or injectors are like large fountain pens with a cartridge of insulin
inserted like an ink cartridge (Figure 3). For most people they make insulin injections
easier to perform. Many of the insulin pens on the market now are disposed of once
the insulin cartridge is empty. It is important that people are educated to use the pen
that most suits their needs eg older people with poor vision or poor dexterity often find
the Innolet easiest to use (Figure 4 below).

Figure 3 window indicating plunger depressed


dose to deliver dose

dial rotated to
replaceable needle deliver dose
to deliver the dose

Figure 4

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


29
Important points when using an insulin pen device
• Roll the pen between your palms 10 times.
• Move the pen up and down at least 10 times to make sure the insulin is well
mixed.
• Put the pen needle on and dial 2 units. Hold the pen with the needle pointing up.
Tap the cartridge gently with your finger a few times to make sure any air
bubbles collect at the top.
• With the needle still pointing upwards press the button in until the dose selector
returns to zero. A drop of insulin should appear at the needle tip. If no insulin
appears repeat the air shot.
• Set the required dose by dialling the number of units.
• Inject.

Insulin pens for inpatients


The safest way to administer insulin in a hospital setting is via an insulin syringe.

Nursing staff are not to administer insulin using an insulin delivery device (eg Innolet or
pen) with removable pen needles unless the patient is able to self administer
independently (ie self inject and then safely dispose of the needle).

If the patient is self administering then it is appropriate for the nurse and patient to
check that the dose and time is correct. The nurse then has a supervisory role to
ensure correct injection technique and appropriate disposal of sharps.

Note: The Department of Health and Ageing Infection Control guidelines state ‘to
prevent injury, needles should not be re-sheathed unless an approved recapping
device is used’.17

There is no approved re capping device for pen needles (the devices supplied by the
pharmaceutical company have not been approved for recapping).

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


30
Disposal of syringes
The following advice should be given to people with diabetes regarding disposal of
syringes but includes safe disposal of all sharps.

Background18
Safe disposal of needles, syringes and lancets is becoming more important with the
increased fear of transmission of infectious diseases, and a growing awareness of
environmental issues.
Many hospitals and health institutions have formulated their own policies for handling
and disposing of sharps. However, no national policies or guidelines exist for
community situations.
In reaching its policy statement, Diabetes Australia recognises that there is only one
means of safe disposal of needles, syringes and lancets within the community and that
is to use an approved, puncture-resistant container. Anything less than this (eg
recapping, clipping or using other sub-standard containers) has the potential to cause
wounds and infections.
Health professionals involved in diabetes education should act as advocates and
promote the necessary skills and education for people with diabetes about the safe
disposal of needles, syringes and lancets.

Agreed education message


• Take care at all times.
• Store supplies carefully (eg child-proof cabinet).
• Use a ‘standards approved’ container.
• Only recap your own needles / lancets.
Recapping your own needle / lancet is a good idea if you are not close
to an approved container (eg at a restaurant).
• For local arrangements about the safe disposal of containers, check:
• your local Diabetes Australia Association.
• your local council
• your local public hospital or community health centre.

Supply of syringes
Register with the National Diabetes Services Scheme through Diabetes Australia for
syringe supply.

Inform person about the availability of syringes / needles without cost and the fact that
they can be mailed out.

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


31
Checklist for people on insulin injections
Check your insulin - type / label / dose / expiry
- timing
- sites
- technique
- supply and storage
- syringes and disposal

Check your control - monitor


- record results

Check your food - timing of meals (and snacks if required)

Check your exercise - if strenuous you will need to adjust insulin / food

Check your survival kit - to cope with emergencies, keep it handy

Check any problem - with your doctor or diabetes nurse

Be aware of resources and contact telephone numbers.

The checklist (Appendix 1) can be used when teaching people to self-administer


insulin.

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32
Insulin Pump Therapy
Insulin pump therapy refers to the use of an infusion system for the purpose of
delivering a continuous supply of insulin (rapid acting insulin only). The pump is
attached via tubing to a small cannula which is inserted subcutaneously into the skin,
usually the abdomen.19 In Australia the pump is used for people with type 1 diabetes.

Normally a pancreas secretes a basal amount of insulin over the entire 24 hour period.
Although this basal rate varies, there is always insulin present. In addition there is an
increase (bolus) in insulin that is secreted automatically in response to food
(carbohydrate) intake. Insulin pump therapy aims to mimic the normal physiologic
response by providing continuous basal insulin as well as the ability to provide bolus
doses whenever there is intake of carbohydrate containing food.

Insulin pump therapy is becoming more widely used both in metropolitan and rural
Australia. It is anticipated that this increased utilisation of pump technology will result
in more and more patients being admitted to hospital on insulin pump therapy.

When a person is started on an insulin pump they require intensive education and
support by a multidisciplinary team including endocrinologist, diabetes educator,
dietitian and in some cases a social worker. This team has been trained and is
experienced at managing insulin pump therapy. A list of Insulin Pump Centres is
available on the Australian Diabetes Educators Association website
(www.adea.com.au). If the person lives in a rural or remote area arrangements will
need to be made for a shared care arrangement with an Insulin Pump Centre. The
diabetes team from the Insulin Pump Centre will ensure appropriate resources and
support are available prior to and after commencing the patient on pump therapy. A
shared care arrangement helps country diabetes educators to develop and maintain
skills in pump education (eg carbohydrate counting, using the pump and managing
hypo and hyperglycaemia).

Whilst it may be appropriate for a representative from an insulin pump company to


show the person the basics of how the pump operates at no stage should they
recommend insulin dose adjustments or be providing diabetes education to the
patient.20

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


33
Temporary interruption of insulin pump therapy
Insulin pump therapy can be interrupted safely for short periods of time such as
showering, sex and sports. Some people may bolus a small amount prior to
interrupting whereas others may just disconnect. Usually 60 minutes of interruption
1
can occur in a well person without causing problems.

24 hour Help Line advice


Medtronic helpline 1800 777 808
Medical Specialities helpline (02) 9417 7955
Animas 24 hr Support 1300 851 056
Roche Diagnostics 1800 802 409

What are the advantages of insulin pump therapy?


• Can provide more flexibility in food choices, timing and meal size.
• Hypoglycaemic episodes may be less frequent and less severe.
• Individuals who experience hypoglycaemia unawareness may find that their
awareness of hypo begins to return.
• May minimise the dawn phenomenon (high blood glucose levels in the morning)
• May reduce blood glucose fluctuations when diabetes is unstable eg
gastroparesis.
• May provide better control and flexibility while travelling, shiftwork, pregnancy
and during exercise.20

Obtaining supplies for insulin pump therapy


The consumables (reservoir, cannula, tubing) are subsidised by the National Diabetes
Services Scheme (NDSS). To receive this subsidy each person must be assessed
against a criteria which has been endorsed by the Commonwealth Department of
Health and Ageing. The assessment may be completed by either a credentialled
diabetes educator, endocrinologist or specialist physician.21 At this time only people
with type 1 diabetes are eligible for the subsidy.

For information about pump therapy whilst a person is in hospital, please refer to
Hospitalisation – Section 4.

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


34
Appendix 1
Patient identification
INSULIN INITIATION CHECKLIST UR: _____________________ OPD: ______________________
Referred by : _______________________________________________________ Surname:
_________________________________________
Insulin name and dose (please circle) - (as cited letter / phone / GP form / casenotes):
Given Names: ________________________________________
___________________________________________________________________________________
D.O.B. ______________________ Sex: ___________________
Medications: _______________________________________________________
Doctor: ________________________ Ward: ________________

Device type: _________________________________________ Needle size: 5 / 6 / 8 / 12 mm

Signature: Name: Date:

LEGEND FOR THE FOLLOWING TABLES (If the section is not applicable then write “NOT APPLICABLE” next to the “DATE”)
L Low knowledge/skills, unsafe, new diagnosis or has no information. Does not understand basic information and needs reinstruction.
M Medium knowledge skills or states demonstrate they may require reinforcements, supervision and explanation. Understands basic information and
demonstrates necessary skills for safe self management.
H High knowledge/skills safe, able and aware. Assumes responsibility for care and applies knowledge for safe self management.

E Explanation given (detailed) P Pamphlet given T Client demonstrated appropriate technique


INJECTION TECHNIQUE Teaching Evaluation Teaching Evaluation Teaching Evaluation
DATE:
Storage of insulin unopened to printed expiry if kept 2 - 8ºC (in
the fridge). One month expiry after opening, stored in a cool area.
Information on onset, action and duration of insulin. Timing of
injections.
Hand wash and assemble equipment appropriately. Check all
equipment is in order and functioning.
Check insulin for discolouring, freezing, formation of a white layer,
or clumping. Discard if these occur.
Gentle rotation of the insulin vial or device to ensure uniform
suspension of the insulin. 10 rocks and 10 rolls.
Prime needle. Check the correct dose before injecting. Single use
needle. Injection sites rotation and correct depth. Check for
lumps or scar tissue. Inject needle at 90°.
Count 10 seconds, withdraw the needle and let go of the pinched
area.
In case of pen equipment failure, syringe technique is taught.

Supplies eg. NDSS, chemist. Sharps disposal. Advise single use


of syringes/pen needle.

SPECIFIC INSULIN ISSUES


DATE:
Cause, signs and symptoms, prevention and treatment of
conscious hypoglycaemia.
Treatment of unconscious hypoglycaemia (glucagon taught to a
relative/friend/neighbour/carer).
Importance of medic alert or similar diabetes identification
discussed.

Individual hypo action plan eg what, who, where, why.


Ambulance cover checked.
Impact of exercise.

Sick day management.

Advised to notify Driver Licensing Authority.

Prevention of hypoglycaemia whilst driving.

SIGNATURE:
BLOOD GLUCOSE MONITORING QA test date: Competent technique:
Yes □ No □

SECTION 10 – MEDICATION – REVISED SEPTEMBER 2009


35
References

1. Donohoo E (2009) MIMs annual CMPMedica (Australia) Ltd, St Leonards.

2. Nathan D, Buse J B, Davidson M B, Ferrannini E, Holman R R, Sherwin R, and


Zinman B (2009) Medical management of hyperglycemia in type 2 diabetes: A
consensus algorithm for the initiation and adjustment of therapy. Diabetes
Care, 32(1): p193-203.

3. Wright A, Burden A C F, Paisey R B, Cull C A, and Holman R R (2002)


Sulphonylurea inadequacy: Efficacy of addition of insulin over 6 years in
patients with type 2 diabetes in the UK Prospective Diabetes Study (UKPCS
57). Diabetes Care, 25(2): p330-336.

4. Harris P, Mann L, London J, Phillips P, and Webster C (2009/10) Diabetes


management in general practice: Guidelines for type 2 diabetes. Diabetes
Australia and Royal Australian College of General Practitioners, Canberra.

5. Holman R, Sanjoy K, Angelyn Bethel A, Matthews D, and Neil H (2008) 10-Year


follow-up of intensive glucose control in type 2 diabetes. The New England
Journal of Medicine, 359(15): p1577-1589.

6. The Royal Australian and New Zealand College of Radiologists (2005)


RANZCR guidelines for metformin hydrochloride and intravascular contrast
media. [Cited 16 September 2009]; Available from:
http://www.ranzcr.edu.au/collegegroups/reference/EBM/mhicm_guidelines.cfm?

7. Rossi S (2009) Australian medicines handbook 2009. Australian Medications


Handbook Pty Ltd, Adelaide.

8. Novo Nordisk Pharmaceuticals Pty Ltd. (2009) NovoNorm® Product


Information [Cited 3 April 2009 (subscription required)]; Available from:
www.mimsonline.com.au

9. National Prescribing Service (2008) Early use of insulin and oral antidiabetic
drugs. National Prescribing Service Newsletter PPS. [Cited December 2008];
Available from:
http://www.nps.org.au/health_professionals/publications/prescribing_practice_r
eview/current/early_use_of_insulin_and_oral_antidiabetic_drugs

10. National Prescribing Service (2008) Rosiglitazone (Avandia) and rosiglitazone


with metformin (Avandamet) for type 2 diabetes mellitus. National Prescribing
Service Newsletter RADAR. [Cited 15 September 2009]; Available from:
http://www.nps.org.au/health_professionals/publications/nps_radar/current/nov
ember_2007/rosiglitazone

11. Lacy C F, Armstrong L L, Goldman M P, and Lance L L (2009) Drug


information handbook: International 18th edition. Lexi-Comp Inc, Hudson.

12. Endocrinology Drug Sub-Committee (2009) Therapeutic guidelines:


Endocrinology - version 4. Therapeutic Guidelines Ltd, Melbourne.

13. Australian Diabetes Educators Association (2004) National standards for the
development and quality assessment of services initiating insulin therapy in the
ambulatory setting. Australian Diabetes Educators Association, Canberra.

SECTION 10 – MEDICATIONS – REVISED SEPTEMBER 2009


36
14. Australian Bureau of Statistics and Australian Institute of Health and Welfare
(2008) The health and welfare of Australia's Aboriginal and Torres Strait
Islander peoples. ABS Catalogue No. 4704.0, AIHW Catalogue No. IHW 21,
Commonwealth of Australia, Canberra.

15. Australasian Paediatric Endocrine Group (2005) Clinical practice guidelines:


Type 1 diabetes in children and adolescents. Department of Health and Ageing,
Canberra.

16. The Queen Elizabeth Hospital (2002) Medication management. The Queen
Elizabeth Hospital, Adelaide.

17. Department of Health and Ageing (2004) Infection control guidelines for the
prevention of transmission of infectious diseases in the health care setting.
Department of Health and Ageing, Canberra.

18. Diabetes Australia (1992) National policy statement for safe disposal of
needles, syringes and lancets, Diabetes Australia, Canberra.

19. White R (2007) Insulin pump therapy (continuous subcutaneous insulin


infusion). Primary Care Clinics in Office Practice, 34(4): p845-871.

20. New South Wales Insulin Pump Interest Group (2006) Insulin pump therapy: An
information booklet for diabetes health professionals interested in establishing
an insulin pump therapy service, Diabetes Australia & ADEA, Canberra.

21. Diabetes Australia) Insulin pump consumerables. [Cited 2009 17 September];


Available from: http://www.ndss.com.au/Products--Outlets/Insulin-pump-
consumables/

SECTION 10 – MEDICATIONS – REVISED SEPTEMBER 2009


37
SECTION 11
Unstable diabetes
Hypoglycaemia and hyperglycaemia occur in both type 1 and type 2 diabetes. The aim
of this section is to provide an overview of these acute complications in the context of
the home / community setting. Refer to Hospitalisation – Section 4 to find out more
about managing hypoglycaemia and hyperglycaemia in a hospital or health service
setting.

Hypoglycaemia
Hypoglycaemia occurs when the blood glucose level falls to values low enough to
cause symptoms and signs. When the level of glucose falls in the blood the cells in
the periphery, and eventually the brain cells do not get adequate glucose to function.
The value at which this occurs is defined at below 4mmol/L but probably differs
according to the age and sex of the person, whether there are any associated medical
conditions such as liver disease or cerebrovascular disease present and the rate at
which blood glucose level has fallen. Significant hypoglycaemic symptoms tend not to
occur until blood glucose levels fall below 4mmol/L.1

There is significant physical and psychological morbidity associated with


hypoglycaemia. Hypoglycaemia can be very frightening for the person and their
family. Furthermore hypoglycaemia can lead to injury such as falling, an accident
while driving and sometimes death. Health professionals play an important role in
helping people to understand, prevent and manage hypoglycaemia.

Type 1 diabetes
Hypoglycaemia is very common for people with type 1 diabetes. For those who are
wanting to improve or maintain target glycaemic control symptomatic hypoglycaemic
episodes may occur on average 2 times a week. Severe hypoglycaemia may occur
approximately 1 time per year.1 It has been estimated that 2-4% of deaths of people
with type 1 diabetes have been attributed to hypoglycaemia.

Type 2 diabetes
The frequency of hypoglycaemia is substantially lower in type 2 diabetes as compared
with type 1 diabetes. The rate of severe hypoglycaemia in type 2 diabetes are less
than 10% of those in type 1 diabetes at the same level of A1c.1 Hypoglycaemia
becomes more problematic for people with type 2 diabetes as their diabetes
progresses and they become more and more insulin deficient. Deaths have been
documented in people with type 2 diabetes who are on sulphonylurea medications.

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1
Clinical features of hypoglycaemia
In people who do not have diabetes a counter-regulatory response is triggered as
blood glucose levels drop. When the blood glucose level (BGL) drops to about
4.2mmol/L the secretion of endogenous insulin is suppressed. In type 1 diabetes this
does not happen because they have no endogenous insulin and the injected
(exogenous) insulin can not be suppressed. In people with type 2 diabetes the body
can suppress some of the insulin because they are still producing their own insulin.1

At about 3.7mmol/L the secretion of glucagon is increased and this results in the
release of stored glucose. Other hormones such as epinephrine, cortisol and growth
hormone are also released in order to raise the blood glucose.1

The symptoms of hypoglycaemia can be classified into two groups.

1. Symptoms in response to adrenaline or the sympathetic nervous system (pale


skin, sweating, shakiness, tingling especially around the lips, palpitations and a
feeling of anxiety).

2. Symptoms due to decreased glucose in the brain (difficulty concentrating,


confusion, inappropriate behavioural and psychological reactions, drowsiness,
ultimately seizures and coma).

Hypoglycaemia can be defined on the basis of physiology using the terminology mild,
moderate or severe (table 1).

Table 1
Mild Moderate Severe
Not capable of self-
Capable of self treating May require prompting
treatment

Tremors, palpitation, Headache, mood changes, Conscious or


sweating, hunger, fatigue low attentiveness unconscious
Adrenergic Neuroglycopenic Neuroglycopenic

Hypoglycaemia at night is often slept through and not noticed. Symptoms of unnoticed
nocturnal hypoglycaemia include:

• morning headaches
• hangover type feeling on waking
• nocturnal sweating.

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2
Primary causes of hypoglycaemia
Hypoglycaemia is a risk for people who are taking glucose lowering medicines or
insulin. There are a number of possible causes of hypoglycaemia that have been
identified:

• missing a meal or snack


• inadequate carbohydrate intake
• delaying a meal (or enteral feeding)
• over-administration of insulin or oral hypoglycaemic agents
• prolonged physical activity with no food or adjustment of insulin
• excessive alcohol intake, especially on an empty stomach
• vomiting eg morning sickness.

In addition, hypoglycaemia has also been associated with:

• onset of menstruation cycle due to hormonal levels which decrease insulin


requirement
• eating disorders such as anorexia nervosa and bulimia
• immediate post-partum period where a rapid decrease in placental hormones
increases insulin effect
• autonomic neuropathy where there may be diminished epinephrine response or
delayed gastric emptying
• extremes in weather temperature eg heat and cold.

Management
Hypoglycaemia must be treated promptly. People with diabetes should have a
hypoglycaemia action plan which clearly steps out their management.

The following is a suggested protocol for the treatment of people with hypoglycaemia
in the community. This protocol may be adapted for any hypoglycaemic situation. You
should refer to Hospitalisation – Section 4 for the hypoglycaemia protocol for health
services and hospitals.

Mild or moderate hypoglycaemia


If hypoglycaemia is suspected, check BGL.

Blood Glucose Level <4mmol/L treat as follows

Step 1
• 15gm fast acting carbohydrate (CHO)
eg 150mls soft drink
or 15g Glucose tablets
or 6 jelly beans (glucose)
• Wait 5-10 minutes
• Repeat Step 1 if BGL still <4mmol/L
• If blood glucose level ≥4mmol/L, move to Step 2.

Step 2
• Slow acting CHO intake
eg 4 water crackers or equivalent or
1 piece of fruit or
1 cup of milk or
meal if only minutes away.
SECTION 11 – UNSTABLE DIABETES – REVISED SEPTEMBER 2009
3
Severe hypoglycaemia
If confusion or loss of consciousness prevents safe administration of oral glucose then
glucagon can be administered by a family member or ambulance officer.

Glucagon (GlucaGen®)

Glucagon is used to treat severe hypoglycaemia whereby a person is unable to


swallow safely. A doctor will need to prescribe a GlucaGen Hypokit for use by the
persons family / carers / friends.

Glucagon should be prescribed for all individuals who are at significant risk of severe
hypoglycaemia eg past history of severe hypo or hypo unaware. Caregivers or family
2
will require instruction.

Glucagon is a hormone that increases glucose levels in the blood. It does this by
releasing glucose from stored carbohydrate (glycogen) in the liver into the blood. This
means that glucagon will only work to increase blood glucose if there are stores of
glycogen in the liver.

What to teach in case of hypoglycaemia

People need to be informed that they will need a script and that they will need to check
expiry dates. Ambulance cover and medic alert are recommended.

It is important to inform the person and their family that if they phone an ambulance
they will be connected to a qualified SAAS call-taker. The call-taker will immediately
assess the situation and can give step-by-step instructions over the phone. This can
provide much needed support during a stressful event. The call taker will assess the
severity and an ambulance will be dispatched if required. Visit the website
www.saambulance.com.au for more information about the ambulance service.

If the person is unconscious, turn on to their side and get help immediately.

Advice for non-medical person: inject the dose of glucagon into the fatty tissue just
below the skin of the thigh or buttocks.

• Adults and children above 25kg: inject full dose (marked on hypokit syringe as
1/1mL)
Children below 25kg: inject half dose (marked on hypokit syringe as 1/2mL)

• The person will normally respond within 10-15 minutes to the injection of glucagon.

• Once conscious, follow usual guide for hypo treatment. Note: It is advisable not to give
food immediately as the person may feel nauseous. Slow sips of a sweet drink is
sufficient.

• People also often have a distressing headache after a severe hypo and they can
be advised to sleep once BGLs are stabilised.

• After a severe hypo the liver stores of glucose may be depleted and so the
person needs to be warned that they are at an increased risk of further hypos.

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4
Storage
o
GlucaGen Hypokit should be stored at room temperature (eg less than 25 C).

Avoid freezing to prevent damage to the glass syringe.

The GlucaGen Hypokit powder vial should be protected from light.

The expiry date (“Expiry”) is printed on the pack. If passed this date, do not use it.
Check the expiry date from time to time to make sure that the glucagon in your
GlucaGen Hypokit has not expired.

The glucagon solution should be injected immediately after it is prepared. It should not be stored for later use.

For further information consult the Product Information leaflet. Information is also
available from Novocare Customer Care Centre on 1800 668 626.

Monitor
Monitor person 15-30 minutes following treatment.

Check blood glucose level after 30 minutes from initial time. If blood glucose level is
<4 repeat Steps 1 and 2 on page 3. It is necessary to ensure that the hypoglycaemia
does not recur and blood glucose level remains within normal range.

Length of observation
The person should be aware that hypoglycaemia might reoccur and that increased
testing for the next 24 hours may be needed. This will depend on the severity and
duration of episode. Some form of fast acting, rapidly absorbed carbohydrate should
be left with the person. After a severe episode of hypoglycaemia the next dose of
medication may need to be modified and the person should discuss their needs with
the appropriate health professional. The person should also be encouraged to
determine the cause of the hypoglycaemia wherever possible to assist in preventing
further episodes.

Hypoglycaemic unawareness
Some people with diabetes may not have any symptoms of hypoglycaemia.
Unawareness of hypoglycaemia symptoms occurs more frequently in people who have
had diabetes for many years or in people who maintain lower blood glucose levels.
Diabetic neuropathy can also lead to hypoglycaemic unawareness.

People who may be at `risk’ of hypoglycaemic unawareness are advised to monitor


blood glucose levels more frequently and need to ensure meal patterns and exercise
are matched. Some people may adjust their insulin dose by 10% depending on activity
levels (see Maintaining a healthy lifestyle – Section 9). People need to discuss target
blood glucose ranges with their GP / MO medical officer.

Education and support for partners / carers and the person themself are also important
issues in managing hypoglycaemic unawareness.

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5
Prevention of hypoglycaemia
Educating people at risk of hypoglycaemia regarding the signs and symptoms, causes
and early treatment of hypoglycaemia is a mainstay of prevention.

People with diabetes should be instructed to carry some form of quick acting
carbohydrate at all times. Educate people at risk to carry an identification card or wear
a bracelet.

Advise people to check their blood glucose level or institute treatment at the first
indication of possible hypoglycaemia.

If hypoglycaemia occurs frequently they must discuss this with the GP / MO so that
some adjustment is made to their treatment plan. Adults trying to lose weight or
maintain their current weight may need to have their medication dosage decreased.

Educate family members and close friends about hypoglycaemia and teach them when
and how to measure blood glucose levels and the use of glucagon injection.

Educate people with diabetes who are at risk of hypoglycaemia to employ special care
(eg increased monitoring, including 3am glucose checks) when activity and diet
patterns are altered, when planning to drive or while driving.

Consider developing a ‘hypo’ action plan


Health professionals have an important role in assisting people to have a hypo action
plan in place. A hypo kit is central to this action plan and the person can be asked to
identify what foods would be most appropriate to keep in their hypo kit. You could
consider working through a plan like the one below.

Example of a personalised ‘hypo plan’

My ‘hypo’ plan

BG ____less than 4mmol/L ________

Step 1 at home ____6 jelly beans_____________

out / car ____glucose tablets___ ________

Step 2 monitor BG – 10-15 min and repeat step 1 until BG over 4

or ____________________________

Step 3 at home ____piece of bread ____________

out / car ____muesli bar________________

Step 4 monitor BG – 1-2 hour increasing gap time until happy no repeat
hypo

or ____repeat BG in 1 hour_________

NB sometimes symptomatic at 5mmol/L - sit quietly to ease anxiety and


have a cup of white tea. _________
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6
Hyperglycaemia
Definition of hyperglycaemia
Hyperglycaemia is defined as a fasting blood glucose concentration of >7.0mmol/L and
3
post prandial concentration of >11.1mmol/L. However, symptoms are more
commonly evident when the blood glucose concentration is >15mmol/L.

Hyperglycaemia as a result of uncontrolled diabetes mellitus may ultimately lead to two


types of metabolic disturbances, conditions known as diabetic ketoacidosis (DKA) and
hyperglycaemic hyperosmolar state (HHS). Diabetic ketoacidosis is a serious life-
threatening complication that results from uncontrolled type 1 diabetes. HHS is also a
life-threatening emergency and is usually seen in the elderly or undiagnosed person
with type 2 diabetes.

Primary causes
• insufficient insulin, omitting the insulin injection
• insufficient oral hypoglycaemic agents or omitting to take medications as
prescribed
• excessive carbohydrate intake
• stress – physical stress increases the body’s energy demands, which increase the
production of glucose and counter regulating hormones. Insulin or oral
hypoglycaemic agents therefore are less effective
• infection and illnesses - gastroenteritis, myocardial infarction, urinary tract infection
• surgery
• rebound hyperglycaemia – Somogyi effect
• other medications, eg steroids such as prednisolone.

Assessment of hyperglycaemia
Assessment is crucial to prevent hyperglycaemia progressing to an advanced
metabolic crisis. This can be prevented by early recognition of signs and symptoms
and prompt treatment. To assess hyperglycaemia:

• perform blood glucose measurement


• in type 1 diabetes test ketones if blood glucose >15mmol/L, or are unwell. If urine
ketone levels 3+ or blood ketone levels are above 1.5mmol/L or ketoacidosis
suspected, contact the GP/MO or diabetes specialist (eg endocrinologist)
immediately.
• continue to monitor blood glucose and ketones as ordered
• ensure medication is given as ordered
• observe for symptoms such as polyuria, polydipsia, polyphagia, lethargy or
infections and monitor progress.

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7
Advanced hyperglycaemia
If the symptoms of hyperglycaemia are not recognised and treated early, the
hyperglycaemia may become advanced and lead to various emergency situations
depending on the type of diabetes.

Ketoacidosis
Diabetic ketoacidosis (DKA) is a medical emergency which has a <5% mortality.4 It is
preventable in people known to have type 1 diabetes and most cases of ketoacidosis
occur in patients with undiagnosed type 1 diabetes.

Ketoacidosis results from the absence of insulin. Although small amounts of


circulating insulin may be present, the presence of large amounts of the counter
regulatory hormones such as glucagon, adrenaline and noradrenaline and cortisol,
result in the insulin being less effective.
4
DKA consists of the biochemical triad of hyperglycaemia, ketonaemia and acidaemia.
The following diagram depicts the development of diabetic ketoacidosis.

Pathophysiology of diabetic ketoacidosis5

Infection, Missed insulin injection


Stress Undiagnosed type 1 diabetes

Insulin
Glucagon and
deficiency
counter-regulatory
hormone excess

Reduced glucose
Lipolysis Glycogenolysis
uptake
Ketogenesis Gluconeogenesis
into tissues

Ketosis Hyperglycaemia

Acidosis Vomiting Osmotic


diuresis

Severe Dehydration

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8
Precipitating factors

Precipitating factors vary from individual to individual but may include:

• Illness / infection.
• Inadequate insulin administration either by the MO or the person with diabetes.
People with gastrointestinal infections often decrease or omit insulin when food
intake is decreased. (The person must be educated regarding appropriate
management during sick days and advised that adjustment of insulin dosages
based on blood glucose levels may be required).
• First presentation of type 1 diabetes.

Features of ketoacidosis

The signs of diabetic ketoacidosis are hyperglycaemia, glycosuria, ketosis, dehydration


and electrolyte imbalance.

Glycosuria: occurs as the concentration of glucose in the blood exceeds the renal
threshold (ie capacity to reabsorb).

Polyuria: glucose in the urine acts as an osmotic diuretic, which can lead to
dehydration if left untreated.

Polydipsia: thirst will occur as the body attempts to replace the lost fluid.

Ketones: as fats are broken down to supply energy, ketoacids accumulate in the
blood stream causing ketosis and acidosis. Ketosis is also recognised by an acetone
breath. The accumulation of ketones in the blood and excretion of ketones in the urine
(ketonuria) leads to more electrolyte imbalance and dehydration.

Gastrointestinal: symptoms are nausea, vomiting, abdominal pain.

Respiratory: symptoms may include hyperpnoea (increased ventilation) and / or deep


rapid breathing (Kussmaul’s respirations) which produces a respiratory alkalosis as the
body attempts to correct the metabolic acidosis.

Polyuria, ketonuria and acidosis cause loss of body potassium. However, acidosis
causes potassium to move from the cells to the plasma. Hence, the circulating
potassium may be low, normal or high.

If acidosis and hyperglycaemia continue, they may lead to coma and death.

Prevention
• Awareness of the early signs and symptoms of uncontrolled diabetes must be
increased. People with diabetes and their family need education.
• The importance of ketone testing during illness should be stressed for people
with type 1 diabetes.
• Management of sick days in the home situation with increased knowledge and
skills is a major factor in prevention.
• Professional education with regard to proper diagnosis and treatment.
• Psychological intervention will need to be included as part of the treatment for
those who have recurrent episodes requiring admission to hospital.

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9
Hyperglycaemic hyperosmolar state (HHS)
4
HHS has a significant mortality rate of approximately 15%. This complication of
diabetes occurs more frequently in elderly people with type 2 diabetes and may occur
as the presenting problem of undiagnosed diabetes. As in diabetic ketoacidosis it is a
life threatening emergency. There is no ketoacidosis present since there is enough
insulin to inhibit the breakdown of fat. Severe hyperglycaemia however causes
osmotic diuresis, leading to severe dehydration, with polyuria, polydipsia and
polyphagia.

If the person is unable to replace fluids, dehydration and mental impairment occurs.
This is especially likely in the elderly. Hence this acute complication often occurs in
the elderly on oral hypoglycaemic agents who may be inadequately monitored or not
receiving adequate fluid intake and unable to communicate their need.

The high plasma osmolality and dehydration lead to:

• decreased skin turgor


• hypotension
• elevated body temperature
• drowsiness
• confusion
• convulsions
• coma.

Note: Kussmaul’s respirations and acetone breath are not present.

Precipitating factors

These include:

• infection
• intercurrent illness such as myocardial infarction, acute airway disease
• medication, eg high dosage corticosteroids, excessive use of diuretics
• pancreatitis
• total parental nutrition
• renal dialysis
• severe burns.

Prevention is the key – education is the answer

To prevent hyperglycaemic hyperosmolar state (HHS) from occurring, identify those at


high risk and ensure the older person is well hydrated.

Teach people with diabetes and family about warning signs and symptoms. Make sure
they know about sick day management and when to seek advice. Health professionals
should be aware of the appropriate management of people who are at risk.

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10
Comparison of features of diabetic ketoacidosis and
hyperglycaemic hyperosmolar state (HHS)
The following table highlights key areas related to the differing features of type 1 and
type 2.6

Feature Ketoacidosis Hyperglycaemic Hyperosmolar


State

Type of diabetes Type 1 Type 2

Age of patient Usually <40 years Usually >40 years

Duration of symptoms Usually <2 days Usually >5 days

Glucose Usually <22mmol/L Usually >22mmol/L

Sodium More likely to be normal More likely to be normal or high


or low

Potassium High, normal or low High, normal or low

Bicarbonate Low Normal

Urinary Ketones 4+’s on dip stick May be present but not relevant

Blood ketones >1.5mmol/L not applicable

Urinary pH Low Normal

Serum osmolality Usually <350mOsm/kg Usually >350mOsm/kg

Cerebral oedema Often sub-clinical; Not evaluated if subclinical; rarely


occasionally clinical clinical

Prognosis 5% mortality 15% mortality

Subsequent course Insulin therapy required in Ongoing insulin therapy often not
all cases required. May be required in the
long term.

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11
Prevention of hyperglycaemic emergencies
• Medication should always be taken as prescribed.

• Notify the GP / MO if blood glucose concentration exceeds 15mmol/L, the person


is unwell or ketones are moderate to large.

• Be aware of the early symptoms of hyperglycaemia before the condition


progresses to a life-threatening situation.

• If the person is administering their own insulin, check their technique and
knowledge.

• On days of illness, usual medication must be taken with usual diet / supplements
and blood tested more frequently, eg 2 hourly. Extra medication may be required.

Sick day management advice


When to follow sick day guidelines
The following information is a synopsis of the Australian Diabetes Educators
Association, Sick Day Management Guidelines for People with Diabetes.7

These guidelines apply when the person with diabetes is feeling unwell or noticing
signs of an illness and / or:

Type 1 diabetes

• Ketones are present in blood or urine.


• Blood glucose is greater than 15mmol/L on two consecutive readings (for
example within a 2–6 hour timeframe).

Type 2 diabetes

• Blood glucose is greater than 15mmol/L on two consecutive readings (for


example within an 8–12 hour timeframe).

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12
Eight tips for self management of minor illnesses7
Whatever the type of diabetes, there are a number of steps to take when you get sick.

1. Stress to the person with diabetes the need to continue insulin or diabetes
medications.
Gastrointestinal illnesses may cause hypoglycaemia for individuals treated with
insulin, sulphonylureas or repaglinide. In this instance these medications may
need to be reduced according to blood glucose readings.

Type 1 diabetes
• stopping insulin when unwell is a very common mistake people make and a
key reason for development of ketoacidosis.

Type 2 diabetes
• metformin should be ceased with onset of intercurrent illness under the
guidance of a GP / MO.

2. Ask the person with diabetes to monitor glucose and ketones (if relevant)
more frequently.

Type 1 diabetes
• blood glucose – two hourly or more frequently if low blood glucose or
significant ketones present.
• ketones – two to four hourly when blood glucose is 15mmol/L or higher
and / or signs of illness (urine or blood ketone testing).

Type 2 diabetes
• blood glucose – two to four hourly, more frequently if low blood glucose.

3. Ensure person with diabetes has adequate support.


Ensure person with diabetes has a support person with them and knows when
the condition can no longer be managed at home.

4. Provide advice on maintaining hydration and carbohydrate intake.


Recommend frequent volumes of fluids to prevent dehydration. As a guide, half
to one cup every hour is suggested.

Encourage person with diabetes to maintain oral intake to reduce risk of


hypoglycaemia and maintain energy requirements.

If unable to consume food the recommendation is:


• Carbohydrate containing fluids if blood glucose less than 15mmol/L
• Carbohydrate free fluids if blood glucose more than 15mmol/L.

Rehydration solutions (eg Gastrolyte) can help to replenish fluid and electrolytes
loss through vomiting, diarrhoea or dehydrated. Rehydration solutions have a
relatively low concentration of carbohydrate therefore additional carbohydrate
may be required.

Care should be taken with hypertonic or sweetened fluids if diarrhoea occurs.


Sweetened fluids may require dilution up to 1–5 times for optimum absorption.

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13
5. Supervise supplemental insulin or OHA doses to manage hyperglycaemia
and ketosis.

Type 2 diabetes
See table 2.

Table 2
Treatment Possible action
• No medication for hyperglycaemia. • May require the addition of
sulphonylureas or insulin
temporarily.
• Treated with hypoglycaemic agents. • If not on maximal dose of
sulphonylureas (only applies to
non-slow release) or glitinides
consider increasing.
• Increasing other
hypoglycaemic agents is not
recommended.
• Treated with hypoglycaemic agents • May require supplemental
and nocte basal insulin. quick acting insulin (see notes
below).
• Treated with mixed insulin. • May require supplemental
quick acting insulin (see
notes below).

Supplemental insulin doses

Variations to insulin dose percentage and monitoring that apply for type 2
diabetes (who have access to short acting insulin) are outlined below.

• Blood glucose >15mmol/L advise extra 10% of insulin dose and 2 hourly
monitoring.

• Blood glucose >22mmol/L advise extra 20% of insulin dose and 2 hourly
monitoring.

Home management should be reconsidered if blood glucose is >15mmol/L


for 2 consecutive readings and rapid or short acting insulin is not
accessible.

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14
Type 1 diabetes
Supplemental doses of rapid or fast acting insulin should be administered.

The dose should be:

• In addition to the usual insulin dose.


• Given straight away and not delayed until the next regular insulin dose is
due.
• Given as a percentage of the usual daily dose.

See table 3 (on next page) for supplemental insulin doses and management
strategies.

Note
Individuals with insulin pumps can develop ketosis and DKA more quickly
because there is no background reservoir of long acting insulin. Always check
for technical problems with the pump and advise use of pen or syringe for
supplemental insulin doses. General sick day guidelines for patients with an
insulin pump include:

• Increase the basal insulin rate by 20-50% during illness when the blood
glucose levels are elevated.
• Use the correction bolus feature of the insulin pump every 3-4 hours to
decrease blood glucose level to its target range.
• Early medical review is essential to ensure correct doses are delivered.

Further details should be sort from the person’s specialist team. See
Hospitalisation – Section 4 for more details.

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15
Table 3: Quick guide to supplemented insulin doses for sick days for type 1
diabetes
Blood Ketones Insulin Review Fluid Intake
Glucose Urine* / supplement
Level Blood* If more than 2 extra Home insulin Stress need to
supplements of supplements should only maintain fluid
insulin are required be advised if client is intake aim for
seek medical care able to maintain hourly 1/2-1 cup hr
telephone contact
Less than Negative May require reduction Hourly until glucose level
4mmol/L in insulin dose normalised
- Take glucose
containing fluids and /
or quick acting CHO
- Consider mini dose
glucagon to prevent
hypo in people with
gastroenteritis or
reduced CHO intake
Positive ketones First priority is to Will require supervised
increase BGL with medical care if ketones
Sweetened
fluid and CHO remain present and blood
fluids are
glucose remains low
recommended if
15mmol/L or Negative / Trace No change to insulin Two hourly
blood glucose is
less or
below 15mmol/L
<1.0-1.4mmol/L
Small - No change to Two hourly
or insulin, re-check
1.0-1.4mmol/L blood glucose and
ketones in two hours
- If persistently
elevated, consider an
extra 5% insulin dose
Moderate / large 5-10% extra insulin Hourly
or -If ketones rising or remain
≥1.5mmol/L large advise to seek
supervised medical care
>15-20mmol/L Negative / Trace 5% extra insulin dose Hourly
or
<1.0-1.4mmol/L
Small 10% extra insulin Hourly
or dose
1.0-1.4mmol/L
Moderate/large 15-20% extra insulin Hourly
or dose - If ketones decreasing or
≥1.5mmol/L remain moderate, review in
one hour, follow guidelines
for further extra insulin
- If ketones are increasing
or remain large, advise to Unsweetened
seek supervised medical fluids are
care recommended if
>22mmol/L Negative / Trace 10% extra insulin Hourly blood glucose is
or dose greater than
<1.0-1.4mmol/L 15mmol/L
Small 15% extra insulin Hourly
or dose
1.0-1.4mmol/L
Moderate / large Take an extra 20% - If ketones are decreasing
or ≥1.5mmol/L insulin dose or remain moderate review
in one hour, follow
guidelines for further
insulin
- If ketones are increasing
or remain large advise to
seek supervised medical
care
Key - % refers to percentage of daily dosage given as rapid or fast acting insulin.
* refers to results of blood 3B-hypdroxybutyrate.

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16
6. Manage the underlying illness.
The intercurrent illness needs to be diagnosed and treated.

Symptoms from the illness need to be differentiated from the symptoms of


hyperglycaemia, hypoglycaemia or ketoacidosis.

The use of sugar free medication is not considered essential.

7. Provide advice on prevention of hypoglycaemia.


Illnesses associated with nausea, vomiting or diarrhoea may cause
hypoglycaemia.

Follow regular recommendations for treatment of hypoglycaemia.

A reduction of insulin by 20-50% or oral hypoglycaemic agents (OHA) may be


required.

Glucagon in small doses may prevent or treat mild hypoglycaemia in people with
gastroenteritis or reduced carbohydrate intake including children.

8. Discontinue home management of sick days if condition deteriorates or


fails to respond to increased insulin.

The following are an indication for seeking medical attention in a supervised


environment.
• Blood glucose – continues to rise despite 2 extra insulin doses or remains
greater than 15mmol/L for those unable to administer supplementary
insulin.
• Ketones – are moderate to heavy (urine) / >1.5mmol/L (blood) or present
and not decreasing with extra insulin.
• Signs of DKA or HHS – such as vomiting, drowsiness, confusion,
disorientated, hyperventilating, dehydration or severe abdominal pain.
• Vomiting – is persistent, especially if frequent for more than 2-4 hours or
becomes bile stained.
• Severe dehydration.
• Hypoglycaemia – is severe or blood glucose cannot be kept above
4mmol/L.
• Too unwell – if the individual or support people are unable to carry out the
monitoring required.
• Unclear diagnosis – if the diagnosis of the underlying illness is unclear.
• Extremes of age – children under 2 years or frail elderly.

Note: Women who are pregnant are advised to seek medical help early if they
are sick.

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17
Other situations that cause unstable
diabetes
Somogyi effect
Rebound hyperglycaemia or the Somogyi effect refers to morning hyperglycaemia that
5
follows an episode of nocturnal hypoglycaemia.

This is a complex phenomenon that usually only occurs in type 1 diabetes. The
Somogyi effect may partly reflect the release of counter-regulatory hormones such as
glucagon, adrenaline, noradrenaline, cortisol, growth hormone stimulated by
hypoglycaemia. These hormones stimulate the release of stored glucose from the
liver, and also increase the manufacture of glucose by the liver. The person’s
response to the hypoglycaemia episode may also contribute because people often eat
more than is required to treat the hypo.

Clinical Presentation

Fasting hyperglycaemia, eg >15mmol/L for 3 consecutive mornings may be a sign of


the Somogyi effect. High blood glucose level may occur at any time and even for
12-24 hours after a severe hypoglycaemic reaction.

Management

• Note any signs of nocturnal sweating or restlessness during the night.


• Perform blood glucose measurement during the night at 0300 hrs. With the
Somogyi effect blood glucose will be low; with inadequate insulin activity blood
glucose will be high.
• Treat hypoglycaemia <4mmol/L as per protocol.
• Document episode and action taken accurately in progress notes.
• Report to medical officer.
• Determine cause (has supper snack been given too early or inadequate
carbohydrate or too much insulin).
• Continue to observe blood glucose patterns over a 24 hour period.
• Ensure medication / CHO intake is adjusted to prevent further episodes.

Honeymoon phase
The `honeymoon phase’ is a term used to describe the period of time immediately
following initial diagnosis of type 1 diabetes.5 The beta cells may continue to produce
insulin for a further 6 to 18 months. Often less insulin is needed and hypoglycaemia
occurs. Young children occasionally require dilution of insulin because so little insulin
is needed. C-peptide blood tests reflecting the amount of insulin secreted by the
person’s pancreas can determine the extent of endogenous insulin production.

SECTION 11 – UNSTABLE DIABETES – REVISED SEPTEMBER 2009


18
Dawn phenomenon
The ‘dawn phenomenon’ is characterised by unacceptably high fasting blood glucose
levels and is more common in type 2 diabetes. Normally blood glucose levels rise from
around 3.00am and gradually increase to a normal fasting level of 5.0mmol/L before
breakfast. When this occurs in people with diabetes who have insufficient or
ineffective endogenous insulin, a higher than normal fasting blood glucose level is
found.

Treatment of the ‘dawn phenomenon’ requires additional insulin activity by either oral
hypoglycaemic agents or insulin therapy but at the same time ensuring hypoglycaemia
is avoided. It is also important to distinguish from the high fasting blood glucose levels
which could be a result of the Somogyi effect.

Management involves regular home blood glucose monitoring with extra monitoring at
3.00am to ascertain the blood glucose levels and to assist with medication
adjustments.

Lactic acidosis
Lactic acidosis is the accumulation of lactic acid in the body. The condition is rare and
generally occurs in the older person.

The risk of lactic acidosis increases where there is decreased tissue perfusion
associated with septicaemia or cardiovascular shock, or with alcohol abuse associated
with renal or hepatic impairment. It may be aggravated by metformin therapy.

Signs of lactic acidosis include deep and rapid breathing, vomiting and abdominal pain.
Metabolic acidosis is present but ketones are absent or minimal.

Lactic acidosis may be present in combination with ketoacidosis or non-ketotic


hyperglycaemia.

Management is as for ketoacidosis, often with sodium bicarbonate to correct acidosis.

SECTION 11 – UNSTABLE DIABETES – REVISED SEPTEMBER 2009


19
References
1. Cryer P E, Davis S N, and Shamoon H S (2003) Hypoglycemia in diabetes.
Diabetes Care, 26(6): p1902-1912.

2. American Diabetes Association (2009) Standards of medical care in diabetes -


2009. Diabetes Care, 32(Suppl 1): pS13-S61.

3. Harris P, Mann L, Marshall P, Phillips P, and Webster C (2008/09) Diabetes


management in general practice: Guidelines for type 2 diabetes. Royal
Australian College of General Practitioners and Diabetes Australia, Canberra.

4. Kitabachi A E, Umpierrez G E, Murphy M B, Barrett E J, Kriesberg R A, Malone


J I, and Wall B M (2001) Management of hyperglycemic crisis in patients with
diabetes. Diabetes Care, 24(1): p131-153.

5. Haire-Joshu D (1996) Management of diabetes mellitus: Perspectives of care


across the life span. Mosby, St Louis.

6. Franz M J, Kulkarni K, Polonsky W H, Yarborough P C, and Zamudio V. eds


(2000) Diabetes education and program management: A core curriculum for
diabetes education. 4th Edition. American Association of Diabetes Educators

7. Australian Diabetes Educator Association (2006) Guidelines for sick day


management for people with diabetes, ADEA, Canberra.

SECTION 11 – UNSTABLE DIABETES – REVISED SEPTEMBER 2009


20
SECTION 12
Long term complications
A major goal in the management of diabetes is to prevent or delay the occurrence of
long term complications.

Long term complications of diabetes present as either microvascular or macrovascular


complications.

Macrovascular complications result from damage to major blood vessels and can
include:

• coronary heart disease


• cerebrovascular disease (eg stroke)
• peripheral vascular disease.

Microvascular complications result from damage to smaller blood vessels and


nerves and can include:

• nephropathy
• retinopathy
• neuropathy.

In both type 1 and type 2 diabetes the microvascular and macrovascular complications
of diabetes substantially increase a persons morbidity and mortality. Two landmark
studies the Diabetes Control and Complications Trial (DCCT)1 and the United Kingdom
Prospective Diabetes Study (UKPDS)2 have demonstrated that a reduction in HbA1c
can substantially lower the risk of long term complications.

In 1993 the DCCT showed unequivocally in type 1 diabetes that lowering blood
glucose delayed the onset and slowed the progression of microvascular complications.
These risk reductions varied from 35 to 75% amongst the microvascular complications.
A reduction in macrovascular complications was seen but it did not reach significance
(this may have been due to the small numbers of complications seen in the time
frame). It was important to assess if these reductions would also be seen in type 2
diabetes and in 1998 the results from the largest and longest study on people with type
2 diabetes was published (UKPDS).2 The UKPDS results demonstrated that
retinopathy, nephropathy and possibly neuropathy are benefited by lowering blood
glucose levels. The overall microvascular complication rate was decreased by 25%.
As in the DCCT trial there was a reduction in cardiovascular complications but it did not
reach significance. The study showed that lowering blood pressure significantly
reduced strokes, diabetes-related deaths, heart failure, microvascular complications
and visual loss.2 The UKPDS was a landmark study which has resulted in a much
more aggressive approach to the treatment of hyperglycaemia, hypertension and other
associated risk factor reduction strategies.

Long term follow up of participants from the original DCCT and UKPDS groups
have demonstrated a legacy effect associated with achieving glucose targets
early in the course of diabetes even when this level of control is not maintained
some years
3, 4
later.

SECTION 12 – COMPLICATIONS – REVISED SEPTEMBER 2009


1
It is important to be aware of the possible long term complications which may
occur in a person with diabetes in order to:

• assist in educating the person about risk factors and indicators of long term
complications
• assist in early detection and monitoring of existing problems
• assist in the management of complications which may already be present.

Note: Our aim in this manual is to alert health care providers to the types of problems
which may occur. More extensive reading is required if you wish to study the
pathophysiology relating to long term complications.

Prevalence
In 2005, diabetes was listed as an underlying or an associated cause of death in
5
11,900 deaths (9% of all deaths in that year).

Prevalence of diabetes complications in type 2 diabetes in South Australia6

Complication People with diabetes with complications


(n=173)
% 95% confidence intervals
One or more microvascular condition 66.1 58.3 – 73.9
One or more macrovascular condition 52.7 44.5 – 60.9
IHD* 34.4 26.7 - 42.1
PVD* 31.9 24.3 - 39.5
IHD & PVD 13.7 8.1 - 19.3
Microalbuminuria 26.6 19.4 - 33.8
Macroalbuminuria 7.9 3.3 - 12.0
Neuropathy 47.9 39.9 - 55.9
Retinopathy (n=139)# 19.0 12.6 - 25.4
*IHD=ischaemic heart disease; PVD=peripheral vascular disease.
#n = 139 assessed for retinopathy

SECTION 12 – COMPLICATIONS – REVISED SEPTEMBER 2009


2
Macrovascular disease
Macrovascular disease accounts for 75% of diabetes related deaths.7 In
macrovascular (large blood vessel) disease, damage to the vessel linings leads to
thickened and blocked arteries. Macrovascular disease can result in heart attack,
stroke, reduce blood flow to lower limbs causing slow healing of cuts and scratches on
the feet, and high blood pressure.

Various forms of macrovascular disease tend to occur in the same individual. Thus
people with diabetes undergoing operations for peripheral vascular disease are at
special risk of peri-operative myocardial infarction or stroke. Assessment includes
checking for risk factors and indicators of macrovascular disease.

Risk factors for macrovascular disease


Fixed Modifiable
age >50 years smoking
family history of cardiovascular hypertension
death under 60 years hyperlipidaemia
obesity (BMI >30)
polycythaemia
poor glycaemic control

Management of risk factors will reduce the risk of developing macrovascular disease.

Indicators of macrovascular disease


What can go wrong What are we looking for
angina, myocardial infarct absent / reduced pulses or bruits
transient ischaemic attacks abnormal fundal arterioles
cerebrovascular accident (stroke) abnormal resting ECG
claudication lower limb

People with type 2 diabetes should be considered for prophylactic aspirin therapy
unless contraindicated.7

SECTION 12 – COMPLICATIONS – REVISED SEPTEMBER 2009


3
Hypertension
8
Diabetes is a major risk factor for the development of hypertension. Untreated high
blood pressure accelerates the blockage of arteries and increases the risk of heart
attacks, stroke and peripheral vascular disease. The aim is to get values under 130
7
systolic and 80 diastolic, and <125/75 if proteinuria >1g/d present.

Early detection, active treatment and frequent review are essential if morbidity is to be
reduced. The treating medical officer / general practitioner should aim for lower blood
pressure levels in the person with diabetes because their blood vessels (both macro
and micro) are more susceptible to hypertension damage (eg ≤130/80). Non-
9

pharmacological treatment, especially maintenance of healthy weight, regular exercise


and minimisation of salt and alcohol in the diet, should be emphasised.

There are various anti-hypertensive agents which can be used to control blood
pressure, however there are some medications which may interfere with the control of
diabetes. Agents such as the angiotensin converting enzyme (ACE) inhibitors are
medications of choice in people with hypertension and diabetes.7 They do not affect
glucose metabolism or lipid profiles and have beneficial effect on renal and
cardiovascular function. Both lying and standing blood pressure must be assessed.

Angiotensin receptor antagonists (ARA’s) have a role for people with micro or macro
albuminuria when ACE inhibitors are not tolerated.9

Hyperlipidaemia

Hyperlipidaemia is frequently observed in diabetes and hypertension.


Hyperlipidaemia is a common finding in people with diabetes. Dyslipidaemia is
an independent risk factor for the macrovascular complications of diabetes. It
is therefore important to identify and treat hyperlipidaemia. Often a poor lipid
profile with persistent hyperglycaemia results in hypertriglyceridaemia. The
triglyceride level will often drop to acceptable levels when adequate control of
weight, diet and glycaemia is achieved. Cholesterol levels will often fall with
weight reduction and metabolic control of diabetes.

The dietary management of dyslipidaemia is similar to that of diabetes. The


diet should be low in saturated fat and total fat. If dietary measures fail
pharmacological treatment should be instituted. The usual first line medication
for isolated hypercholesterolaemia are statins.7 Adherence is good and they
are extremely effective.

Target Levels9
Total cholesterol <4.0mmol/L
Triglycerides <1.5mmol/L
HDL – C >1.0mmol.L
LDL – C <2.5mmol/L

SECTION 12 – COMPLICATIONS – REVISED SEPTEMBER 2009


4
Smoking
Smoking is by far the most powerful treatable risk factor for macrovascular disease for
10, 11
people with diabetes. The added risk from smoking is compounded in comparison
with people without diabetes.

There is evidence that minimal intervention in the general practice setting can improve
cessation rates. The diagnosis of diabetes is often a crisis point for the person, and
can be an opportunity to bring about cessation of smoking.

The health care provider can assist a person to quit by:

• recording the smoking status of the person


• determining the stage of readiness of the person (pre-contemplation /
contemplation, etc)
• offering advice when the person is in the contemplative stage of quitting
• offering advice on the use of nicotine adjunctive therapy.

The national QUITLINE contact is 13 7848.

Cardiovascular risk profiles


As previously mentioned diabetes is a risk factor for cardiovascular disease (CVD).
The National Heart Foundation has developed an Australian risk chart that can be
used to estimate a 5 year risk level for CVD. These charts can be used by health
professionals to demonstrate the level of risk for an individual. Using coloured squares
the chart clearly demonstrates how risk can be decreased by addressing risk factors
such as smoking, lipids and blood pressure. It can be used as a tool to explain to a
person why certain risk factors are a priority. The tool can be accessed at
http://www.heartfoundation.org.au/Professional_Information/Clinical_Practice/Pages/de
fault.aspx.

SECTION 12 – COMPLICATIONS – REVISED SEPTEMBER 2009


5
Microvascular disease
Microvascular disease refers to disease of the small blood vessels associated with
thickening of the basement membranes.

Consequences are: kidney damage – nephropathy


eye disease – retinopathy
nerve damage – neuropathy

Kidney damage – nephropathy


This is one of the microvascular complications and is closely related to hyperglycaemia
and hypertension. In turn renal impairment aggravates hypertension and a vicious
cycle develops. Early detection is important so that blood pressure and glycaemic
control can be improved.

Microalbuminuria provides the easiest warning of renal damage, however once


microalbuminuria is present, damage has already occurred. Proteinuria however is the
hallmark of nephropathy and represents irreversible renal damage. The time of onset
of proteinuria and the rate of increase is variable. Once clinical proteinuria occurs (dip
stick positive, >500mg/day) progressive renal damage is likely. The rate of decline in
renal function is accelerated by hypertension. Microalbuminuria should be checked
annually as an early screening.

Goals for management of urinary albumin excretion:

• <20 µg/min timed overnight collection


• <20 mg/L spot collection
• <3.5 mg/mmol women, <2.5 mg/mmol men (albumin creatinine ratio)

Risk factors for diabetic nephropathy12


Fixed Modifiable
hereditary glycaemia
age dyslipidaemia
duration of diabetes cigarette smoking
impaired renal function hypertension

The significance of proteinuria is as follows:9

• ten year survival is poor once persistent, significant proteinuria is present


(ie 2+ or more)
• retinopathy often occurs simultaneously with nephropathy. The person should be
reviewed for retinal problems and have treatment initiated (eg photocoagulation)
if necessary.
• hypertension should be treated aggressively and blood pressure maintained at
levels <130/80 (<125/75 if proteinuria >1g/d exists) in order to slow the
progression of nephropathy
• urine should be screened regularly for infection, a common exacerbating factor in
diabetic nephropathy.

If a kidney problem is suspected and the presentation is atypical think of less common
problems related to diabetes – eg papillary necrosis and arterial disease.

SECTION 12 – COMPLICATIONS – REVISED SEPTEMBER 2009


6
Eye disease – retinopathy
Retinopathy occurs in one third of people with diabetes therefore regular review by an
ophthalmologist or optometrist should occur at the time of diagnosis and then at least
every 2 years. For children with the onset of diabetes pre-puberty, screening of eyes
9, 13
should occur at puberty.

Retinopathy occurs as a result of microvascular disease of the retina. Loss of acuity


not corrected with pinhole testing may be due to retinopathy.

Changes seen are:

• dot and blot haemorrhages


• soft and hard exudates
• proliferative blood vessel formation.

Damage affecting the retina responsible for control, colour and fine vision
(maculopathy) is the most common cause of visual loss in people with diabetes.

Other eye problems like glaucoma and ischaemic neuropathy are also more
common in people with diabetes.

Risk factors for diabetic eye disease


Fixed Modifiable
age hypertension
duration of diabetes hyperlipidaemia
family history (cataracts/retinopathy) polycythaemia
other eye problems such as poor glycaemic control
glaucoma, myopia smoking
other microvascular disease

Nerve damage – neuropathy


Foot problems cause a large proportion of all amputations and of hospital bed days.
Many problems can be prevented by an organised program of education and
supervision.14, 15

Prevention is the most important aspect of management of the person’s feet. Early
and regular screening of feet to assess potential abnormal architecture and regular
review of neuropathy, vascular disease or deformity is essential. Subsequent referral
to podiatry services for those people with at risk feet is imperative.15

Features of peripheral neuropathy may be acute and / or chronic, sensory and / or


motor, somatic and / or automatic. The commonest form is an insidious, unremitting
sensory neuropathy.14

The aetiology of peripheral neuropathy is probably multi-factorial, ischaemic


(microvascular) and metabolic (sorbitol accumulation and myoinositol depletion). Both
components are affected by glycaemic control and may be related.

SECTION 12 – COMPLICATIONS – REVISED SEPTEMBER 2009


7
Risk factors for diabetic neuropathy
Fixed Modifiable
long duration of diabetes poor glycaemic control
age over 60 years ethanol (alcohol) more than 4
other microvascular complications drinks per day

Neuropathy can also be categorised as autonomic.

Autonomic neuropathy may result in:

• orthostatic hypotension
• impaired gastric emptying
• diarrhoea
• delayed / incomplete bladder emptying
• erectile impotence and retrograde ejaculation in males
• reduced vaginal lubrication with arousal in women
• loss of cardiac pain and ‘silent’ ischaemia or infarction
• sudden, unexpected cardio-respiratory arrest especially under an anaesthetic or
treatment with respiratory depressant medications
• difficulty recognising hypoglycaemia.

Neuropathy associated with peripheral vascular disease is the major risk factor for foot
problems. Ulcers and infections which lead to amputation can be asymptomatic in
people who cannot feel their feet. Other risk factors for podiatric problems include:

• vascular disease alone


• abnormal foot structure
• lack of self care.

Ulcers
The most common site for ulceration is the plantar surface of the foot, directly under
the metatarsal head. Abnormal shearing forces (such as movement within a shoe) can
cause a bruise under the epidermis. Infection then intervenes; the overlying skin or
callus becomes necrotic, sloughs and reveals an ulcer. Complications include
cellulitis, thrombotic arterial occlusion and gangrene.

If the ulcer is deep, or if cellulitis is present, hospitalisation and bed rest are usually
necessary. Subsequent antibiotic treatment and appropriate diabetes management
will be required. Inappropriate management of an ulcer can lead to osteomyelitis and
amputation. A podiatrist, endocrinologist and vascular surgeon should be involved in
the care and management of the acute diabetic foot.9

If ulcer is not infected and is superficial, care can be ambulatory. Only health
professionals who are experienced at managing diabetic foot ulcers or a podiatrist
should remove excess callus from around the ulcer to facilitate drainage. The person
should be encouraged to keep pressure off the lesion as much as possible to
encourage wound healing. Continual pressure on the surface of an ulcer can cause
delayed healing. Consult a podiatrist for advice about footwear modification to
alleviate pressure.

SECTION 12 – COMPLICATIONS – REVISED SEPTEMBER 2009


8
Foot care

Preventative foot care is an important aspect of management. Early foot risk


assessment and self care education is essential. Refer to Footcare – Section 6 for
more in-depth information.

Neuropathic joint damage


A painful, swollen, reddened and / or hot foot is not always due to infection. It is
important to differentiate between infection and Charcot’s arthropathy as the treatment
is very different. This damage can occur as a result of minor trauma. Initial X-ray can
be normal but serial X-rays will show fracture, new bone formation and joint
disorganisation. The metatarsal joints are most commonly affected but the ankle and
metatarso-tarsal joints can also be affected. An early bone scan will confirm the
diagnosis. Differentiation from osteomyelitis or septic arthritis can usually be made by
a normal white cell count and absence of fever.

Treatment is with non-weight bearing crutches, appliances fitted by a podiatrist to


reduce further damage and possibly a below knee cast until inflammation has
subsided.

Sexual function
It is important to inquire about this in the annual screening because the prevalence in
men over 40 years old with diabetes may be as high as 50%.9

It is important to differentiate psychogenic from organic erectile impotence. Usually


inquiring about spontaneous erections while asleep or in non-sexual situations will
help. Psychogenic impotence requires counselling and behavioural therapy. People
with organic impotence should be counselled supportively.

The help of a sympathetic specialist urologist should be sought for those considering
penile injection with vasoactive agents (preparations now commercially available) or
surgical treatment.

Women with diabetes do not seem to suffer from as much sexual dysfunction as men.
Some women with diabetes complain of impairment in vaginal lubrication with arousal,
presumably due to pelvic autonomic neuropathy. Explanation and use of lubricants
may be useful.

SECTION 12 – COMPLICATIONS – REVISED SEPTEMBER 2009


9
Other problems
Diabetes, its complications and hyperglycaemia may cause other problems.

Thrush
Poor glycaemic control predisposes to refractory moniliasis (thrush). Other
predisposing factors include the oral contraceptive pill and antibiotic therapy.

Urine infections
Urinary tract infections are more common and more refractory, especially in women
with diabetes. Incomplete bladder emptying may contribute and may require drug or
surgical therapy. Urinary tract infections may be asymptomatic and should be looked
for especially in women (eg by a dipstick testing for blood, pyuria and bacteriuria).

Skin infections
High blood glucose levels and glycosuria encourage the growth of monilia (thrush) and
a number of bacteria (especially staphylococci). Often these infections persist until
blood glucose levels are controlled.

Refractive changes
Can occur because of high blood glucose levels.

Cataracts
Can occur because of long term osmotic effect on the lens.

Dental and periodontal problems


Dental and periodontal problems are more common in people who have diabetes.
Regular dental review and good oral hygiene is important.

SECTION 12 – COMPLICATIONS – REVISED SEPTEMBER 2009


10
What to discuss with your doctor
Your eyes
• Early detection means early treatment.
• If you have type 2 diabetes, have your eyes checked at diagnosis and every 1-2 years
depending on risk factors.
• If you have type 1 diabetes, have your eyes checked within 5 years from diagnosis, then
1-2 yearly depending on risk factors.

Your blood pressure


• Have your blood pressure checked at each visit. Treatment of high blood pressure can
prevent or minimise further diabetes complications.

Your feet
• Have your feet checked every six months. The health professional should check the skin,
pulses and sensation in your feet. Remember to wear shoes and socks that are easy to
take off.
• Know if your feet are at risk and have a footcare action plan.

Your weight and height


• Keeping you weight stable (or losing weight if overweight) will help manage blood glucose
levels.
• Check your weight regularly.

Your insulin injection sites (if applicable to you)


• Your doctor needs to examine your injection sites because problems at these sites can
make your diabetes control worse.

Your teeth
• Visit your dentist regularly to ensure any existing problems are treated immediately.
• Learn how to take care of your mouth, gums and teeth.
• Tell your dentist you have diabetes.

Your exercise plan


• It is important to see your doctor before starting a new exercise program.
• Your doctor can make sure your exercise program is safe for you.

Pathology tests
Become interested in the tests ordered by your doctor, and know your numbers.
Common ones are:
• Glycosylated haemoglobin
This test is usually done 3-4 times a year and shows your overall blood glucose control
over the past three months. Target is less than 7%.
• Cholesterol
Have this measured every year. High cholesterol is a risk for heart attacks (coronary
artery disease) and circulation problems. Total cholesterol target is less than 4.
• Microalbuminuria
First morning urine collected and done each year.

SECTION 12 – LONG TERM COMPLICATIONS – REVISED SEPTEMBER 2009


11
References
1. National Diabetes Information Clearinghouse (NDIC) (1993) Diabetes Control
and Complications Trial. [Cited 18 June 2009]; Available from:
http://diabetes.niddk.nih.gov/dm/pubs/control/

2. Genuth S, Kahn R, Klein R, Lachin J, Lebovitz H, Nathan D, and Vinicor F


(2002) Implications of the United Kingdom Prospective Diabetes Study
(UKPDS). Diabetes Care, 25(S1): pS28-S32.

3. Holman R, Sanjoy K, Angelyn Bethel A, Matthews D, and Neil H (2008) 10-Year


follow-up of intensive glucose control in type 2 diabetes. The New England
Journal of Medicine, 359(15): p1577-1589.

4. Epidemiology of Diabetes Interventions and Complications (EDIC) (1999)


Design, implementation, and preliminary results of a long-term follow-up of the
Diabetes Control and Complications Trial cohort. Diabetes Care, 22(1): p99-
111.

5. Australian Institute of Health and Welfare (2008) Diabetes: Australian facts


2008. Cat. no. CVD 40, Australian Institute of Health and Welfare, Canberra.

6. Parsons J, D W, and Scadigno A (2000) The impact of diabetes in South


Australia: The summary. SA Diabetes Clearing House, SA Department of
Human Services, Adelaide.

7. National Health & Medical Research Council (2004) Part 5: Prevention and
detection of macrovascular disease in type 2 diabetes. Evidence based
guidelines for case detection and diagnosis of type 2 diabetes. NHMRC,
Canberra.

8. Haire-Joshu D (1996) Management of diabetes mellitus: Perspectives of care


across the life span. Mosby, St Louis.

9. Harris P, Mann L, Marshall P, Phillips P, and Webster C (2008/09) Diabetes


management in general practice: Guidelines for type 2 diabetes. Royal
Australian College of General Practitioners and Diabetes Australia, Canberra.

10. Litt J (2002) How to provide effective smoking cessation advice. Australian
Family Physician, 31(12): p1-7.

11. Litt J, Ling M-Y, and McAvoy B (2003) How to help your patients quit: Practice-
based strategies for smoking cessation. Asia Pacific Family Medicine, 2: p175-
179.

12. Yong T Y, Phillips P, and Coates P T H (2006) Neglected nephropathy.


Australian Family Physician, 35(6): p398-402.

13. Australian Diabetes Society (2008) Guidelines for the management of diabetic
retinopathy, NHMRC and Department of Health & Ageing, Canberra.

14. Apelqvist J, Bakker K, van Houtum W H, and Schaper N C (2008) Practical


guidelines on the management and prevention of the diabetic foot. Diabetes /
Metabolism Research and Reviews, 24(Suppl 1): pS181-S187.

15. National Health & Medical Research Council (2005) Part 6: Detection and
prevention of foot problems in type 2 diabetes. National evidence based
guidelines for the management of type 2 diabetes mellitus. March, NHMRC,
Canberra.
SECTION 12 – LONG TERM COMPLICATIONS – REVISED SEPTEMBER 2009
12
SECTION 13
Pregnancy and Diabetes
5.5 % of all pregnancies in South Australia will be complicated by diabetes mellitus.
(0.6% in women with pre-existing diabetes – type 1 or type 2 and 4.9% gestational
1
diabetes). Diabetes which occurs during pregnancy is known as gestational diabetes.
Gestational diabetes usually disappears after the baby is born but women have an
increased lifetime risk of developing type 2 diabetes.

Regardless of the type of maternal diabetes, babies of women with diabetes are at an
increased risk of intrauterine death, macrosomia (causing difficulties with delivery),
neonatal respiratory distress syndrome, neonatal hypoglycaemia, jaundice and
others.2, 3

We recommend that health care professionals who work with women who are
pregnant and have diabetes become familiar with two key documents:

• The Australasian Diabetes in Pregnancy Society (2005) ‘Consensus guidelines


for the management of type 1 and type 2 diabetes in relation to pregnancy’.4
• The Australasian Diabetes in Pregnancy Society (1998) ‘Gestational diabetes
mellitus management guidelines’.5

This section has been spilt into two sections:

1. Pre-existing diabetes and pregnancy

2. Gestational diabetes.

SECTION 13 – PREGNANCY AND DIABETES – REVISED SEPTEMBER 2009


1
Pre-existing diabetes and pregnancy
Risks to the mother and baby
Diabetes in pregnancy is associated with risks to the woman and the developing
foetus. Miscarriage, pre-eclampsia and preterm labour are more common in women
who have pre-existing diabetes. Diabetic retinopathy can worsen rapidly during
pregnancy. Stillbirth, congenital malformation, birth injury, peri natal mortality and
hypoglycaemia are more common in babies who are born to women with pre-existing
diabetes.6 However these complications can be greatly reduced if women receive pre-
pregnancy counselling and are able to achieve tight glucose control before conception
4
and then maintained as close to normal throughout the pregnancy.

Before pregnancy
All women with type 1 and type 2 diabetes should receive counselling and
information about potential problems of diabetes in pregnancy, the potential
dangers of an unplanned pregnancy, and the benefits of pre-pregnancy
counselling.4

Women with pre-existing diabetes should plan their pregnancy. They should have their
HbA1c monitored and obtain tight control prior to and during early conception, noting
that careful management should aim to prevent severe maternal hypoglycaemia. The
ideal HbA1c preconception is less than 6.1%. Less than 7.0% is satisfactory and 7.0%
to 8.0% is borderline. An HbA1c greater than 8.0% is not satisfactory and should be
tightened before conception, and those with HbA1c greater than 10.0% should be
advised of their extreme risk should they get pregnant.7

Folic acid 5mg daily should be commenced to minimise the risk of folate
deficiency induced birth defects.

Management of diabetes in the preconception phase aims to ensure the best outcome
for both mother and baby. Questions that might arise include fertility, spontaneous
abortion, incidence of diabetes mellitus in offspring, effects of pregnancy on existing
diabetes complications and expected outcomes. These questions should be
addressed in a supportive manner to reduce anxiety.

Diabetes complication screening is essential and should occur preconception or as


early in the pregnancy as possible. Some pre-existing complications are
contraindications to pregnancy.4 The complication screening involves a check for
retinopathy, nephropathy, macrovascular disease and autonomic neuropathy.

SECTION 13 – PREGNANCY AND DIABETES – REVISED SEPTEMBER 2009


2
Pregnancy
Women with pre-existing diabetes should be managed by a specialised
multidisciplinary team. This is more difficult in rural areas but the use of virtual teams
and distance communication technologies (eg videoconferencing) can be an option.

Healthy nutrition is important for all pregnant women (see Healthy eating – Section 8).
Energy and nutrient requirements must be individualised. However, it is recommended
that all women with diabetes be assessed by a dietitian and advice given on
appropriate meal planning and weight gain.

It is important to monitor insulin requirements as these can change frequently


during pregnancy. For women with pre-existing diabetes insulin requirements
may initially fall during the first three months. Hypoglycaemia particularly
overnight is more frequent from the 6th to 18th weeks of gestation but should be
assessed at all times throughout the pregnancy. At about 24-28 weeks insulin
counteracting hormones reach their peak and by the third trimester insulin
requirements may be more than twice pre-pregnancy dose.

The ADIPS consensus guidelines (2005) states that there is insufficient


evidence about the safety of the long acting analogue insulin and so caution
4
must be used. Women need to be informed about their choices.

Women with pre-existing type 2 diabetes who are planning pregnancy are
advised that insulin therapy carries the least risk for the baby and is the gold
standard.4 Oral hypoglycaemic agents are not recommended because there is
limited information regarding their safety in pregnancy.4, 6 Although there is
some short term data about the use of metformin in pregnancy the long term
follow-up data for offspring of mothers is still lacking.4, 8 Consequently most
clinicians are cautious and continue to limit the use of metformin to those
women who have extreme insulin resistance or needle phobia. Women with
type 2 diabetes may also be taking antihypertensive or lipid lowering
medications. Some antihypertensives are safer than others but lipid lowering
medication is contraindicated in pregnancy.4

Women on oral hypoglycaemics are advised to go on to insulin therapy before


they conceive.4, 6 If however a woman on oral hypoglycaemic agents becomes
pregnant whilst taking oral hypoglycaemics then insulin can be commenced
with a slow withdrawal of orals so that diabetes control can still be maintained
during this transition period. An abrupt stopping of orals can lead to poor
diabetes control which can have adverse effects during pregnancy.4

Close monitoring of women throughout the pregnancy is required. It is


important that these women have their medication reviewed and adjusted
frequently to maintain optimal glucose control. It may be required as frequently
as twice a week. Some diabetes services offer phone stabilisation services
which decrease the need for face to face visits.

Management is monitored by blood glucose levels and glycosylated haemoglobin


concentrations (HbA1c). Blood glucose levels are monitored by the woman at home,
usually a minimum of four tests daily (fasting and 3 post prandial measures) or as
recommended by the physician or obstetrician. The frequency of home testing will
increase or decrease depending on the woman’s BGL control.

SECTION 13 – PREGNANCY AND DIABETES – REVISED SEPTEMBER 2009


3
Targets are Less than 5.5mmol/L fasting
Less than 7.0mmol/L 2 hours post prandial

If diabetes control becomes very unstable, consider the possibility of urinary or vaginal
infections. Micro cultures for infection should be checked 3 monthly. The presence of
ketones needs to be addressed as it suggests inadequate dietary intake or
progressing ketoacidosis in those with pre-existing type 1 diabetes. Pregnant women
with type 1 diabetes are at a higher risk of ketoacidosis.4

Women are at an increased risk of pre-eclampsia and should be regularly assessed.


If the woman has poor diabetes control there is an increased risk of foetal cardiac
defects and so a foetal echocardiograph is recommended at 24 weeks.

The pregnancy is monitored the same as other pregnancies with an extra scan at
around 32-34 weeks to check foetal growth should be considered.

Labour
Obstetric assessment is essential in determining the mode of delivery. Encourage
women to discuss their delivery plans with the obstetrician early in the pregnancy.
Delivery should be at term unless obstetric or medical factors dictate otherwise.4

Often women are advised to continue taking their usual insulin until the start of labour
or until they commence fasting for a caesarean. At this point the woman would
commence an insulin / glucose infusion protocol. Each hospital should have its own
agreed protocol for insulin and blood glucose management during and post labour.
The goal during labour is to provide adequate carbohydrate intake to meet maternal
energy requirements and to maintain euglycaemia.

After delivery
Mother
Following delivery, insulin requirements of women with pre-existing diabetes decrease
before returning to around pre-pregnancy requirements (this time is variable and can
take days). If fasting the woman will require a glucose infusion and the hospital
protocol needs to account for the unpredictability of the blood glucose levels. The
woman has an increase in insulin sensitivity (ie reduced insulin requirements) and
consequently hypoglycaemia risk is increased during this period.

If there is no reduction in insulin requirement consider the possibility of an underlying


infection. Women who decide to breast feed will have decreased insulin requirements
and increased energy requirements. Continuing dietetic assessment and support is
recommended. Women need to be aware of the increased risk of hypoglycaemia
particularly nocturnal and that breastfeeding may accentuate this risk. Discharge from
hospital should be delayed until the blood glucose levels have stabilised (may take 4 or
5 days).

Baby
The baby must be monitored for hypoglycaemia during the first 24 hours. Each
hospital should have an agreed protocol to guide the care of the baby. The
paediatrician or medical officer (MO) will assess and manage post delivery
complications.

SECTION 13 – PREGNANCY AND DIABETES – REVISED SEPTEMBER 2009


4
Gestational diabetes
Risks
In gestational diabetes the risk of perinatal mortality is not increased but the risk of
macrosomia is. Other perinatal risks include shoulder dystocia, birth injuries, and
hypoglycaemia. Long term health outcomes among infants born to mothers with
3
gestational diabetes include sustained impairment of glucose tolerance and others.
As with pre-existing diabetes the risk of complications is decreased if blood glucose
targets are met. Women who have had gestational diabetes carry a lifelong risk of
developing type 2 diabetes.

Screening for gestational diabetes


All pregnant women should be screened for gestational diabetes. Gestational diabetes
5
is defined as glucose intolerance with onset during pregnancy.

Consider early screening (OGTT at 13 weeks):


• If woman is obese with BMI greater than 35.
• History of gestational diabetes.
• Known glucose intolerance (impaired glucose tolerance or impaired fasting
glucose).

If the OGTT is negative repeat 75gm OGTT at 24-28 weeks. If a woman vomits during
the OGTT an option is to do 2 weeks of home blood glucose monitoring instead of
repeating the OGTT. The woman can be asked to test fasting and 2 hour post
prandial at breakfast, lunch and tea. If the fasting BGL is above 5.5mol/L or the 2 hour
post prandial is above 7.8mmol/L then they can be classified as having gestational
9
diabetes.

SECTION 13 – PREGNANCY AND DIABETES – REVISED SEPTEMBER 2009


5
Screen all pregnant women for gestational diabetes at 26 – 28 weeks

Screening Tests: Oral Glucose Challenge Test


(OGCT)
50g load, abnormal >7.8mmol/L at 1 hour Diagnosis of GDM
(26-30wks)
If high, proceed to diagnostic 75g Oral Glucose Test
75 g OGTT
(OGTT) FBG >5.5mmol/L
or
2 hour BG >8.0mmol/L

Management

Nutritional advice & exercise


Self blood glucose monitoring
Refer to dietitian and/or diabetes educator

Aim for normoglycaemia Persistent hyperglycaemia


FBG < 5.5mmol/l FBG > 5.5mmol/L OR
AND 2 hour postprandial >7.0mmol/L
2 hour postprandial <7.0mmol/L Seek specialist advice;
Continue dietary management Insulin or oral hypoglycaemics (see
page 2); Ultrasound at 32-34 weeks;
Foetal monitoring

Clinically Clinically Good control Poor BGL control.


uncomplicated. complicated and no Notify obstetrician
Usual pregnancy eg pre-eclampsia, macrosomia or Consider delivery
care with close hypertension, complications. >38 weeks.
blood glucose macrosomia, Consider
and clinical polyhydramnios. delivery at full
monitoring. Seek specialist term.
advice. Foetal
monitoring.
Consider delivery
>38 weeks.

Close monitoring of baby for hypoglycaemia and respiratory distress syndrome.


Encourage breast feeding.

SECTION 13 – PREGNANCY AND DIABETES – REVISED SEPTEMBER 2009


6
Education
Once gestational diabetes is detected, referral for diabetes education and
management advice as soon as possible (ideally within 1 week).

All women should receive individual education, counselling and specific dietary advice
from a diabetes educator, a dietitian and a medical consultant.

Women are taught self blood glucose monitoring and in some services are loaned a
blood glucose meter. The diabetes educator should make arrangements for the
woman to make contact with them on a one to two weekly basis (either by phone or
face to face). Women should have access to a dietitian as needed. Technique and
accuracy of blood glucose testing should be regularly checked.

Regular activity is encouraged as tolerated.

Aim of treatment
Management of the pregnancy is as for pre-existing diabetes. The mainstay of
treatment is a healthy diet with regular intake of carbohydrates. If diet alone does not
control blood glucose levels, then insulin is commenced.

The overall aim of treatment is to maintain fasting blood glucose values less than
5.5mmol/L and less than 7.0mmol/L 2 hours post prandial. Insulin therapy is started if
fasting blood glucose values exceed this more than twice in a one to two week interval.

Insulin therapy is often commenced as an outpatient unless contra-indicated by either


medical or social circumstances.

The women should have access to 24 hour phone support for any problems from the
diabetes and obstetric services or obstetric registrar.

Labour
Spontaneous labour at term should be considered for those whose blood glucose
levels have been optimal throughout and whose pregnancy is clinically uncomplicated
(eg no pre-eclampsia, hypertension, poor glycaemic control, foetal growth, amniotic
fluid abnormalities on ultrasound, urinary infections or other infections). However, a
woman should not go beyond full term. The obstetrician will arrange for an
interventional delivery at 38 weeks if required.

After delivery the need for insulin therapy usually ceases. It is recommended that
each hospital adheres to an agreed protocol for the assessment of blood glucose
levels.

SECTION 13 – PREGNANCY AND DIABETES – REVISED SEPTEMBER 2009


7
Post delivery
Recommended blood glucose monitoring protocol

Timing Frequency Rationale

First 3-4 hours post Hourly blood glucose levels if To monitor hypoglycaemia
5
partum glucose/insulin infusion in patients who have
ceased insulin therapy

Post natally before Monitor blood glucose up to QID To exclude ongoing


5
discharge (fasting and pre-meal) during the diabetes
first 24 - 48 hours.

6 – 8 weeks Offer testing for diabetes using a Exclude permanent


75g OGTT diabetes

1 – 2 yearly5 Repeat testing Diabetes high risk


screening
NB: OGTT is the gold standard
but yearly venous fasting is
acceptable6

SECTION 13 – PREGNANCY AND DIABETES – REVISED SEPTEMBER 2009


8
Post delivery and long term follow up
Risks to the mother
At least 50% of women with gestational diabetes will develop type 2 diabetes over the
10
next 30 years. Maintaining healthy body weight, healthy eating, regular exercise and
a healthy lifestyle will reduce the risk.

Women are encouraged to breastfeed as this assists blood glucose and weight control
in addition to all the normal benefits of breastfeeding.

All women who have had gestational diabetes should be counselled about the life long
risk of developing type 2 diabetes and the need for yearly follow up.

Risks to the baby


There is evidence that exposure to high glucose in utero places the child at risk of the
metabolic syndrome later in life. The infant also has the family inherited risk from its
mother.

Monitoring
There is no need for ongoing self-monitoring if the women’s blood glucose level is
normal after delivery. Women should know that the symptoms of polyuria, polydipsia,
polyphagia, thrush and blurred vision may indicate the development of type 2 diabetes.
Women who have had gestational diabetes should have 1 yearly blood tests done to
assess for diabetes.5

Subsequent pregnancies
Women should be counselled as to the risk of GDM in subsequent pregnancies and/or
development of type 2 diabetes prior to any subsequent pregnancy. Pre-conception
screening and earlier screening in pregnancy (13-14 weeks) is advised. A healthy
lifestyle is to be encouraged between pregnancies.

Contraception
It is very important to discuss contraception with all women postnatally. Women
should discuss the most appropriate option with their GP or specialist physician.

Women who have gestational diabetes need to be informed that they should visit their
GP for preconception diabetes screening prior to stopping contraception. Women with
pre existing diabetes should plan any subsequent pregnancies with their GP or
specialist physician prior to stopping contraception.

SECTION 13 – PREGNANCY AND DIABETES – REVISED SEPTEMBER 2009


9
References
1. Chan A, Scott J, Nguyen A M, and Sage L (2008) Pregnancy outcome in South
Australia. December, Pregnancy Outcome Unit, SA Health, Adelaide.

2. The HAPO Study Cooperative Research Group (2008) Hyperglycemia and


adverse pregnancy outcomes. The New England Journal of Medicine, 358:
p1991-2002.

3. Crowther C A, Hiller J E, Moss J R, McPhee A J, Jefferies W S, and Robinson


J S (2005) Effect of treatment of gestational diabetes mellitus on pregnancy
outcomes. The New England Journal of Medicine, 352(24): p2477-2486.

4. McElduff A, Cheung N W, McIntyre H D, Lanstrom J, Oats J J, Ross G P,


Simmons D, Walters B N, and Wein P (2005) The Australian Diabetes in
Pregnancy Society consensus guidelines for the management of type 1 and
type 2 diabetes in relation to pregnancy. Medical Journal of Australia, 183(7):
p373-377.

5. Hoffman L, Nolan C, Wilson J D, Oats J J, and Simmons D (1998) Gestational


diabetes mellitus management guidelines. Medical Journal of Australia. 169.
p93-97. 18 June 2009. Available from:
http://www.mja.com.au/public/issues/jul20/hoffman/hoffman.html

6. Walker J (2008) NICE guidance on diabetes in pregnancy: Management of


diabetes and its complications from preconception to the postnatal period.
Diabetic Medicine, 25: p1025-1027.

7. The Guideline Development Group (2008) Management of diabetes from


preconception to the postnatal period: summary of NICE guidance. British
Medical Journal, 336(29 March): p714-717.

8. Simmons D, Walters B N, Rowan J A, and David M H (2004) Metformin therapy


and diabetes in pregnancy. Medical Journal of Australia, 180: p462-464.

9. Jeffries Bill (Lyell McEwin Hospital) (2009) Screening for gestational diabetes:
Personal communication. Diabetes Outreach, Adelaide.

10. Lee A, Hiscock R, Wein P, Walker S, and Permezel M (2007) Gestational


diabetes mellitus: Clinical predictors and long-term risk of developing type 2
diabetes. Diabetes Care, 30(4): p878–883.

SECTION 13 – PREGNANCY AND DIABETES – REVISED SEPTEMBER 2009


10
SECTION 14
Residential Care
The aim and purpose of this section is to provide information that specifically relates to the care
and education of residents with diabetes or at risk of developing diabetes. There is a growing
need to consider people who live with diabetes in residential care. The increasing population of
aged people and the range of other residential care facilities has highlighted specific issues for
management and care.

Australia’s aged care system is structured around two main forms of formal care delivery,
residential and community care. Residential care facilities function to either provide services, or
provide access to services. These services range from nursing homes and hostels to retirement
villages for older people.

Other alternatives can include temporary homeless shelters, homes for the mentally ill, homes
for the mentally challenged, homes for the disabled, respite services, ‘in-home’ care or home
care community services. For more information about aged care services, go to
www.agedcareaustralia.gov.au.

Why diabetes is an important issue


1
1 in 4 people over the age of 25 years have type 2 diabetes or pre diabetes. If you are older,
have a family history of type 2 diabetes, there is an increased risk of developing type 2 diabetes.
If the person is overweight or has other health problems eg hypertension, the risk increases
even further. For those people with a mental illness, the use of an atypical antipsychotic
2
medication can also increase the risk.

For people who have any type of diabetes, the consequences of not receiving adequate
treatment and care can be devastating. Long standing uncontrolled diabetes places the person
at risk of short and long term complications.

In the short term, uncontrolled blood glucose can cause confusion, sleep disturbances,
incontinence and thrush. Low blood glucose can worsen the risk of falls.

In the long term, uncontrolled diabetes affects the heart and other major blood vessels, eyes,
kidneys, feet and nerves, causing disability and loss of quality of life. It also contributes to the
3
worsening of existing complications.

Applying the guidelines in residential care


Primary prevention, risk identification and screening
There is some evidence that type 2 diabetes can be delayed or prevented with improvement of
4
modifiable risk factors such as weight management and increased activity. Utilising a risk
identification activity such as the one below can assist in identifying those residents that are at
risk and what modifiable risk factors are able to be addressed.

SECTION 14 – RESIDENTIAL CARE – REVISED SEPTEMBER 2009


1
5
Type 2 Diabetes Risk Check
1. Over 55 years of age
2. Over 45 years of age AND are overweight
3. Over 45 years of age AND have an immediate family member with type two
diabetes
4. Over 45 years of age AND have high blood pressure
5. Over 35 years AND from an Aboriginal, Torres Strait Island, Pacific Island, Indian
sub-continent, or Chinese cultural background
6. Have heart disease or have had a heart attack
7. Had diabetes when pregnant (gestational diabetes)
8. Have impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)
9. Have polycystic ovary syndrome AND are overweight
Yes to any of the above questions should facilitate a blood glucose check with a
general practitioner.

Given the persons age, mobility, mental capacity, the potential to reduce some risks may be
limited. Nevertheless, risk factor identification is an important aspect of primary prevention for
both type 2 diabetes, cardiovascular disease and kidney disease.

Diagnosis
A diagnosis criterion is based on the Royal Australian College of General Practitioners
6
Guidelines , and can be found in Understanding diabetes – Section 2 of this manual.

Cycle of care
Residents with diabetes have a right to an individualised diabetes management plan. This plan
should take into account the person’s age, functional mobility and cognitive capacity.

A diabetes educator may assist in care planning by undertaking a comprehensive diabetes


assessment on which care can be based. This would include appropriate and realistic goal
setting.

If residents are cared for by a general practitioner, they will be eligible for either a GP
Management Plan and / or a Team Care Arrangement. These items will facilitate access to
specialist health professionals such as diabetes educator, podiatrist and dietitian.
6
A cycle of care for a person with diabetes includes routine monitoring of:

• blood pressure
• height/ weight/waist BMI
• feet examination
• glycaemic control (HbA1c)
• blood lipids
• microalbuminuria
• eye examination
• smoking
• healthy eating plan
• physical activity
• self-care education.

SECTION 14 – RESIDENTIAL CARE – REVISED SEPTEMBER 2009


2
Specific issues for older people with
diabetes
Cognitive impairment
Cognitive performance can be impaired in the older person with diabetes. The risk of cognitive
impairment increases with the duration of diabetes. Cognitive impairment can be associated
with compromised adherence to treatment and poor diabetes control. This can be due to erratic
nutrition and increased risk of medication mistakes thus increasing the risk of hypoglycaemia
7
and hyperglycaemia.

Mental health issues


Depression is at least two times higher in people with diabetes when compared with the general
8
population and is associated with poor adherence to treatment and medication.

Loss of appetite, adherence to medication regimes, performance of physical activity,


9
socialisation and well being can be affected by depression. A regular weekly weigh-in can be
an alert for weight loss or weight gain. Appropriate action needs to be taken if the person is not
achieving a healthy weight range. Weight loss in elderly people is not recommended unless they
10
are at least 20% overweight.

Depression can result in a loss of meaning in life and a decrease in ’positive’ behaviour.
11
Features of depression include:

• feel sad, down or miserable most of the time


• lose interest or pleasure in most usual activities
• loss or gain a lot of weight OR had an decrease or increase in appetite
• sleep disturbance
• feel slowed down, restless or excessively busy
• feel tired or has no energy
• feel worthless OR feel excessively guilty OR feel guilt about things the person should not
be feeling guilty about
• poor concentration OR difficulties thinking OR very indecisive
• recurrent thoughts of death.

If any of the above are noted or of concern it is important to seek advice from senior staff or the
person’s general practitioner.

Hypoglycaemia
As part of the ageing process there is reduced glucose counterregulation and this can decrease
the awareness for hypoglycaemia. Increased blood glucose monitoring may be required to
10
detect unrecognised hypoglycaemia. Refer to Understanding diabetes – Section 11 for more
information

Hyperglycaemia
It is important to consider the possibility of hyperosmolar hyperglycaemic nonketotic state for
those with type 2 diabetes and ketoacidosis for those with type 1 diabetes, if the older person
10
has extremely high glucose levels. Refer to Understanding diabetes – Section 11 for more
information.

SECTION 14 – RESIDENTIAL CARE – REVISED SEPTEMBER 2009


3
Providing diabetes care
Staffing mix in residential care facilities can vary dramatically. Access to qualified registered
nurses can be limited and / or absent depending on the level of care offered.
Whatever the staff mix, it is essential to have someone in the organisation that is aware of the
6
diabetes cycle of care and the resources available for support and training of both residents and
staff.

Staff training
All staff (RN’s, EN’s and carers) should have access to training about the needs of a person with
diabetes (all types of diabetes) and be aware of the risks of developing type 2 diabetes.

Training should include awareness of the criteria for diagnosis, primary prevention strategies,
risk screening and cycle of care for management of diabetes. Possessing the necessary
knowledge and skills to respond to acute presentations of hypoglycaemia and hyperglycaemia in
a competent and timely manner is paramount in order to prevent further deterioration and
possible hospitalisation.

Other aspects such as medication management, foot and dental care, healthy eating and
suitable activity are also important to maintain a level of desirable wellness.

It is also important to include information about the psychosocial aspects of diabetes and the
9
impact this can have on the individual and their family. Developing links with the local / regional
diabetes education team can provide support and advice re training opportunities.

Virtual teams
Teams don’t have to be located together in the same building or health service. The use of
virtual teams will enable organisations to develop appropriate networks utilising telephone, fax
and email. A diabetes educator is one member of this team that can help staff learn how to
better care for people with all types of diabetes.

Teaming up with a diabetes educator can help with information about:

• Facilitating partnerships with other allied health professionals such as dietitian,


pharmacists, podiatrist, counsellor, etc.
• Improving staff confidence by contributing to their continuing education and thereby their
ability to assist residents’ in diabetes management.
• Balancing eating, physical activity, medication, and blood glucose monitoring routines.

12
Incorporating appropriate food choices within aged care.
• Incorporating lifestyle needs, such as cultural eating habits and exercise preferences, into
a management plan.
• Making everyday food choices healthy choices.
• Managing high and low blood glucose, and devising a plan for sick days (see Unstable
diabetes – Section 11).
• Developing appropriate foot care strategies to prevent problems (see Footcare – Section
6).
• Establishing and maintaining a sustainable diabetes care plan.
• Helping to prevent or delay the onset of complications such as heart disease, blindness,
kidney failure, nerve damage, and sexual problems (see Long term complications –
Section 12).

SECTION 14 – RESIDENTIAL CARE – REVISED SEPTEMBER 2009


4
The organisations´ responsibility
Depending on the level of care provided, the organisations responsibility will vary. It is important
to ensure residents with diabetes have access to:

• A general practitioner confident in the management of diabetes.


• A diabetes educator and allied health team as needed.
• Residential nursing staff confident and competent in the management of diabetes.

Organisational responsibility also extends to the provision of appropriate policy and procedure
being in place. These policies and procedures more commonly cover care issues such as cycle
of care, blood glucose monitoring, medications including administration of insulin,
hypoglycaemia and hyperglycaemia and sick day management

Refer to other sections of this manual to assist with policy and procedure development.

Considerations when caring for people in residential


care
• All staff caring for residents with diabetes should be aware of the care plan including the
cycle of care.
• Ensure communication with the residents’ diabetes education team.
• All staff involved in blood glucose monitoring are aware of the targets and response
protocol relating to hypoglycaemia, hyperglycaemia and sick day management.
• Medications (oral) should be reviewed annually and a webster pack considered for clients
self-medicating.
• Residents who are prescribed insulin have access to diabetes education and have a
documented care plan and appropriate response protocols in place.
• All nursing staff involved in the administration of insulin are competent and demonstrate
current and relevancy of practice relating to insulin therapy and medication administration
reflected in an up to date medication authority care plan and with associated response
protocols in place.
• Residents meals are reviewed to ensure appropriateness.

SECTION 14 – RESIDENTIAL CARE – REVISED SEPTEMBER 2009


5
Conclusion
When assessing the needs of a resident with diabetes it is important to consult with the persons‘
general practitioner and diabetes education team. Care plans and action plans will vary
depending on the type of diabetes, the persons age, and capacity to self-care.

It is extremely important to consider the staffing and training needs of the organisation to ensure
all levels of staff possess an acceptable level of competency. Also consider what policies and
procedures will need to be in place to ensure a safe environment for the resident.

Accessing Diabetes Services


• Local diabetes education service at a hospital or community health service
• Diabetes Australia on 1300 136 588.
• The Royal District Nursing Service SA Inc – Diabetes Team on 1300 364 264
• RDNS can assist with staff training.
• Assessment, care planning and clinical support relating to individual residents’.
• Assist with the development of diabetes related policies, guidelines and procedures.

SECTION 14 – RESIDENTIAL CARE – REVISED SEPTEMBER 2009


6
References
1. Dunstan D, Zimmet P, Welborm T, Sicree R, Armstrong T, Atkins R, and et al (2001)
Australian diabetes obesity and lifestyle study (AusDiab), International Diabetes
Institute, Melbourne.

2. American Diabetes Association (2004) Consensus development conference on


antipsychotic drugs and obesity and diabetes. Diabetes Care, 27(2): p596-602.

3. Australian Diabetes Educators Association (2003) Guidelines for the management and
care of diabetes in the elderly: Report. Australian Diabetes Educators Association,
Canberra.

4. Diabetes Prevention Program Research Group (2002) The diabetes prevention program
(DPP). Diabetes Care, 25(12): p2165-2171.

5. Diabetes Australia (2005) Tick Test. [Cited 15 June 2009]; Available from:
http://www.diabetesaction.com.au/diabetesaustralia/display.asp?entityid=4081

6. Harris P, Mann L, Marshall P, Phillips P, and Webster C (2008/09) Diabetes


management in general practice: Guidelines for type 2 diabetes. Royal Australian
College of General Practitioners and Diabetes Australia, Canberra.

7. Sinclair AJ (2006) Special considerations in older adults with diabetes: Meeting the
challenge. Diabetes Spectrum, 19(4): p229-233.

8. Suhl E and Bonsignore P (2006) Diabetes self-management education for older adults:
General principles and practical application. Diabetes Spectrum, 19(4): p234-240.

9. DAWN (Diabetes Attitudes Wishes Needs) Study (2001) Living with diabetes. [Cited 14
June 2009]; Available from:
http://www.dawnstudy.com/documents/home_page/document/index.asp

10. Australian Diabetes Educators Association (2003) Guidelines: Management and care of
diabetes in the elderly: Summary. ADEA, Canberra.

11. BeyondBlue (2009) Depression checklist: Kessler psychological distress scale (K10).
[Cited 15 June 2009]; Available from:
http://www.beyondblue.org.au/index.aspx?link_id=103.882

12. Diabetes Centre (2007) Healthy eating and diabetes: A guide for aged care facilities.
Diabetes Centre, Adelaide.

SECTION 14 – RESIDENTIAL CARE – REVISED SEPTEMBER 2009


7
SECTION 15
Resources
Community resources
The National Diabetes Services Scheme
This scheme is funded by the Commonwealth Government and administered by
Diabetes Australia – a partnership which provides significant benefits for people with
diabetes.

The scheme provides:

• free insulin syringes


• free needles for insulin injection devices
• subsidised blood glucose testing strips
• subsidised urine testing strips
• subsidised insulin pump consumables.

For further information contact a Diabetes Australia office on 1300 136 588 (local call
cost).

Diabetes Australia
Diabetes Australia is the national coordinating organisation representing consumers (people with
diabetes), research organisations, doctors and other health
professionals with a special interest in diabetes.

Diabetes Australia administers the National Diabetic Services Scheme (NDSS) which
offers subsidised prices for reagent strips, free syringes and needles and subsidised
insulin pump consumables to Australians with diabetes. Diabetes Australia also has a
comprehensive range of approved, educational material on diabetes management.

Contact phone numbers for diabetes associations in each capital city:


TELEPHONE FAX
Australian Capital Territory (02) 6232 3800 (02) 6230 1535
New South Wales (02) 9552 9900 (02) 9660 3633
Northern Territory (08) 8927 8488 (08) 8927 8515
Queensland (07) 3506 0999 (07) 3506 0909
South Australia (08) 8234 1977 (08) 8234 2013
Tasmania (03) 6234 5223 (03) 6234 5828
Victoria (03) 9667 1777 (03) 9667 1778
Western Australia (08) 9325 7699 (08) 9221 1183

SECTION 15 – RESOURCES – REVISED SEPTEMBER 2009


1
The services provided include the following.

• Friendly, knowledgeable staff willing to assist with questions and enquiries about
diabetes or refer you to appropriate health professionals.
• A comprehensive range of brochures and diabetes information sheets to assist in
managing diabetes.
• A quarterly publication, ‘CONQUEST’ which focuses on medical articles and
research of professional note.
• Arranging annual camps for children and ‘parents and children’ to assist with
diabetes management and education.
• A lobby group presenting the views of people with diabetes to government.
• Seminars and information days held throughout the year on a variety of topics to
help people with their diabetes management.

National Office:
Level 2 103-105 Northbourne Ave
TURNER ACT 2612
Telephone: (02) 6232 3800 Fax: (02) 6230 1535

Other member organisations of Diabetes Australia:

Australian Diabetes Society


Australian Diabetes Educators Association
Diabetes Research Foundation of Western Australia
Kellion Diabetes Foundation

SECTION 15 – RESOURCES – REVISED SEPTEMBER 2009


2
Health care facilities in South Australia
Metropolitan hospitals
The following South Australian hospitals provide a service for diabetes care and
education.

Name Telephone

Flinders Medical Centre


Flinders Drive, Bedford Park SA 5042 (08) 8204 5511

Lyell McEwen Health Service


Haydown Road, Elizabeth Vale SA 5113 (08) 8182 9000

Modbury Hospital
Smart Road, Modbury SA 5092 (08) 8161 2000

Repatriation General Hospital


Daws Road, Daw Park SA 5041 (08) 8276 9666

Royal Adelaide Hospital


North Terrace, Adelaide SA 5000 (08) 8222 4000

The Queen Elizabeth Hospital


28 Woodville Road, Woodville SA 5011 (08) 8222 6000

Women’s & Children’s Hospital


72 King William Road, North Adelaide SA 5006 (08) 8161 7000

Private
Ashford Community Hospital
(08) 8375 5222
55 Anzac Highway, Ashford SA 5035

Burnside War Memorial Hospital


(08) 8202 7222
120 Kensington Road, Toorak Gardens SA 5067

Flinders Private Hospital


(08) 8384 9222
1 Flinders Drive, Bedford Park SA 5042

Noarlunga Private Hospital


(08) 8384 9372
Alexander Kelly Drive, Noarlunga SA 5168

Western Hospital
(08) 8356 1222
168 Cudmore Terrace, Henley Beach SA 5022

SECTION 15 – RESOURCES – REVISED SEPTEMBER 2009


3
Rural diabetes health services
Hills, Mallee, Southern Region
Kingscote 8553 4231 Kangaroo Island CHS
Mount Barker 8393 1833 Mt Barker CHS
Murray Bridge 8535 6800 Murray Mallee CHS
Victor Harbor 8552 0600 Southern Fleurieu HS

Wakefield Region
Angaston 8564 2996 Barossa CHS
Clare 8842 6555 Lower North CHS
Gawler 8521 2000 Gawler Health Service
Minlaton 8853 2380 York Peninsula HS
Wallaroo 8823 3122 Wallaroo CHS
Yorketown 8852 1200 Yorketown HS

Mid North Region


Laura 8663 3100 Hospital
Peterborough 8651 0400 Hospital
Pt Pirie 8638 4693 Regional Health Service

Riverland Region
Berri 8580 2500 Riverland Regional HS

South East Region


Bordertown 8752 9000 Hospital
Kingston 8767 0238 Community Health
Mt Gambier 8721 1460 South East Regional HS
Naracoorte 8762 8160 Community Health Service

Eyre Peninsula Region


Ceduna 8626 2110 Hospital
Cleve 8628 2399 Hospital
Cummins 8676 2101 Hospital
Kimba 8627 2400 Hospital
Pt Lincoln 8683 2077 Community Health Centre
Streaky Bay 8626 1009 Mid West Health Hospital

Whyalla, Flinders & Far North Region


Pt Augusta 8648 5500 Hospital
Whyalla 8648 8300 Whyalla Hospital and HS
Coober Pedy 8672 5009 Hospital & HS

Broken Hill
Broken Hill 8088 5441 Regional Diabetes Centre

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4
Community health centres
Community health centres may also provide diabetes services. Contact the local
community health centre for information about services provided. Look under
Community Health Centres in the business section of the white pages.

Home nursing services


Home Nurses (Private) (08) 8372 4999
Royal District Nursing Service 1300 364 264

General resources in South Australia


Exercise
There are a wide variety of commercial organisations which offer fitness and exercise
programs. Most centres are staffed by accredited fitness instructors but the cost to
attend classes can be high. The Office for Recreation and Sport, can provide advice on
choosing a fitness centre. Telephone: (08) 7424 7677.

It is worth checking Community and Neighbourhood Centres, Community Health


Centres, church organisations and other community groups to see what exercise
facilities are offered locally.

Support / psychological
Relationships Australia provides courses that develop self-understanding, self-
confidence and skills in communication, assertion and stress management for
teenagers and adults. The Relationships Australia Bookshop has a wide range of
books dealing with human relations and self development. A lending library service is
also available. For more information, contact:

Australian Institute of Social Relations


Human Relations Training Centre
49a Orsmond Street HINDMARSH SA 5007
Telephone: (08) 8245 8100 Fax: (08) 8346 7333

Relationships Australia 49A Orsmond St


Bookshop and Library HINDMARSH SA
Telephone: (08) 8245 8111

Aboriginal health services


Aboriginal Health Council of SA
9 King William Rd
UNLEY SA 5061
Telephone: (08) 8273 7200

Disability Information and Resource Centre Inc.


195 Gilles Street
ADELAIDE SA 5000
Telephone: (08) 8236 0555 Fax: (08) 8236 0566
SA only: 1300 305 558

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5
Telephone Interpreter Services
This is a 24 hour service available for those having difficulty communicating in English.
For further information contact:

Translating & Interpreting Service (T.I.S.)


Commonwealth Department of Immigration
& Multicultural Affairs
55 Currie Street
ADELAIDE SA 5000 Telephone: 13 1450 (local call cost only)

Professional organisations
• Australian Diabetes Educators Association
• Dietetics Association of Australia
• Australian Podiatry Association
• The Australian Nutrition Foundation
• National Heart Foundation
• Australian Kidney Foundation
• Exercise Physiologists
• Psychology Association

Resources for the visually impaired


Guide Dogs SA.NT
251 Morphett Street
ADELAIDE SA 5000 Telephone: (08) 8203 8333

Royal Society for the Blind


230 Pirie Street
ADELAIDE SA 5000 Telephone: (08) 8232 2444

For help to quit smoking


Quitline Telephone: 137 848

Cancer Council 202 Greenhill Road EASTWOOD SA 5063


Telephone: (08) 8291 4111

Drug and Alcohol Services 161 Greenhill Road PARKSIDE SA 5063


Telephone: (08) 8274 3333
OR: 1300 131 340- 24hr confidential counselling and
information

Heart Foundation 155 Hutt Street ADELAIDE SA 5000


Telephone: (08) 8224 2888

SECTION 15 – RESOURCES – REVISED SEPTEMBER 2009


6
Health promotion units
Flinders Medical Centre Flinders Drive, BEDFORD PARK SA 5042
Telephone: (08) 8204 5511 and ask the switchboard to
put you through to the health promotion unit.

Royal Adelaide Hospital North Terrace ADELAIDE SA 5000


Telephone (08) 8222 4000 and ask the switchboard to
put you through to the health promotion unit.

SA Health 11 Hindmarsh Square ADELAIDE SA 5000


PO BOX 287 Rundle Mall 5000
Telephone: (08) 8226 6000 and ask the switchboard to
put you through to the health promotion unit.

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7
Pharmaceutical companies
The following organisations supply equipment and can provide information and
assistance with teaching resources:

Abbott Diagnostics Telephone: 612 9384 9700


32 – 34 Lord Street
Botany NSW 2019

Alpha Pharm Telephone: (02) 9298 3999


Corner Wentworth Park Road
and Bay Street
GLEBE NSW 2037

Astra Zeneca Telephone: 1800 805 342


PO BOX 131
NORTH RYDE NSW 1670

Bayer Australia Ltd Telephone: 08 82223 6077


254 Halifax Street
ADELAIDE SA

BD Medical Systems Telephone: 612 8875 7000


4 Research Park Drive
Macquarie University Research Park
North Ryde NSW 2113

Bristol-Myers Squibb Australia Telephone (03) 9213 4000


556 Princes Highway
NOBLE PARK VIC 3174

Hoechst Australia Telephone: (07) 3260 5324


86 Peters Avenue
MULGRAVE VIC 3170

Eli Lilly Australia Telephone: (02) 9325 4444


112 Wharf Road
West Ryde NSW 2114

National Diagnostic Products (Aust) Pty Ltd Telephone: (02) 9432 8100
Unit 22, 39 Herbert Street
St Leonards NSW 2065

Novo-Nordisk Pty Ltd Telephone: 1800 224 321


PO BOX 7856
Baulkam Hills NSW 2153

Pfizer Pty Ltd Telephone: (02) 9850 3333


38 – 42 Wharf Road Or: 1800 999 543
WEST RYDE NSW 2114

Roche Diagnostics (Australia) Pty Ltd Telephone: 1800 802 409


31 Victoria Avenue
CASTLE HILL SA 2154

Sanofi Aventis Telephone: (02) 8666 2000


Talavera Corporate Centre, Building D
12 – 24 Talavera Road
SECTION 15 – RESOURCES – REVISED SEPTEMBER 2009
8
Macquarie Park NSW 21113
Servier Laboratories Telephone: (08) 8132 5555
8 Beulah Road Or: 1800 331 675
NORWOOD SA 5067

Terumo Corporation Telephone: 0412 829 736


PO BOX 366
TORRENS PARK SA 5062

SECTION 15 – RESOURCES – REVISED SEPTEMBER 2009


9
SECTION 16
Glossary
A1c – see glycosylated (glycated) haemoglobin.

acanthosis nigricans – a skin condition characterised by darkened skin patches;


common in people whose body is not responding correctly to the insulin that they
make in their pancreas (insulin resistance). This skin condition is also seen in people
who have pre-diabetes or type 2 diabetes.

acetone – a chemical (see ketone bodies) formed when the body breaks down fat
instead of glucose for energy. Levels rise and acetone ‘spills’ into urine and is exhaled
in the breath producing a ‘fruity’ smell.

alkalosis – a pathologic condition resulting from an accumulation of alkaline chemicals


or from the loss of acids without comparable loss of alkali in the body fluids. It is
characterised by decrease in hydrogen ion concentration and an increase in pH.

alpha cells – cells in the pancreas that produce the hormone glucagon.

anabolism – the constructive growth and repair phase of metabolism within the body
cells.

angiography – an X-ray of blood vessels of the body.

arteriosclerosis – an arterial disease characterised by thickening and loss of elasticity


of the arterial walls. Often known as ‘hardening of the arteries’.

atherosclerosis – a form of arteriosclerosis in which plaques of fatty deposits build up


in the large and medium arteries. This causes thickening of the arterial wall and
reduces blood flow.

auscultation – listening for sounds within the body, chiefly to ascertain the condition
of the thoracic or abdominal viscera and to detect pregnancy.

background retinopathy – an early stage of diabetic retinopathy that usually does not
impair vision – also referred to as ‘non-proliferative retinopathy’.

bacteriuria – bacteria in the urine.

beta cells – the insulin producing cells of the pancreas.

bolus – a concentrated mass of pharmaceutical preparation such as insulin therapy


when neutral insulin doses are given prior to each meal.

bruit – a sound or murmur heard in auscultation, especially an abnormal one.

carbohydrate (CHO) – one of the main food groups which provides an immediate
source of energy for the body. Carbohydrates which include sugars and starches are
digested into simple sugars such as glucose. Carbohydrates are stored as glycogen.

catabolism – the destruction phase of metabolism whereby substances are converted


into an energy source for cellular activity.

SECTION 16 – GLOSSARY – REVISED SEPTEMBER 2009


1
creatinine – a nitrogenous compound formed in the muscle in small amounts, passed
into the blood and excreted in the urine. A test of the amount of creatinine in blood or
urine may be an indicator of kidney disease.

CSII (Continuous Subcutaneous Insulin Infusion) – see insulin pump therapy.

CT scan – abbreviation for computed tomography scan that produces images of


‘slices’ of a person’s body.

dawn phenomenon – the early morning (4am – 8am) rise in blood glucose level.

diabetes insipidus – a disease of the pituitary gland not diabetes mellitus. Often
known as ‘water diabetes’ due to a deficient quantity of anti-diuretic hormone being
released or produced resulting in failure of reabsorption of water from the renal
tubules.

diabetes mellitus – a term used to describe a syndrome where there is relative or


absolute deficiency of insulin. The condition is characterised by disturbances in
carbohydrate, fat and protein metabolism. This is due to a malfunction of the beta
cells of the pancreas whose role is to produce insulin. There are two main types of
diabetes and other subtypes.

Type 1 accounts for 10-15% of all types of diabetes mellitus. Its clinical onset
is sudden and usually occurs in people under the age of 30 but can occur at
any age. This type of diabetes is dependent on injections and exogenous
insulin as there is an absolute insulin deficiency.

Type 2 has an onset which is insidious and usually occurs in people over 40
years of age but is becoming more common in the younger age group. It is
characterised by a relative deficiency of insulin and resistance to insulin action.

diabetogenic – producing diabetes.

dialysis – artificial removal of waste products from the blood when the kidneys fail.

Doppler instrument – a device for measuring blood flow within an artery or vein.
Sound waves are reflected by the moving red blood cells back towards the transducer.
The sound is proportional to the velocity of blood flow. It is used in assessment of
vascular status and abnormalities in major arteries and veins.

dorsalis pedis – the pulse on the upper outer part of the foot.

dyspnoea – laboured or difficult breathing.

electrolytes – chemical substances which when dissolved in water or melted,


disassociate into electrically charged particles and are capable of conducting an
electric current.

endocrine glands – glands that produce chemicals (hormones) which affect other
body cells.

endogenous – grown or made inside the body. Insulin that is made by the person’s
own pancreas is endogenous.

erectile dysfunction – see impotence.

SECTION 16 – GLOSSARY – REVISED SEPTEMBER 2009


2
erythematous – characterised by redness of the skin caused by congestion of the
capillaries in the lower layers of the skin. It occurs with any skin injury, infection or
inflammation.

euglycaemia – a normal level of glucose in the blood.

exchanges – servings of food that contain the same food value. Also known as
portions.

exogenous – grown or made outside of the body. Insulin that is manufactured from
animal pancreas or genetically engineered is exogenous insulin.

femoral – pertaining to the femur or to the thigh.

flourescein – a harmless yellow coloured dye that is used to outline the vessels of the
eye.

fructosamine – a glycated protein like glycated haemoglobin that measures glucose


control over the preceding weeks.

gastroparesis – a form of neuropathy that affects the stomach. Digestion of food may
be incomplete or delayed, resulting in nausea, vomiting or bloating which makes blood
glucose control difficult.

gestational diabetes – a type of diabetes that presents and is recognised during


pregnancy. It usually occurs in the second half of the pregnancy at about 24-28
weeks’ gestation. The condition usually reverts to normal glucose tolerance after
delivery. However, women with a history of gestational diabetes are at high risk of
developing overt diabetes later in life and should receive education and counselling.

glomerular filtration rate – measure of the kidneys’ ability to filter and remove waste
products.

glomerulus – a tiny tuft of blood vessels that is part of the functional unit of the
kidney.

glucagon – a hormone produced by the alpha cells in the pancreas. Glucagon is an


insulin antagonist and increases blood glucose levels by stimulating the production of
glucose in the liver. Glucagon injections are used in the treatment of severe
hypoglycaemia.

gluconeogenesis – the formation of glucose by the liver from non-carbohydrate


molecules such as fats and proteins. It occurs whenever the supply of glucose is
insufficient and is stimulated by the sympathetic nervous system.

glucose – a simple sugar – a monosaccharide also known as dextrose. Glucose is


the end product of carbohydrate digestion. The molecular formula is C6 H12 O6.

glucose tolerance test – a diagnostic test for diabetes involving a drink of glucose
(after an overnight fast) followed by a series of blood glucose estimations over 2
hours.

glycogen – a substance made up of sugars or polysaccharides, and is formed by and


stored in the liver and to a lesser extent in the muscles. Liver glycogen is converted
into glucose and released into the blood when needed. Glycogen is the chief source of
stored carbohydrate in the body.

glycogenesis – the conversion of glucose into glycogen for storage in the liver.
SECTION 16 – GLOSSARY – REVISED SEPTEMBER 2009
3
glycogenolysis – the breakdown of glycogen into glucose in the liver when blood
glucose levels are very low.

glycosuria – the presence of glucose in the urine.

glycosylated (glycated) haemoglobin (HbA1c) – a haemoglobin molecule with


glucose attached. The amount of glucose attached to the haemoglobin will be
determined by the concentration of glucose in the blood and the lifespan of the red
cells. A glycosylated haemoglobin test is a measure of the average blood glucose
levels from the previous 4-6 weeks.

HbA1c – see glycosylated (glycated) haemoglobin.

honeymoon phase – temporary remission of hyperglycaemia that occurs in some


people newly diagnosed with type 1 diabetes, when some insulin secretion resumes
for a short time, usually for a few months, before stopping again.

hyperglycaemia – abnormally increased blood glucose concentration which is a


pathological sign of diabetes. Hyperglycaemia is accompanied by symptoms of
polyuria, polydipsia and polyphagia. Hyperglycaemia left untreated can progress to
more severe conditions such as ketoacidosis and hyperglycaemic non-ketotic
hyperosmolar state.

hyperglycaemic hyperosmolar state – a rare but serious condition that occurs in


type 2 diabetes and is characterised by hyperglycaemia, hyperosmolality and
dehydration but without ketoacidosis. Random blood glucose levels are often found to
be greater than 25mmol/L. (Previously known as HONK – hypersmolar hyperglycaemic
nonketonic coma).

hyperinsulinemia – a condition in which the level of insulin in the blood is higher than
normal. Caused by overproduction of insulin in the body. Related to insulin
resistance.

hyperlipidaemia – elevated concentrations of any or all of the lipids (fats) in plasma.

hyperosmolality – an increased concentration of osmotically active substances – eg


increased glucose concentration in body fluids.

hypoglycaemia – abnormally low blood glucose levels of less than 4mmol/L. A risk
for people who require medication to control diabetes.

hypoglycaemia unawareness – a state in which a person does not feel or recognise


the symptoms of hypoglycaemia. People who have frequent episodes of
hypoglycaemia may no longer experience the warning signs of it.

impaired fasting glucose (IFT) – describes a condition in which blood glucose levels
are moderately elevated but not elevated to the range diagnostic of diabetes mellitus.
Fasting blood glucose is found between 5.5 and 6.9mmol/L. See pre-diabetes.

impaired glucose tolerance (IGT) – describes a condition in which blood glucose


levels are moderately elevated but not elevated to the range diagnostic of diabetes
mellitus. IGT is diagnosed when the 2 hour value post oral glucose test is between 7.8
and 11.0mmol/L. See pre-diabetes.

impotence – the inability to get or maintain an erection for sexual activity. Also called
erectile dysfunction.

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4
insulin – is a hormone that is secreted by the beta cells of the pancreas and is the
major fuel regulating hormone. Insulin is secreted in response to a rise in blood
glucose and facilitates the utilisation of glucose by the cells. Insulin enables the
transport of glucose across the cell membrane. Insulin is responsible for the storage
of glucose and amino acids, increases protein and fat synthesis and inhibits the
breakdown of fat.

insulin (basal)

intermediate acting – (12-24hrs) – cloudy insulin (*Isophane) prolonged


duration of action, mixed/biphasic insulins also fall into this category. They
comprise a combination of ultra-short acting or short acting insulin, in varying
proportions with an intermediate acting insulin. *Isohane – scientific name for a
type of intermediate-acting insulin. Also known as NPH.

long acting – (24-36hrs) – clear insulin (*analogue) prolonged duration of


action, a constant basal insulin over 24 hours and is given once daily. Long
acting insulin analogues cannot be mixed with other insulins before
administration. Human insulin *analogue – insulin produced in the laboratory,
using genetic engineering technology, that has a slightly altered structure
compared to the insulin found in the human pancreas; this alteration changes
the onset and duration of action of the insulin.

insulin basal rate – a steady trickle of small amounts of *ultra-short acting insulin
used in insulin pumps.

types of ultra-short acting insulin


*Aspart – insulin aspart. A copy of human insulin made by recombinant DNA
technology (genetic engineering). This is a ultra short acting insulin and so
starts to work very quickly.
*Lispro – insulin lispro. A copy of human insulin made by recombinant DNA
technology (genetic engineering). This is a ultra short acting insulin and so
starts to work very quickly.

insulin bolus – an amount of insulin taken to cover an expected rise in blood glucose,
often related to a meal or snack.

insulin pump therapy (also known as CSII – Continuous Subcutaneous Insulin


Infusion) – a device that delivers a continuous supply of short-acting insulin into the
body.

insulin resistance – the body’s inability to respond to and use the insulin it produces;
may be linked to obesity, hypertension, and high levels of fat in the blood.

intermittent claudication – symptoms characterised by pain in calf muscles of one or


both legs. Pain is brought on by walking and relieved by rest. The cause is due to
diminished blood supply in the femoral artery which is diseased with atherosclerotic
lesions. Treatment involves vascular reconstructive surgery.

ionic agents – an atom or group of atoms having a positive or negative electric


charge. Substances forming ions are electrolytes.

ischaemia – a deficient blood supply to part of the body due to constriction or actual
obstruction of a blood vessel.

islet cell autoantibodies (ICA) – proteins found in the blood of people with newly
diagnosed type 1 diabetes. They are also found in people who may be developing

SECTION 16 – GLOSSARY – REVISED SEPTEMBER 2009


5
type 1 diabetes. The presence of ICA indicates that the body’s immune system has
been damaging beta cells in the pancreas.

islets of Langerhans – a group of cells in the pancreas that make and secrete
hormones. Beta cells make insulin. Alpha cells make glucagon. Delta cells make
somatostatin.

ketoacidosis – a severe metabolic disturbance with hyperglycaemia, hyperosmolality


and metabolic acidosis. Fat catabolism leads to accumulation of ketone bodies in the
blood. If not corrected diabetic ketoacidosis is life threatening.

ketone bodies – chemicals which occur as a result of fat catabolism or breakdown.

ketonuria – the presence of ketones in urine.

ketosis – accumulation of large quantities of ketone-bodies in the body tissue and


fluids.

Kussmaul respirations – rapid, deep, laboured breathing which occurs in


ketoacidosis. Also called ‘air hunger’.

lactic acidosis – a serious condition caused by the build up of lactic acid which is
produced from glucose when there is not enough oxygen. Similar effects as
ketoacidosis.

laser (Light Amplification by Stimulated Emission of Radiation) – an intense


narrow beam of light which can be used to heal damaged areas in the body (eg blood
vessels in the eye).

lipoatrophy – atrophy of the subcutaneous tissue which may occur at injection sites
due to poor injection techniques.

lipohypertrophy – lumps that may occur at injection sites due to poor injection
technique and over use of the site of injection.

lipolysis – fat catabolism or breakdown.

lypodystrophy – lumps or small dimples seen on the skin of people using insulin
injections. The cause is due to poor injection technique or not rotating the injection
site and then over using the same injection area and/or administering cold insulin.

macrosomia – greater than normal bodily size. In full term babies this is determined
by birth weights greater than 4.4 kilograms.

macrovascular disease – a disease of large and medium blood vessels. Vessels


become diseased due to scarring and fatty plaque deposits which occur on the vessel
lining.

metabolism – the physical and chemical processes and reactions taking place among
ions, molecules and atoms in the body. The utilisation of nutrients following digestion.

microalbuminuria – the presence of small amounts of albumin in the urine and is an


early sign of kidney damage.

microvascular disease – a disease of the smallest blood vessels. The walls of the
vessels become thickened and weak which results in blood and protein leakage or
blockage.

SECTION 16 – GLOSSARY – REVISED SEPTEMBER 2009


6
millimole (mmol) – a concentration of the concentration of chemicals in the blood.

nephropathy – disease of the kidneys caused by degeneration of the small blood


vessels or the glomeruli (kidney units that filter blood). Damage can progress to
chronic renal failure.

nephrotoxic – an agent or drug that is destructive to the kidney.

neuropathy – disease of the nervous system due to degenerative changes of the


sensory motor and autonomic nerves. The severity of neuropathy is directly related to
the duration and control of diabetes. Although any nerve may become affected
peripheral neuropathy is more common. Effects include loss of sensation, power,
double vision, diarrhoea, paralysis of the bladder and sexual problems in both men and
women.

oral hypoglycaemic agents (OHA’s) – medications taken by mouth that stimulate the
release or improve the action of insulin:

biguanides – reduces the amount of glucose produced by the liver and helping
the body respond better to the insulin made in the pancreas.

sulfonylurea – lowers blood glucose by increasing the amount of insulin it


makes.

meglitinides – lowers blood glucose by helping the pancreas make more


insulin immediately after meals.

thiazolidinedione – a group of medicines called glitazones, decreases insulin


resistance.

alpha-glucosidase inhibitor – slows and lowers rise in blood glucose


throughout the day. Slows down the digestion of carboydrates (complex
sugars) from your diet, especially post prandial.

glucagon like peptide (GLP-1) – enhances insulin secretion, inhibits glucagon


secretion and reduces both fasting and post prandial blood glucose.

osmolality – the concentration of a solution in terms of osmotically active particles


(osmoles of solutes per kilogram of solvent).

pancreas – an elongated gland that lies in the abdomen posterior to the stomach and
partially surrounded by a loop of the small intestine. Its exocrine function is to produce
and secrete digestive enzymes. The endocrine function in relation to diabetes is to
produce and release insulin and glucagon.

paresthaesiae – abnormal sensations such as burning or prickling.

pedal pulses – arterial pulses which can be palpated on the dorsum (dorsalis pedis)
and medial site (posterior tebial).

photocoagulation – a treatment for diabetic retinopathy. A strong beam of light


(laser) is used to seal off bleeding blood vessels in the eye and to burn away extra
blood vessels that should not have grown there.

polycythaemia – an increase in the total cell mass of the blood.

polydipsia – excessive thirst.

SECTION 16 – GLOSSARY – REVISED SEPTEMBER 2009


7
polyphagia – excessive ingestion of food.

polyuria – excessive excretion of urine.

popliteal – pertaining to the area behind the knee.

portions – see exchanges.

post prandial – after a meal.

post prandial blood glucose – the blood glucose level taken 2 hours after eating.

pre- diabetes – a condition in which blood glucose levels are higher than normal but
are not high enough for a diagnosis of diabetes. People with pre-diabetes are at
increased risk for developing type 2 diabetes and for heart disease and stroke. Other
names for pre-diabetes are impaired glucose tolerance and impaired fasting glucose.

pruritus – itching.

pyelography – x-ray of the kidney and ureter after injection of a contrast medium.

pyuria – pus in the urine.

rebound hyperglycaemia – see Somogyi effect.

retinopathy – microvascular degeneration in the retina of the eye causing impaired


vision. The changes can lead to aneurysms, haemorrhage and exudates with
resultant blindness. Retinopathy is one of the major long term complications of
diabetes mellitus.

s/c – abbreviation for subcutaneous as in subcutaneous insulin injections.

serum osmolality – a measure of the number of dissolved particles per unit of water
in serum.

Somogyi effect – rebound hyperglycaemia following a hypoglycaemic episode.

teratogenic – an agent or influence that causes physical defects in the developing


embryo.

type 1 diabetes – a condition characterised by high blood glucose levels caused by a


total lack of insulin. The body’s immune system attacks the insulin-producing beta
cells in the pancreas and destroys them. The pancreas then produces little or no
insulin. Type 1 diabetes develops most often in young people but can appear in
adults.

type 2 diabetes – a condition characterised by high blood glucose levels caused by


either a lack of insulin or the body’s inability to use insulin efficiently. Type 2 diabetes
develops most often in middle aged and older adults but can appear in young people.

uremia – the illness associated with a build up of urea in the blood because the
kidneys are not working effectively. Symptoms include nausea, vomiting, loss of
appetite, weakness and mental confusion.

SECTION 16 – GLOSSARY – REVISED SEPTEMBER 2009


8