DIABETES

Diabetes is a metabolic disorder in which there is persistent hyperglycaemia (raised blood glucose) as a result of defects in pancreatic insulin secretion, insulin action or both, and abnormalities of carbohydrate and lipid metabolism. The number of people with diabetes in the UK is rapidly increasing, and most recent figures show that there are 3.8 million people living with diabetes, 90% of whom have type 2 diabetes. Diabetes significantly increases the risk of coronary heart disease and stroke. It is also the biggest cause of kidney failure, the leading cause of blindness in adults of working age and a major cause of limb amputation.

 

Type 1 diabetes

• Accounts for only 5–15% of people with diabetes
• No insulin is produced, usually because pancreatic beta-cells are destroyed (autoimmune disease)
• Rapidly fatal without treatment with insulin
• Generally diagnosed at a young age but can sometimes develop later in life

Type 2 diabetes

• Accounts for 85–95% of people with diabetes
• Large proportion of affected individuals overweight or obese
• Some but not enough insulin is produced, or the body is resistant to the action of insulin
• Patients often asymptomatic initially. Long survival without treatment is possible, but diagnosis and treatment essential to minimise complications
• Generally diagnosed from 3rd decade, but increasingly occurring in younger people

Gestational diabetes

• Hyperglycaemia of variable severity that arises during pregnancy and usually disappears on delivery

Treatment aims to keep blood glucose levels as near as possible in the normal range. First-line treatment for type 1 diabetes is insulin, given by injection. For type 2 diabetes, the key is healthy eating, aided by increased physical activty where possible, to reduce weight, reduce blood lipids and increase insulin sensitivity. If lifestyle measures fail to control blood glucose, treatment is with an oral hypoglycaemic drug e.g. metformin and then, if necessary, additional oral hypoglycaemic agents and/or insulin.

Care planning is a process of shared decision making that offers people with diabetes active involvement in deciding, agreeing, and owning how their diabetes is managed. A care plan is a means to record that involvement, and the outcomes of negotiation with the patient. 

Those at increased risk of type 2 diabetes are:

• People >40 years of age.
• People of Asian and Afro-Caribbean origin.
• Individuals who are overweight.
• Those with a family history of diabetes.
• Women with a history of gestational diabetes or who have had a large baby (>4kg).

Symptoms that may present

• Thirst
• Polyuria/nocturia
• Incontinence in elderly people
• Irritability (mood changes)
• Unexplained weight loss
• Blurred vision
• Genital infections (candidiasis)
• Recurrent infections slow to clear
• Numbness/tingling (feet/legs/hands).

Other factors that may precipitate diabetes

• Certain drugs (steroids, thiazides)
• Pancreatic defects/diseases
• Endocrine disorders.

DIAGNOSING DIABETES

In the absence of symptoms, never diagnose diabetes on the basis of glycosuria or capillary blood glucose alone. Laboratory plasma glucose estimation is essential.

DIAGNOSTIC CRITERIA (WHO)

Values are venous plasma glucose concentrations (mmol/l)

• Diabetes: fasting >7.0mmol/l; random >11.1mmol/l, detected: 
  • once in the presence of symptoms,
  • or on two occasions on different days in the absence of symptoms, or  
  • >11.1mmol/l detected 2h after a 75g oral glucose load given after an overnight fast.

• Impaired glucose tolerance (2 hours post 75g glucose drink) ≥7.8mmol/l and <11.0mmol/l
• Impaired fasting glucose ≥6.1mmol/l and <7.0mmol/l

Monitoring blood glucose

People with diabetes can monitor their blood sugar levels day-to-day by testing capillary blood samples (obtained by pricking the skin), using a glucometer. In certain patients, the results are a guide to adjusting their insulin dosage as necessary. Glucometers must be calibrated regularly.

• Normal range: 20–42 mmol/mol (4.0–6.0%)
• Target: 48 mmol/mol (6.5%), or individual target as agreed with the person with type 2 diabetes, which may be higher than that of 48mmol/mol set for people with type 2 diabetes in general

HbA1c unit/value conversion

HbA1c (mmol/mol)	HbA1c (%)
42	6.0
48	6.5
53	7.0
59	7.5
64	8.0
75	9.0

 

Diabetes management and education

Practice nurses can help ensure that people with diabetes have the necessary education and skills to manage the condition.

NICE recommends:

• structured education is offered to every person and/or their carer at and around the time of diagnosis, with annual reinforcement and review.
• people with diabetes and their carers are informed that structured education is an integral part of diabetes care.

The structured education programmes to improve self-care listed below may be available in your area, or there may be locally developed sessions. Otherwise, the onus is on the practice nurse.

Training and resources for health professionals

• Education for Health https://www.educationforhealth.org
• Primary Care Diabetes Society https://www.pcdsociety.org
• Diabetes UK Professional memberships offers numerous benefits 0345 123 2399 https://www.diabetes.org.uk

Diabetes review

Every patient with diabetes should be seen at least annually, and receive the nine NICE-recommended care processes:  

• HbA1c 
• Blood pressure 
• Serum cholesterol 
• Kidney function (urinary albumin:creatinine ratio and serum creatinine) 
• Foot surveillance
• BMI
• Smoking history
• Retinal screening

Also need to discuss concerns or worries; in males, erectile dysfunction can result from condition or medication. Asking open questions, e.g. ‘Are you managing well at the moment? What are you struggling with? Is there anything you need?’ can improve involvement and outcomes.

• Assess and monitor symptoms and complications
• Review results and findings
• Check peripheral pulses and monitor absence/presence of neuropathy
• Discuss/monitor lifestyle issues, smoking, care of feet, BMI, diet, alcohol consumption, and physical activity
• Offer seasonal vaccination(s)
• Review medication: side-effects, assess effectiveness of additions or alterations, and adherence; document by Read codes if contraindications or side-effects prevent use of recommended medications; re-issue prescription as appropriate
• Check technique for use of glucometer if appropriate
• If using insulin, check injection technique and injection sites, and care of insulin (must not be frozen, e.g. when flying, never pack insulin in hold baggage)
• Discuss management plan if appropriate, and offer information on Diabetes UK
• Offer retinal screening and foot check
• Discuss fitness to drive in relation to latest Driver and Vehicle Licensing Authority (DVLA) regulations; regular updates are posted on line