Diabetes General Information
Posted November 13, 2017
Diabetes General Information
WHAT IS DIABETES
What is diabetes
Diabetes mellitus is a common serious chronic medical condition, largely managed by GPs, and is characterised by the body being unable to store blood glucose. This high blood glucose can become poisonous to tissues and so if diabetes is left uncontrolled it can lead to life-threatening complications.
Diabetes should be regarded more as a vulnerable state than a disease; it should not be viewed as a death sentence. On the contrary, with high quality care and a proactive attitude, a person with diabetes can be a picture of health without disease complications.
Glucose itself is an essential energy source for cells and a single carbohydrate unit. Without glucose cells can not function; think for example about the effects of low blood glucose on brain cells and the conscious state. Glucose gets into the bloodstream from the diet in the form of sugars, bread, rice, potato, pasta and is also broken down from body’s stores when required.
The pancreas, an organ in the abdomen, produces a hormone called insulin, which is released into the bloodstream when there is a high amount of glucose in the blood, for example after a meal. Insulin acts quickly to make cells absorb glucose into cells in order for it to be used for energy or be stored for when It is needed by the body. Equally, when the blood’s glucose concentration is reducing less insulin s released which activates glucose store breakdown and release from stores, increasing the blood glucose concentration before it can be felt by the body. This tight control is called ‘autoregulation’.
Diabetes is when this autoregulation of blood glucose levels becomes faulty, exposing the body to higher than tolerated blood glucose concentrations. This is toxic to cells, leading to various organs to become diseased, such effects as:
- Heart attack and stroke (glucose speeds up atherosclerotic blockages in blood vessels)
- Blindness – damaged retinal cells
- Kidney failure – damaged filtration cells (nephrons)
- Nerve damage – neurones in the leg in particular which leads to numbness and foot damage.
- Skin damage & infections – bacteria love glucose, ulcers form and can not heal.
TYPES OF DIABETES
Types of Diabetes Mellitus
Type 1 Diabetes
Also known as ‘insulin dependent diabetes’, this usually occurs in younger people. Insulin production ceases altogether due to an ‘autoimmune’ inflammatory reaction which destroys cells in the pancreas.
It presents as a very unwell, dehydrated child or adult with extremely high blood sugar readings (well over 10). There is a need for lifelong daily insulin replacement through injections.
Type 2 Diabetes
This is by far the most common type of diabetes. It largely presents later on in adulthood and can be without symptoms initially, thus is commonly incidentally picked up on a routine blood test.
People lose their ability to store blood glucose since the body’s cells become resistant to the actions of insulin; the blood glucose levels therefore rise. Lifestyle decisions (as well as genetics) play a large part in causing this to happen. It is thought that people who eat high energy and sugary foods expose the cells to high levels of glucose and these cells simply tire of having to deal with this.
Type 2 diabetes is managed with lifestyle measures, then a combination of medications and finally with insulin injections if blood sugar levels can not be controlled.
Some pregnant women can temporarily develop diabetes in the latter stages of pregnancy. This transient resistance to insulin and subsequent high blood sugar levels can cause the developing foetus increase in size, which pose problems with delivery, as well as cause hypoglycaemia to the newborn baby.
Gestational diabetes is therefore screened with a blood test in the 2nd trimester. Women are then managed initially with diet but may need insulin in some cases. Once they have delivered the diabetes usually disappears but may return at subsequent pregnancies.
People may have subtle warning signs of being a high risk for type 2 diabetes, or pre-diabetic, in the years running up to the diagnosis. It is a precursor to diabetes itself. It is a critical problem since unless pre-diabetics patients change their lifestyle dramatically, a high proportion of such people will end up with diabetes and health complications.
Warning signs may be a borderline fasting blood sugar level or being obese with a high waist circumference. If these people identified prior to full blown diabetes and they are motivated to change their lifestyle then they could be regarded as lucky since they have an opportunity to turn around their fortunes before trouble really begins. GPS are well placed to advise on appropriate lifestyle changes to prevent diabetes developing and organise yearly tests to check on progress.
Impaired Fasting Glycaemia
An early subtle sign of diabetes developing is a higher than expected blood glucose level after fasting (5.4-6.9). This can be seen on routine blood tests and can show no symptoms. This pre-diabetic person has a 1.5fold increased chance of developing diabetes over the next decade.
Once recognised this person should adopt a healthier lifestyle and have yearly blood tests.
Also known as ‘syndrome X’, this is a common condition recognised by a combination of a few metabolic markers that are high risk precursors to diabetes and cardiovascular disease:
- Central Obesity (a large abdominal circumference
- Impaired fasting glycaemia
- High Triglyceride cholesterol and low HDL cholesterol
- High blood pressure
This person is a ticking timebomb for medical problems and needs to act quickly with lifestyle measures.
DIAGNOSIS & MONITORING OF DIABETES
Diabetes is recognised by a combination of symptoms and a blood test to confirm. The diagnostic criteria are:
- 12 hour fasting glucose >7 (once if symptoms, twice if no symptoms)
- HBA1C blood test >6.5
- Glucose tolerance test – 2hours post sugar load of >11
Once diagnosed we recommend registering with the NDSS, an organisation to assist people with diabetes. Click here.
HBA1C – The blood test that never lies
Every diabetic should have an HBA1C at least once a year. It is a long term measure of blood glucose levels; high blood glucose causes a chemical change to haemoglobin in the blood which can persist for many weeks. The proportion of altered haemoglobin gives a direct indication of a person’s long term diabetic control. It is a great tool for clinicians to monitor and plan diabetes care.
The HBA1C is also being used for diagnosis of diabetes as well now, replacing the traditional glucose tolerance test.
Home Blood Glucose Monitoring
Home monitoring of blood glucose can be done by finger prick blood glucose monitoring (& less commonly urine testing).
Finger prick testing, which is mildly painful, involves using equipment to prick the end of the finger with a disposable lancet needle to extract a small amount of blood and then connecting a disposable test strip to a small machine which analyses the glucose level.
Diabetic people are encouraged to regularly check their blood glucose if their control is variable, they are unwell, have regular hypos, are pregnant but mainly when they are on medications such as insulin. An insulin-dependent diabetic would probably be best advised to check the glucose levels before meals (fasting levels) and 2 hours after their evening meal (thus 4x/day). This assists in deciding the dose of insulin they need.
If performed 2 hours after a meal, blood glucose monitoring is a good means for the person to see how certain foods, especially sugars and carbs, can make the glucose levels shoot up; these would be foods to avoid.
Urine albumin levels
High blood glucose levels in diabetes are toxic to the kidney cells. This can be avoided by good diabetes control. Early stages of kidney damage can be screened for by the loss of a protein called albumin being shed from the kidney into the urine. All diabetics should have an annual urine test to look for these changes.
Other blood tests
Annual blood tests can look at overall health as well as risk factors for cardiovascular disease. The routine tests should be:
- Kidney function
- Liver function
Blood Pressure Check
People with diabetes should have their blood pressure checked at least annually (ideally at every GP appointment). Since high blood pressure increases the risk of cardiovascular disease, people with diabetes should have a very well controlled blood pressure, eg below 140/90.
An annual eye check is essential for people with diabetes since high blood glucose will damage retinal cells as well as increase the chance of cataracts which can all lead to blindness. Whilst good diabetic control will prevent this, retinal photography at an optometrist or opthalmologist will check for subtle changes before they become a problem.
An annual foot check for changes associated with poor diabetes control are also essential since glucose damages nerve cells, leading to numbness and possible damage to the foot. Clinicians should be checking for sensation in the feet and any damage to the skin, but a podiatrist will provide a comprehensive check of the foot and educate people with diabetes about appropriate foot care.
Weight should be monitored since obesity is another risk factor for cardiovascular disease as well as worsening diabetes.
RESOURCES & TRANSLATED INFORMATION
Living with Diabetes
LIFESTYLE - EXERCISE & DIET
The first stage of managing type 2 diabetes is lifestyle changes; doctors generally will try to keep people off medications for diabetes for as long as they can. Since unhealthy lifestyles are a major risk factor for developing type 2 diabetes, the initial treatment and long term basis of management is to improve fitness and diet.
People with type 2 diabetes can be sustained on lifestyle measures (as a diet-controlled diabetic), and, in some cases people can almost entirely reverse the diagnosis of diabetes for many years by working on their diet and exercise levels. Unfortunately once the body has tipped into insulin resistance/diabetes they are forever vulnerable of developing or deteriorating into a state of high blood sugars and diabetic complications. It is therefore a lifelong battle sadly.
Physical activity improves diabetes; it helps people lose weight and reduces insulin resistance. People with diabetes will see an improvement in the blood sugar levels and their long term HBA1C levels with regular exercise.
All diabetics should attempt to do at least 30 mins of aerobic exercise in the form of a brisk walk, cycling, swimming at least 4 times a week in order to gain these advantages. Being just physically busy with manual tasks often is not enough.
Dietary intake has a dramatic impact on a diabetic person’s body and blood glucose levels. An essential part of controlling a diabetic person’s blood glucose levels and subsequent chances of complications of diabetes. A diabetic diet is merely a healthy one, with particular consideration of carbohydrate intake.
A healthy well balanced diabetic diet should have:
- Low Glycaemic Index Carbohydrates
- Low calorie content
- Moderate to low alcohol intake
Carbohydrates, Sugars & the Glycaemic Index
Labelling sugar as the main culprit is a very simplistic view
Rather than just stopping sugar in the diet, which is a simplistic view on diet control of diabetes, the key is maintaining a ‘healthy’ and well balanced diet. Everyone, and especially people with diabetes need some carbohydrates; the amount just needs to be curbed to stop large rises in blood glucose. This will ideally help the person lose weight, reduce their insulin resistance, cardiovascular risk and hold off the need for medications for diabetes.
It is often hard to be motivated to change as these are the most difficult habits to kick. It is often surprising how little we know about healthy foods, and this is where a good GP, a diabetes nurse educator and a dietitian can give good practical advice and even develop meals plans with you.
Glycaemic Index (GI) refers to the rate a dietary carbohydrate is broken down to a single unit of glucose by the body:
- High GI carbohydrates (eg white bread, sugar, lollies, potatoes, white rice) cause a rapid rise in blood glucose.
- Low GI carbohydrates (eg grainy & brown breads, brown rice, soy, lentils, porridge, some pastas) cause a slow rise in blood glucose.
Diets with a low glycaemic index (GI) can assist in controlling blood glucose levels in people with diabetes
Over time a proactive person with diabetes will get to know which foods, and particularly carbohydrates, will send their blood sugar levels up (with finger prick testing) and modify their diet accordingly.
Type 2 diabetes is managed initially only with lifestyle measures. But once blood glucose levels rise or complications arise there is a need for medication; and there are a good number of different tablet medications to treat blood glucose.
Realistically a lot of people with type 2 diabetes see a gradual deterioration in their ability to deal with glucose, thus needing an increasing amount of medications at increasing doses to keep the harmful effects of high blood glucose at bay. These people regrettably need to go on a journey of constant vigilance and surveillance as well as careful clinical care to select the appropriate medications for their needs. At times type 2 diabetes becomes so resistant to these tablets that insulin needs to become part of their management. To find out more click here.
Metformin – Diabex
Metformin is the the first choice medicine for people with type 2 diabetes. It improves glucose uptake by cells, reducing insulin resistance and improving blood glucose levels.
It is a very effective and well tolerated medication but it can cause nausea and diarrhoea in some people and should not be taken by people with severe liver or kidney problems. It can cross react if a contrast dye is given, such as an angiogram. It does not cause significant weight gain or cause hypoglycaemia like some other diabetic medications.
Sulphonylurea – Gliclazide, Diamicron
A commonly prescribed medication, reserved often in combination with metformin further down the line. This increases insulin release from the pancreas, driving down blood glucose. Whilst effective, sulphonylurea medicine can cause weight gain and a slight risk of hypoglycaemia.
DPP4 Inhibitor – Trajenta, Januvia
Another alternative or combination with metformin and a sulphonylurea medication, this medicine indirectly increases insulin in the blood by blocking the action of an enzyme. It is favourable as it does not cause hypoglycaemia or weight gain, but it can cause common cold symptoms, aches and headaches.
SGLT2 Inhibitors – Jardiance, Forxiga
Another good alternative medicine that increases excretionof glucose through the kidneys. It can cause urinary tract infections,dehydration and constipation. It can also help with weight loss.
Thiazolidinediones – Glitazones, Avandia, Actos
This medication increases insulin sensitivity. It is effective at diabetes control but it will cause weight gain and sometimes fluid accumulation.
GLP1 Analogue – Byetta, Victoza
Like many of the other anti-diabetic medications, this increases insulin release amongst other actions and is very effective at reducing blood glucose levels as well as causing weight loss. The downside is that it needs to be injected and can cause, nausea, vomiting, diarrhoea and constipation.
Insulin is the ideal diabetic medication as it is the hormone that is either absent or ineffective in people with diabetes. It can be manufactured and is available as an injectable medication. There is a variety of injectable insulin preparations such as quick and slow release as well as a mix of the two. These choices of insulin preparations can be matched to a particular person’s insulin needs and preferences.
People with type 1 diabetes will be commenced on insulin from day 1 but those with type 2 diabetes will have gone on a lengthy journey of lifestyle management then anti-diabetic tablets and finally arrive at the need for insulin injections to successfully manage their blood glucose. Whilst this is often reached with apprehension and anguish by patients, insulin therapy is often lifesaving.
The main drawback of insulin therapy are the need for regular self injections; the person will be given good education on the method and become confident with it. Click here.
The other issue that can arise is the potential for hypoglycaemia. Insulin can also cause weight gain.
A diabetes nurse educator is a very useful person at this stage. In partnership with the doctor, the diabetes nurse educator will have lengthy discussions with the person about what regime they will be using, how to inject and lots of practical advice so that they know what they are doing. This person will have regular follow ups to check on their progress and so they do not feel alone in managing their diabetes with insulin therapy. For more information click here.
HYPOGLYCAEMIA & HYPERGLYCAEMIA
Taking too high a dose of insulin (or certain diabetic medications that trigger insulin release) or not eating enough food after taking medications will lower the blood glucose. Once the blood glucose goes below a threshold (usually below 4) then a person will experience hypoglycaemia, or a ‘hypo’. This can be serious in some cases. For practical information click here.
A hypo is dangerous since cells are being starved of energy. Symptoms to recognise include:
- Drowsiness/altered conscious state
The person, or their carer should react to this immediately as ignoring it could lead to a loss of consciousness (in which case the person needs emergency treatment.
In a mild to moderate case of hypo (ideally confirmed as below 4 but if unable to test just presume) where the person is conscious and can swallow follow the ‘rule of 15’ as outlined in the RACGP below or click here:
- 15 g of quick-acting carbohydrate (eg half a can of regular – non-diet – soft drink, half a glass of fruit juice, three teaspoons of sugar or honey, six or seven jellybeans, three glucose tablets)
- wait 15 minutes and repeat blood glucose check – if the level is not rising, suggest eating another quick-acting carbohydrate from the above list
- longer acting carbohydrate if the patient’s next meal is more than 15 minutes away (eg a sandwich; one glass of milk or soy milk; one piece of fruit; two or three pieces of dried apricots, figs or other dried fruit; one tub of natural lowfat yoghurt; six small dry biscuits and cheese)
- test glucose every one to two hours for the next four hours.
If the hypo is more severe and the person’s conscious state is reduced and they can not swallow then an ambulance should be called and glucagon injection (if available) can be used.
Hyperglycaemia is a state of high blood glucose. It is also very dangerous; the glucose and lots of fluid floods out through the urine rendering the person inappropriately dehydrated which can lead to organ shut down This is compounded by the fact that the body’s cells have no access to essential glucose so they produce acids, in the form of ketones, to compensate. High acid levels are poisonous to the body.
Hyperglycaemic emergencies where the blood glucose can far exceed 15, and the effects described above are as a result of a sudden uprise in the blood glucose levels which can be experienced in a sudden loss of insulin or its powers:
- A new case of type 1 diabetes
- A person with diabetes who forgets to take insulin
- A person with diabetes who gets unwell with an infection
This problem is termed as ‘diabetic ketoacidosis’ or ‘DKA’ and is very possible in type 1 diabetes. In type 2 diabetes people can also succumb to a state of hyperglycaemia and severe dehydration called ‘Hyperosmolar hyperglycaemic state’.
The symptoms to look out for include:
- Drinking lots of fluids (sugary), passing lots of urine
- Dehydration – dry lips, mouth, confused, drowsiness
- Fast breathing & ketone-smelling breath
Confirmed hyperglycaemia with worsening symptoms needs immediate reinstatement of insulin, but often hospitilization for intravenous insulin therapy, fluid rehydration and careful monitoring.
Atherosclerosis – Heart Attack & Stroke
High blood glucose levels increases the damaging process of atherosclerosis, or formation of plaques that narrow and block arteries. Total blockage in essential arteries to the brain or heart muscle can cause stroke or heart attack as well as poor circulation to the feet.
People with diabetes are very vulnerable to these problems. If they suffer this fate they need to go immediately to hospital. However, avoidance of stroke or heart attack (or a repeated event) are most important; not only should people with diabetes maintain good glucose control but they should have strict monitoring and control of other risk factors such as:
- Blood pressure
Poor circulation to the feet (caused by atherosclerosis), poor sensation and glucose attracting bacteria infection can combine in poorly controlled diabetes to create poorly healing ulcers.
Any injury or ulcer can be managed most effectively if recognised and reported to a GP early.
Peripheral Neuropathy – Numbness
Nerve cell damage is most pronounced in the long nerves to the legs and feet. In poorly controlled diabetes people experience numbness, making them vulnerable to tissue damage from injuries that they can not feel or withdraw from. Poor circulation and infection can worsen this situation, leading to irreversible damage, disability, and, in extreme cases, amputation.
To avoid these real problems, besides good diabetic control, people are urged to get regular podiatry foot checks, screening for peripheral neuropathy and to report any foot injuries as soon as possible.
Retinopathy – Visual Loss
Retinal cell damage due to glucose can lead to gradual and worsening visual loss. People with diabetes are more likely to develop cataracts.
People with diabetics are advised to get yearly retinal photography and the input of an eye specialist to recognise and manage these changes if they arise.
Nephropathy – Kidney Failure
Diabetes is the leading cause of kidney failure and the need for dialysis. High blood glucose will damage nephrons, the kidney cells that filter the blood of toxins.
In the early stages of kidney damage these nephrons will shed a protein called albumin into the urine. A person with diabetes should perform annual urine tests to screen for albumin. The presence of early kidney damage should be managed with tight diabetes and blood pressure control, which is proven to slow progression to kidney failure.
Diabetes Management at EMC
HIGH QUALITY DIABETES CARE
At EMC we are proud of the fact that we offer high quality diabetes care. Our highly trained caring staff are very knowledgeable in this field and are very proficient at advising appropriate up-to-date and evidence based management of diabetes and its complications. We are willing to listen to your concerns and tailor your care to your views and preferences. We are confident of positive diabetes health outcomes if you are willing to work with us.
We have amassed a great extended team to work with people with diabetes so we can offer the majority of your diabetes care can take place within our medical centre rather than having to be outsourced to other facilities.
NEWLY DIAGNOSED DIABETES - WHAT TO DO
What to do?
You may have been told you have diabetes by your doctor. But what does this mean now?
For people with type 2 diabetes it can be quite confusing since the person may feel well with no symptoms; but this is deceptive as the real risks exist already and it is important to take action.
The next step will be to book in with one of the practice nurses for a ‘diabetes care plan’. This is an appointment that is much longer than a standard GP appointment and gives the person time to discuss diabetes and what it means to them, how they can alter their lifestyle and also plan the other care providers they require for the year ahead.
Unless the person with newly diagnosed type 2 diabetes has been very unwell with high blood glucose, which is rare initially, no medications will need to be provided yet. A person will be monitored for 6-12 months on lifestyle changes, after which medications may be considered if blood glucose remains high.
On the contrary, type 1 diabetes always requires immediate insulin therapy and intensive specialist endocrinology input, but we are also waiting in the wings to assist too.
The key players for your diabetes care here at EMC are:
- Your GP – monitoring, advising, providing medications & general medical care.
- Practice Nurses – arranging diabetic care plans, planning the priorities in care as well as advising on management and lifestyle.
Other allied health members who regularly consult here at EMC, and we refer for diabetes care:
- Diabetes nurse educator – A specialist nurse trained solely for the care of diabetes who provides long appointments to provide indispensable practical advice to people with diabetes and liaise with their GP about their care. We are fortunate to have the expert assistance of Kerrie Peacock in this role.
- Podiatry – Regular feet checks are essential in diabetes care and we have expert podiatrists in the form of Tim Mulholland and Tanya Contis to provide this at EMC.
- Dietitian – Advice and guidance on a healthy diet to control. Our dietitian provides excellent assistance to people with diabetes to achieve these goals.
Other diabetes health care providers that would need to be accessed at an alternative location may be:
- Optometrist – for regular eye checks
- Exercise physiologist – to assist with exercise lifestyle changes
- Endocrinologist – a doctor who specialises in diabetes. May be required in more complex diabetes cases.
- Other medical specialists – a diabetic may need other specialists such as cardiologist, ophthalmologist, renal physician, vascular surgeon.
DIABETES CYCLE OF CARE
Diabetes Annual Cycle of Care
Diabetes care needs a structure to reduce the risk of health complications. The annual cycle of care is the structure by which diabetes is managed by GP teams each year. Click here for more information. Medicare provides extra funding to enable a person with diabetes to regularly catch up with their GP and the practice nurse to perform:
- Essential monitoring (such as weight, blood pressure, blood tests, feet etc).
- Lifestyle and medication advice.
- Identify any health issues.
- Plan the focus of diabetes management in the next year, e.g. podiatry, dietitian for weight control, eye checks etc. This is subsidised by medicare by performing a diabetes care plan.
Here at EMC we have the appropriate clinical staff in place to provide high quality diabetes care based on the cycle of care structure.
Once a person with diabetes is registered at EMC we will put into place recall reminders to ensure the diabetes care plan and review as well as essential diabetes monitoring are performed annually. By doing so we hope to be able to recognise diabetes health problems and deal with them before they become critical.