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Diabetes essentials

This resource has been developed by the RCN Diabetes Forum to assist you in developing your knowledge of diabetes mellitus in adults, in order to promote safe, competent and compassionate care for people living with diabetes. 

Diabetes Essentials will also signpost you to other resources to support your learning and professional development.

Introduction

This resource has been developed by the RCN Diabetes Forum to assist you in developing your knowledge of diabetes mellitus in adults, in order to promote safe, competent and compassionate care for people living with diabetes. 

Diabetes Essentials will also signpost you to other resources to support your learning and professional development.

You can review Diabetes Essentials in its entirety, or select relevant sections to review, depending on your area of practice and your pre-existing knowledge. Where appropriate we will suggest other resources for more advanced practitioners.

This resource is designed to provide an overview of:

  • the core concepts of diabetes
  • diagnosis and current treatments
  • your role and responsibilities regarding the treatment of adults living with diabetes
  • key concepts in relation to diabetes mellitus are considered, contextualised within case studies in order to relate your learning to practice. 

We hope you enjoy this resource. Please do contact the RCN Diabetes Forum with any suggestions in relation to this resource. 

Diabetes Essentials is for all UK registered nurses, nursing associates, nursing students and allied health care practitioners working with adults. It aims to support the non-specialist practitioner to better understand the needs of people living with diabetes so that you can deliver safe and competent care to people with diabetes in daily living and during periods of illness.

It is designed to support those providing healthcare in the community, in nursing homes and during hospital admissions.

Being at the forefront of care you are ideally placed to spot symptoms of poor self-management early on and even the first signs of diabetes within an adult. You are also ideally placed to support people with diabetes in maintaining the knowledge, skills, resources, confidence and motivation they need to manage their diabetes effectively within the limits of your own competence and to direct them to other members of the MDT who can provide this care and support.

Diabetes mellitus (DM) is a common long-term health condition characterised by excess levels of glucose in the blood. In the UK, diabetes affects approximately 4.7 million people with an estimated one million unaware that they have diabetes. This means that one person in every fifteen of the population has diabetes and one in six hospital beds are occupied by a person living with diabetes.

Type 2 diabetes is the most common type of diabetes: about 90% of people with diabetes have type 2 diabetes (T2DM) about 8% have type 1 diabetes (T1DM) and about 2% have rarer types (Diabetes UK (2019) Facts and figures).

Diabetes is a condition where the amount of glucose is a person’s blood is too high because their body is unable to process this glucose properly. This could be for two reasons:

  • their pancreas does not produce any insulin or does not produce enough insulin to allow glucose to enter the cells of their body. This is called insulin deficiency.
  • the insulin they are producing does not work properly. This is called insulin resistance.

For the majority of people diagnosed with diabetes, it is a life-long condition which requires long-term motivation and competence to keep their blood sugar levels as close to normal as they are able. The role of self-management of diabetes cannot be over-emphasised. The World Health Organization estimates that 99% of diabetes-related healthcare decisions are made independently by the person with diabetes. This burden is a large part of the reason why diabetes is associated with increased rates of depression  (World Health Organization, 2007, Diabetes UK, 2019). 

Blood glucose control

Insulin is essential for life. It is a hormone produced in the pancreas. An important job that insulin does is to move glucose into cells around the body to produce the energy needed for everyday life. 

Glucose comes mainly from digesting carbohydrates. Many foods contain carbohydrates. These include starchy foods such as bread, rice, potatoes and chapattis, fruit, some dairy products, sugary food and drinks. For this reason, diet is an important part of diabetes management.

Glucose can be stored in the liver and muscles. When the blood glucose levels fall this is released again in a process known as gluconeogenesis. Glucose is also stored in body fat. This ability to store glucose to use later is what allows us to undergo periods of hunger and fasting.

Normal glucose metabolism is illustrated below.

 

Normal blood glucose

 

Abnormal glucose metabolism in diabetes 

You can think of insulin as the key which opens the glucose channel into the cells of the body. If there are not enough keys (insulin deficiency) or if the locks have become stiff so insulin cannot open them (insulin resistance) then the cells cannot use the glucose effectively and glucose levels in the blood rise above normal. 

This is called hyperglycaemia and it is important because we know that over time hyperglycaemia causes damage to the body, in particular the blood vessels.

For example this means that over a period of years if poorly controlled, diabetes can damage the eyes, kidneys and nerves as well as increasing the risk of heart disease. These are called the long-term complications of diabetes. 

Core concepts of diabetes table 

References

Types of diabetes

Types of diabetes This section looks at the different types of diabetes and how it can affect different age groups and stages in life.

In type 1 diabetes the person in no longer able to produce any insulin at all. This is because all the cells in the pancreas that produce insulin have been destroyed. These cells are called pancreatic beta-cells and are destroyed by an autoimmune process. This means that the body’s immune system attacks and destroys parts of its own tissues. In the case of type 1 diabetes, the body’s immune system destroys all the pancreatic beta-cells resulting in the complete loss of ability to produce insulin. 

The person with type 1 diabetes does not produce any insulin. This means they must inject insulin for the rest of their lives. 

Insulin is essential to life. This means their insulin injections should NEVER be discontinued. 

Stopping insulin injections in type 1 diabetes leads to a condition called diabetic ketoacidosis which is a life threatening emergency. 

type 1 diabetes table

What causes type 1 diabetes?

It is likely that the cause of type 1 diabetes is a combination two factors. Firstly some genetic variations which make the person susceptible to type 1 diabetes then something in their environment which triggers the autoimmune response. This is called an environmental trigger and an example might be catching a virus. 

The most common age for this to happen is between 10 and 14 years old. It is usually diagnosed after a short period of passing lots of urine, thirst, tiredness and weight loss. 

It is estimated that 400,000 people in the UK have type 1 diabetes (Diabetes UK, 2019).

Type 1 diabetes

This diagram is explained in this video produced by the charity Diabetes UK. See: What is Type 1 diabetes?

How is type 1 diabetes managed?

Good glycaemic control in type 1 diabetes can reduce long-term complications by up to 76% as shown in the seminal Diabetes Control and Complications Trial.

People with type 1 diabetes usually take four or five insulin injections per day. Some people with type 1 diabetes use an insulin pump. Their insulin doses must be adjusted around variables such as diet and exercise. People living with type 1 diabetes are taught to adjust their insulin on a structured education program. They are also taught carbohydrate counting.

Testing blood glucose is essential for adjusting insulin doses and avoiding hyperglycaemia and hypoglycaemia. NICE recommends testing between four and ten times per day for most people with type 1 diabetes. Some people with type 1 diabetes will wear a glucose monitoring sensor. 

People living with type 1 diabetes also need to check their ketone levels sometimes. This is because ketones can be a sign of serious illness.

People with type 1 diabetes should be cared for by a specialist multidisciplinary team usually in secondary care. Self-management of type 1 diabetes is complex and demanding, and the person living with type 1 diabetes usually knows more about this than the non-specialist health care professional. For this reason, if they are able to people with type 1 diabetes should manage their own insulin doses during a hospital admission.

Further resources

  • NICE guideline (updated 2021) Type 1 diabetes in adults: diagnosis and management. This guideline covers care and treatment for adults (aged 18 and over) with type 1 diabetes. It includes advice on diagnosis, education and support, blood glucose management, cardiovascular risk, and identifying and managing long-term complications. In July 2021, NICE reviewed the evidence and updated the recommendations on long-acting insulin therapy.

Type 2 diabetes

What causes type 2 diabetes?

Type 2 diabetes develops when the body can still produce some insulin but not enough for energy from glucose to be utilised properly, or when the cells in the body do not react properly to insulin. This is called insulin resistance.

How is type 2 diabetes managed?

The treatment of type 2 diabetes centres on lifestyle management including a healthy diet, regular exercise and the person monitoring their blood glucose level. As the condition progresses over time a number of oral glucose therapies are also used, with or without additional insulin injections and Incretin mimetics / GLP-1 analogues. Some medications help the body to use insulin more effectively whilst others increase the amount of insulin that the body produces.

Type 2 diabetes is often associated with obesity, and is also increasingly becoming more common in children, adolescents and young people of all ethnicities. Type 2 diabetes is far more common than type 1 diabetes - around 90% of all adults in the UK with diabetes have type 2 diabetes.

Type 2 diabetes risk factors include:

  • carrying too much excess body fat – especially central body fat
  • having high blood pressure or cholesterol
  • genetics: having a close family member with type 2 diabetes (mother, farther, brother or sister)
  • having previously had gestational diabetes
  • drugs such as steroids and anti-depressants
  • ethnicity: common in Asian and Afro-Caribbean.

Further resources

Non-diabetic hyperglycaemia (NDH) is a recognised condition and a growing problem across the globe. It is closely linked to obesity and is putting an increasing burden on health care systems.

NDH is defined as an HbA1c of 42-47 mmol/ml or fasting plasma glucose of between 5.5-6.9 mmol/l in the last 12 months.

People with NDH are at increased risk of developing type 2 diabetes. They are also at risk of other cardiovascular conditions. 1.3 million people in England are recorded as having NDH (NHS Digital (2019) Diabetes Prevention Programme, 2017-18 Diagnoses and Demographics).

Many people often do not know that they have NDH or indeed, may not be diagnosed with type 2 diabetes until complications develop. People may live with type 2 diabetes for up to 10 years before noticing symptoms. It is estimated that a third of adults in England may have NDH (Diabetes UK. Prediabetes).

NDH occurs when blood glucose levels exceed normal levels but do not climb high enough to warrant a diagnosis of diabetes. It can be known as Impaired Glucose Tolerance (IGT) and Impaired Fasting Glycaemia (IFG).

NDH may sometimes be referred to as pre-diabetes – some healthcare professionals avoid this term as it is indicative of an inevitable progression to diabetes, which, with intervention may be avoided. 

The 2002 Diabetes Prevention Program study showed that patients with NDH can prevent it developing into type 2 diabetes, by making changes in their diet and increasing their physical activity.

Impaired Glucose Tolerance

The patient's blood glucose level is raised beyond the normal range, but not to the diagnostic level of diabetes. Between 25% and 75% of people with IGT will develop diabetes within 10 years.

Impaired Fasting Glycaemia

The fasting blood glucose level is consistently elevated above what is considered normal, but not enough to be diagnosed as diabetes. It can progress into type 2 if lifestyle changes are not made. Information on the diagnostic ranges for IGT and IFG can be found in the diagnosis and screening section of this resource.

If your patient has NDH

If NDH is left untreated it will quickly develop into type 2 diabetes, usually in less than ten years. The average time that patients with IFG develop type 2 diabetes has been estimated to be less than 3 years (source: Progression From Newly Acquired Impaired Fasting Glucose to Type 2 Diabetes. Gregory A. Nichols, PHD1, Teresa A. Hillier, MD, MS1 and Jonathan B. Brown, PHD, MPP1).

The 2002 Diabetes Prevention Program study showed that patients with pre-diabetes can prevent it developing into type 2 diabetes by making changes in their diet and increasing their physical activity, realising a 58% reduction in the incidence rate of diabetes. Working with your patient, you can support them in their lifestyle change and encourage them to be involved in the management of their condition.

Patients with NDH have the opportunity to change their condition and early supportive action can slow down or even stop the development of type 2 diabetes.

This section of the resource aims to give a summary of the issues caused by diabetes in pregnancy. It is written for non-specialist registered and unregistered nursing and midwifery practitioners. It is designed to promote the health of women with diabetes and their babies.

This section does not replace the need for registered practitioners to be familiar with their local protocols and pathways.

All registered practitioners should be aware of the national guidelines which underpin local protocols. Some of these are signposted below in the resources section. 

Pregnancy and diabetes

Women with diabetes make up 5% of pregnancies in England and Wales. This is around 35,000 pregnancies per year (Diabetes UK, 2019).

Diabetes has a profound effect on the risks of pregnancy to the foetus and the mother. This in turn affects the care women with diabetes or a history of gestational diabetes need.

The challenge for health care professionals is to provide safe, competent care to a relatively rare but very high risk pregnancy group. Any woman with diabetes who is already pregnant should be referred to the specialist diabetes team immediately.

There are various types of diabetes affecting pregnancy:

Pregnancy and diabetes 2

*figures for England and Wales (Diabetes UK, 2019)

What are the risks of pregnancy in diabetes?

The complications of diabetes in pregnancy can be truly devastating. By planning pregnancy in diabetes and following effective care pathways from conception to delivery and beyond we have the opportunity to help women and babies avoid them.

It is helpful to understand the reasons why pregnancies in diabetes are high risk. Understanding this gives insight into the challenges women with diabetes experience during pregnancy. It also shows how important it is that the specialist diabetes team is involved in individual care planning as early as possible. Understanding the risks of pregnancy in diabetes also helps understand why planning the pregnancy is so important.

Pregnancy and diabetes 3 

These risks are explained in more detail below:

Hypoglycaemia becomes more likely as blood sugar management is tightened using insulin. To bring their HbA1c down to a target of 48mmol/mol, women aim for a blood glucose below 7mmol/l before meals when planning for, and during pregnancy. Many areas now have funding for continuous glucose monitoring during pregnancy for women with type 1 diabetes to help avoid low blood glucose. This funding does not cover preconception or other types of diabetes. This means it is important that HCPs are able to recognise the signs of hypoglycaemia and to help the woman recognise and treat these. Women using insulin must also be aware of DVLA rules for diabetes and driving.

Congenital abnormalities are more common if blood glucose is raised at conception and during the first trimester.

Birth injuries to mother and baby and macrosomia. Birth injuries are more likely in diabetes due to macrosomia. Macrosomia refers to abnormally large babies. This is due to the baby having excess nutrition during later gestation and is associated with raised blood glucose in the second and third trimesters. Large babies are more likely to suffer injuries and other complications during delivery.

Worsening diabetic retinopathy occurs in pregnancy due to the effects of tightening blood glucose control and the stresses of pregnancy on the blood vessels of the back of the eye. Retinal screening and stabilisation of retinopathy before trying to conceive are important. (Lo Wang and Shah 2016)

Pre-eclampsia occurs between 20 weeks of pregnancy and 6 weeks post-delivery. It is likely to be caused by inadequate blood supply to the placenta. The placenta keeps the foetus healthy by supplying nutrients and oxygen and removing waste products. Symptoms include high blood pressure, protein in the mother’s urine, headaches, visual disturbances and oedema to the face, hands and feet. Early detection and monitoring are important to prevent more serious complications including reduced foetal growth and maternal fitting, CVA and clotting disorders.

Miscarriage, still birth, neonatal death and birth before 37 weeks are all more common if diabetes is poorly controlled during the second and third trimesters. A miscarriage is when a baby dies before 24 weeks gestation and after this it is called a still birth. A neonatal death is when a baby dies within 4 weeks of being born. A baby born before 37 weeks gestation is considered to be premature and the earlier the birth the higher the risk to the baby of health problems (Tommys.org).

Neonatal hypoglycaemia is more common in poorly controlled diabetes during later pregnancy. If the blood supplied to the foetus through the placenta contains raised glucose then the foetus will produce more insulin. The baby will continue to produce more insulin after delivery and this can cause neonatal hypoglycaemia. This can potentially cause neonatal death and damage a baby’s neurological development (Lo Wang and Shah 2016).

How can nursing professionals support women with diabetes to plan pregnancies?

Pregnancy in diabetes should always be planned. This allows the MDT to protect mum and her baby from complications during pregnancy, delivery and beyond. Whilst all risk cannot be removed, planning a pregnancy allows mum’s and baby’s health to be protected before trying to conceive and so reduces these risks.

Pre-conception counselling should be a routine part of diabetes care for all women of childbearing age. They should all be advised to use contraception according to their preference and to approach their health care team before stopping contraception.

Preconception care for diabetes includes:

  • reducing the risk of congenital abnormalities and miscarriage
  • screening mum for complications of diabetes to manage them during the pregnancy
  • managing blood glucose to a target HbA1c of 48 mmol/mol. One barrier to this is that hypoglycaemia becomes harder to avoid as blood glucose levels are reduced
  • finding alternatives to medications known to be, or suspected of being harmful to the foetus
  • and preparing mum for the time, effort and lifestyle adjustments required for pregnancy and diabetes.

The risks of pregnancy in diabetes to the woman and her baby need to be discussed sensitively without scaring the woman. It should emphasise that her care before, during and after pregnancy is designed to reduce these risks and is based on the latest research. It is important that the woman with diabetes and her partner understand this so that they are motivated to manage the demands of diabetes treatment during pregnancy. Most antenatal clinics will see women with diabetes at least every fortnight. The time, effort and lifestyle adjustments required for pregnancy with diabetes are significant.

The woman should be referred to the specialist diabetes team for care planning and education according to the local pathway. Women often need specialist diabetes support to achieve their glucose targets before conception. They should be referred for structured education if they have not already had this opportunity.

It is important that the woman understands she should not stop using contraception until this is agreed with her health care team. She also should not tighten her glucose control rapidly until significant retinopathy has been excluded.

Blood and urine tests should be organised. These will include:

  • HbA1c (to assess current glycaemic control)
  • U+Es and urinary ACR (to assess for diabetic nephropathy)

It is also important to find out if the woman has had retinal screening in the last 6 months. If not, this should be booked. This allows significant retinopathy to be stabilised with laser therapy to reduce the risk of damage during pregnancy. She should not tighten her glucose control rapidly until this is done.

The woman will need a medication review before conception. This will include:

  • review of her medications for diabetes, hypertension, dyslipidaemia and other comorbidities. Alternatives must be prescribed for medications known to be, or suspected of being, harmful to the fetus. For diabetes this effectively means optimising blood glucose on diet, metformin and insulin.
  • as in all pregnancies, Folic Acid 5mg OD should be started prior to trying to conceive. This is to reduce the risk of neural tube defects which can affect a baby’s brain and spinal cord or spine. This is a higher dose of Folic Acid than is used in pregnancies without diabetes.

Women with diabetes will also benefit from dietary education before conception and support to lose weight if their BMI is >27. In women who do not have diabetes, the risk of gestational diabetes increases if her BMI is above 30kg/m2. Thus losing weight before conceiving can reduce her risk of gestational diabetes.

To bring their HbA1c down to 48mmol/mol women aim for a target blood glucose of below 7 before meals. This tight control increases the likelihood of episodes of hypoglycaemia. Many areas now have funding for continuous glucose monitoring during pregnancy for women with type 1 diabetes to help avoid low blood glucose. This funding does not cover the period before conception. Thus it is important that HCPs are able to recognise the signs of low blood glucose and to help the woman recognise and treat these. Women must also be aware of DVLA rules for diabetes and driving.

Further resources

References

  • Low Wang, C., and Shah, A. (2016) Medical management of type 1 diabetes. Virginia: American Diabetes Association.

This section provides a brief overview of diabetes in childhood.

The nursing care of people under the age of 18 is beyond the scope of this resource which is for the care of diabetes in adults. Resources which may be useful to those working with diabetes in children are provided at the end of this section.

Over 3000 children in the UK are diagnosed with diabetes each year meaning that 2 in every 1000 children aged 18 and younger have diabetes. 

  • 95% of children have type 1
  • 5% of children with diabetes have type 2 diabetes, cystic fibrosis related diabetes or monogenic diabetes (see table below) (NPDA, 2020).

The management of diabetes in children usually takes place in hospitals and is led by the paediatric diabetes MDT.

Diagnosis of any type of diabetes in childhood is traumatic and living with diabetes in childhood is challenging. It affects the whole family as well as the child’s schooling and leisure activities. Adolescence can be a particularly challenging time when the young person struggles to come to terms with their diabetes. They begin to manage their own diabetes as they begin to take over from their parents. Regular contact with the diabetes team is important, as is maintaining a good, non-judgemental relationship with the young person.

Most services run a joint paediatric and adult clinic between the ages of 16 and 19. They support the young person as they begin to manage their diabetes independently whilst often sitting exams and looking for employment or further education places. Many services provide a Young Adult Diabetes Service to provide extra support up to the age of 25.

Diabetes and children 

Further resources

In addition to type 1, type 2 and gestational diabetes there are other types of diabetes, which are just as important to recognise.

Rare types of diabetes account for approximately 2% of people who have diabetes. These include different types of monogenic diabetes, secondary diabetes and diabetes caused by rare syndromes. Certain medications such as steroids and antipsychotics medications could lead to other types of diabetes, as well as having pancreatic surgery.

A misdiagnosis can lead to delays in getting the right treatment. Ongoing healthcare professional education and research are crucial to ensure better diagnosis and treatments for all types of diabetes.

Rarer types of diabetes

Type 3c diabetes

Type 3c diabetes is a type of diabetes that develops when the disease and/or surgery causes damage to the pancreas. This could be due to pancreatic cancer, pancreatitis, cystic fibrosis or haemochromatosis. Type 3c diabetes can also happen when part or all of the pancreas is removed because of other damage.

Steroid-induced diabetes

Some people who require steroids to treat other conditions can develop diabetes. This is known as steroid-induced diabetes, and is often more common in people who are at higher risk of type 2 diabetes.

Latent autoimmune diabetes in adults (LADA)

LADA is a type of diabetes which seems to overlap type 1 and type 2 diabetes. Some parts of it are more like type 1, and other parts are more like type 2. That's why it is sometimes called type 1.5 diabetes or type 1 ½ diabetes.

It’s not currently defined as a separate type of diabetes as more research is needed to help identify exactly what makes it different from type 1 and type 2 diabetes.

Monogenic diabetes (MODY)

MODY is a rare form of diabetes which is different from both type 1 and type 2 diabetes and it is characterised by strong family history of diabetes. MODY is caused by a mutation (or change) in a single gene. If a parent has this gene mutation, any child they have has a 50 per cent chance of inheriting it from them. If a child does inherit the mutation, they will generally go on to develop MODY before they’re 25, whatever their weight, lifestyle, ethnic group etc.

Neonatal diabetes

Neonatal diabetes is a form of diabetes that is diagnosed under the age of six months. It’s a different type of diabetes to type 1 diabetes as it’s not an autoimmune condition (where the body has destroyed its insulin producing β cells) but caused by the single gene mutation (where the insulin producing β cells are switched off due to change in gene).

Wolfram Syndrome

Wolfram Syndrome is a rare genetic disorder which is also known as DIDMOAD syndrome after its four most common features (Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness).

Alström Syndrome

Alström Syndrome is a rare genetically inherited syndrome which has several common features including diabetes.

Cystic fibrosis diabetes

Cystic fibrosis diabetes is the most common type of diabetes in people with cystic fibrosis. Although it has features of both type 1 and type 2, it is a different condition.

Further resources

Diagnosis of diabetes

Diagnosis of diabetes This section explores the signs and symptoms to look out for and the tests that can be used when diagnosing diabetes.

Until recently type 2 diabetes was often discovered using a urine dipstick test when a person began to experience symptoms. In recent years, screening for type 2 diabetes has been expanded and now it is more often diagnosed using a blood test before any symptoms develop.

Type 1 diabetes symptoms normally develop very rapidly, sometimes over a couple of weeks. They tend to be more severe. 23% of type 1 diagnosis occur when the person presents in diabetic ketoacidosis. Type 2 diabetes symptoms are normally milder and develop gradually. These symptoms are caused by the effect of raised blood glucose levels on the body.

If the level of glucose in the blood becomes too high, excess glucose is removed from the blood by the kidneys and excreted via the urine (glycosuria). This results in greater urine production and causes the patient to urinate frequently. This may also lead to frequent episodes of thrush. Water held in the cells is required to replace lost blood volume and further causes dehydration and thirst.

Symptoms of type 1 diabetes:

  • polyuria - the need to urinate frequently
  • polydipsia - increased thirst & fluid intake
  • polyphagia - increased appetite
  • weight loss
  • tiredness.

Other major symptoms include:

Blurred vision - a change in glucose absorption can bring about a change in the shape of the lens in the eye, leading to an altered vision quality. This can cause blurred vision, a common complaint that can indicate type 1 or type 2 diabetes.

Diabetic ketoacidosis - diabetic ketoacidosis occurs when the body begins to break down stores of fat as an alternative source of energy, leading to a build-up of acids in the blood known as ketones. This can result in weight loss and muscle wasting. Diabetic ketoacidosis is a rare and acute complication of diabetes, often requiring admission to ITU / HDU. Diabetic Ketoacidosis can result in coma and possibly death if left untreated. Symptoms of type 1 diabetes can develop quickly, over weeks or even days.

Symptoms of type 2 diabetes:

In type 2 diabetes the signs and symptoms are not always obvious as the condition usually develops slowly over a period of years. It may only be picked up in a routine medical check-up. The common symptoms are:

  • tiredness
  • poor healing process
  • malaise
  • sometimes weight gain or weight loss
  • thirsty and nocturia
  • dry mouth.

Thirst and polyuria will develop as hyperglycaemia progresses, particularly in the elderly. It is important to be vigilant for the signs and symptoms of diabetes as early diagnosis and treatment can reduce the risk of developing complications later. Many people have type 2 diabetes for years without knowing it because early symptoms can be general.

If you or your patient suspects that these symptoms may indicate diabetes then it needs to be correctly diagnosed before treatment can be given. It is important to be vigilant for the signs and symptoms of diabetes and non-diabetic hyperglycaemia when treating patients, and to diagnose as early as possible so that treatment can be started. In the case of NDH, early diagnosis could mean that Type 2 diabetes can be prevented. Once somebody is diagnosed with diabetes, they should be entered onto their GPs diabetes register to ensure they begin the diabetes care pathway.

Diabetes is often missed in the elderly. A range of diagnostic approaches are outlined below:

HbA1c

Glycated haemoglobin is the chemical that carries oxygen in red blood cells, which also has glucose attached to it. It differs from a blood glucose level as it provides a longer-term average reading (approximately three months – the lifespan of a red blood cell). The HbA1c test is usually done in hospital or a GP clinic and then sent to a laboratory and is usually checked at six monthly intervals. Increasingly, instant readings may be obtained at new ‘point of care’ testing stations.

HbA1c has become the most common method of diagnosing diabetes, as recommended by the World Health Organisation (WHO). It primarily measures the levels of HbA1c in the blood to identify the average plasma glucose concentration over the previous six to twelve weeks. The test measures a part of the amount of blood glucose attached to haemoglobin. The test gives a good indication of an average blood glucose control as it reflects periods of higher blood glucose e.g. following meals and periods of lower blood glucose e.g. following exercise.

Red blood cell and glucose

A blood sample is required. An HbA1c of 48mmol/l (6.5%) or more is a diagnosis of diabetes in most situations. HbA1c is also used to monitor diabetes in a patient and will normally be done every two to six months. Patients with diabetes aim to lower the HbA1c level to below a target level, normally around 48-53 mmol/mol (6.5% - 7.0%, NICE guidelines 2018). However, individualisation of the target goal level will be negotiated between the patient and their diabetes team as the levels may vary for each patient, e.g. in the elderly and frail. Attempting to maintain a low HbA1c may place an elderly or frail patient at risk of hypoglycaemia and falls.

When it cannot be used:

  • children and young people
  • if patient is suspected of having type 1 diabetes
  • patients has symptoms of diabetes for less than two months
  • patients who are acutely ill
  • if patient is taking medication that may cause rapid glucose rise, for example steroids
  • patient has acute pancreatic damage, including pancreatic surgery
  • pregnancy.
  • patients with abnormal red blood cells such as Thalissaemia.

Random blood glucose test

In a medical emergency, when a patient (most often a child) has such high glucose levels that they are drifting in and out of a coma, a blood glucose reading can be found by taking a blood sample to measure the glucose with no consideration to when the last meal was eaten. A level of 11.1 mmol/L or more in the blood sample indicates diabetes. A further blood glucose test will need to be done to confirm the diagnosis.

Fasting blood glucose test (FBG)

The FBG test is taken using a blood sample obtained following a period of fasting (so no food or drink, except water) of at least eight hours. The fast normally starts from midnight. A sample of blood is taken early the next day, before food or drink. A level of 7.0 mmol/L or more after an overnight fast indicates diabetes. To confirm the diagnosis, it is usually necessary to repeat the test a second time on a different day.

Oral glucose tolerance test (OGTT)

For this test the patient fasts from midnight and then a baseline fasting blood glucose test is taken. The patient then consumes a drink that contains 75g of glucose (lucozade is normally used)– recent reductions in the sugar content of certain drinks should be checked to ensure the correct dose is administered. Two hours later the blood glucose level is measured again. This test is different from the others as the patient drinks a sugary drink as a way of measuring how effectively the pancreas secretes insulin to manage the glucose load. In a person without diabetes glucose levels rise and fall quickly, as the body naturally produces insulin to lower the blood glucose. A person with diabetes will see a sharp rise and a sustained high level of glucose during this test. This is because the pancreas is unable to deliver the insulin needed to lower the glucose in the blood. A blood glucose level of 11.1 mmol/L or more in the blood sample taken after two hours indicates diabetes.

Urine test for glucose

A simple dipstick test can detect glucose in a sample of urine. In a dipstick test, a doctor or nurse uses a special chemical strip that is dipped into a sample of the patient's urine. Colour changes on the strip show whether there is glucose in the urine sample. Some people have kidneys that are more 'leaky' and glucose may leak into urine with a normal blood level. If a patient's urine contains any glucose a blood test should be carried out to measure the blood level of glucose to confirm, or rule out, diabetes.

Whether a fasting glucose, random glucose or HbA1c is used to test for diabetes it will generally need to be repeated as there should be evidence of two results using the same testing method to confirm diagnostic testing.

Diagnostic values

According to the World Health Organization, someone may have diabetes if they have:

  • an HbA1c of 48mmol/l (6.5%) or above is a diagnostic of diabetes in most situations (2 tests 3 months apart)
  • a fasting blood glucose of 7 mmol/L or more, OR
  • a blood glucose 11.1 mmol/L or more after a 2-hour oral glucose tolerance test. (GTT).

Someone has impaired glucose tolerance if they have:

  • a fasting blood glucose of less than 7 mmol/L, AND
  • a blood glucose of 7.8 mmol/L or more but less than 11.1mmol/L after a 2-hour oral GTT (where a person is fasted and then given a quantity of glucose to observe the pancreatic response to raised blood glucose).

Someone has impaired fasting glycaemia if they have:

  • a fasting blood glucose between 6.1 to 6.9 mmol/L, AND
  • a blood glucose of less than 7.8 mmol/L after a 2-hour oral GTT.

Prevention, treatment and self-management

Prevention, treatment and self-management This section looks at the different aspects of preventing, treating and managing diabetes.

NHS Diabetes Prevention Programme

There are currently five million people in England at high risk of developing type 2 diabetes – if trends continue then by 2034, one in ten will develop type 2 diabetes (NHS England, 2021). 

There is strong international evidence that behavioural interventions can significantly reduce the risk of developing the condition, through reducing weight, increasing physical activity and improving the diet of those at high risk (NEJM, 2001).

diabetes prevention food exercise

The NHS Diabetes Prevention Programme (NHS DPP) aims to target those identified at high risk and refers them to a behaviour change programme – those at risk are also able to self-refer. Eligibility criteria to join the programme are people aged over 18 with non-diabetic hyperglycaemia (NDH).

NDH is defined as having an HbA1c 42 – 47 mmol/mol (6.0 – 6.4%) or a fasting plasma glucose (FPG) of 5.5 – 6.9 mmol/l. The blood result indicating NDH must be within the last 12 months to be eligible for referral and only the most recent blood reading can be used.

Referral routes into the programme vary according to local pathways. Primary mechanisms for referral are:

  • Those who have already been identified as having NDH and have been included on a register of patients with high HbA1c or FPG.
  • The NHS Health Check programme, which is currently available for individuals between 40 and 74. NHS Health Checks includes a diabetes filter, those identified to be at high risk through stage 1 of the filter are offered a blood test to confirm risk.
  • Those who are identified with non-diabetic hyperglycaemia through opportunistic assessment as part of routine clinical care.

Individuals can also complete a risk calculation online and self-refer for further evaluation to commence the programme.

The programme runs for nine months and provides support to achieve a healthier weight, improve nutrition and increase physical activity. Delivery of the programme varies by geographical area.

Typically, the programme offers support to participants via:

  • initial 1-2-1 assessment with a health and well-being coach
  • attendance at a local group programme, which consists of nutritional guidance and support, strategies to enable long term progress and physical activity sessions and advice
  • an end of programme 1-2-1 review with a health and well-being coach to celebrate success and consolidate learning.

Reversal of type 2 diabetes – diabetes ‘remission’

The DiRECT study (Diabetes Remission Clinical Trial) aimed to determine whether a structured weight management programme delivered in a realistic primary care setting was a viable treatment for producing remission of type 2 diabetes. Results showed that some people with type 2 diabetes can become non-diabetic again, at least for a period. A remission of diabetes will allow the patient to stop taking anti-diabetic drugs. This is important as the drugs are inconvenient and can cause side effects. The impact of remission on future health could be highly significant.

Further resources

Whilst lifestyle advice remains the cornerstone of diabetes management, the addition of pharmacological treatments for diabetes helps people to control blood glucose levels, reduce cardiovascular risk factors and minimise the risk of developing long term complications.

Treatment for type 1 diabetes

Type 1 diabetes is characterised by an absolute lack of insulin production within the beta cells of the pancreas therefore insulin replacement therapy is an essential treatment to preserve life. Various insulin types, regimes and delivery devices (see insulin section) are available and are prescribed in conjunction with a treatment plan that centres on the individual needs and goals of a person. This should include a structured education program including dietary advice, carbohydrate counting, home blood glucose monitoring, activity, psychological health and the use of technology. This helps support the person with T1DM to adjust their insulin doses around their diet and other daily acitivites which affect their blood glucose. 

Insulin must never be stopped in people with type 1 diabetes. Metformin may be prescribed to support insulin therapy and more rarely SGLT-2 inhibitors (see medication section for more information).

Treatment for type 2 diabetes

Type 2 diabetes is a condition characterised predominately by insulin resistance. At diagnosis it may be possible for a person to reduce or maintain their blood glucose levels within an agreed target range and control the symptoms of type 2 diabetes by following a healthy diet and taking regular exercise. However, type 2 diabetes is a progressive condition and there may be a need to take prescribed diabetes medication alongside lifestyle measures to reduce high blood glucose levels. An important part of their treatment is structured group education to improve the knowledge and skills about managing their diabetes. 

Treatments for type 2 diabetes are available in both tablet and injectable preparations. Metformin is typically the first medication prescribed for people with type 2 diabetes. Other common groups of diabetes medications include:

  • SGLT-2 
  • DPP-4 inhibitors
  • Sulphonylureas
  • GLP-1. 

Over time, many people with type 2 diabetes will also require insulin therapy, often in combination with some of the medications above. This is because insulin resistance can be followed by a gradual loss of ability to produce adequate insulin by the pancreas. It is important to remember this does not change the type of diagnosis and should be referred to as insulin treated type 2 diabetes. 

Treatment plans should always be agreed in collaboration with the person with diabetes and tailored to suit their lifestyle needs and goals. Type 2 diabetes is most effectively controlled when a person is involved in the management of their own programme of treatment. Effective 'self-management' is essential to successfully achieving healthy targets for HbA1c, blood pressure and cholesterol levels. A typical management plan may include one or a combination of the following:

  • diabetes structured education
  • monotherapy - Oral medication such as metformin 
  • combination therapy (See references below for “What next after metformin”)
  • injectable GLP-1 and / or insulin therapy.

When deciding on medications it is important to consider the persons pre-existing conditions such as heart failure (consider SGLT-2 with proven benefit), cardiovascular disease (consider GLP-1 or SGLT-2 with proven benefit) and chronic kidney disease (consider SGLT-2 if eGFR allows). The documented benefits and efficacy of newer diabetes medications can support treatment choices whilst also improving long term outcomes for people with diabetes. Other clinical considerations include the need to reduce weight (consider SGLT-2 or GLP-1), minimise risk of hypoglycaemia (avoid sulphonylureas and insulin) and cost implications. 

Maintaining blood glucose control and reducing cardiovascular risk is vital in minimising the risk of diabetes complications and therefore it is important that treatments are initiated and titrated proactively in response to deteriorating glycaemic control.

Further resources

Interventions which improve diet and lifestyle have been shown to delay the onset of type 2 diabetes and to improve risk factors related to long term complications (Ley et al, 2014).

NHS Diabetes Prevention Programme

There are currently 5 million people in England at high risk of developing type 2 diabetes – if trends continue by 2034, one in ten will develop type 2 diabetes (NHS England, 2021). The NHS Diabetes Prevention Programme (NHS DPP) aims to target those identified at high risk and refers them to a behaviour change programme – those at risk are also able to self-refer. Eligibility criteria to join the programme are as follows: Individuals eligible for inclusion have ‘non-diabetic hyperglycaemia’ (NDH), defined as having an HbA1c 42 – 47 mmol/mol (6.0 – 6.4%) or a fasting plasma glucose (FPG) of 5.5 – 6.9 mmol/l. The blood result indicating NDH must be within the last 12 months to be eligible for referral and only the most recent blood reading can be used. Only individuals aged 18 years or over are eligible for the intervention. Referral routes into the programme vary according to local case finding pathways. Primary mechanisms for referral are:

  • Those who have already been identified as having an appropriately elevated risk level (HbA1c or FPG) in the past and who have been included on a register of patients with high HbA1c or FPG.
  • The NHS Health Check programme, which is currently available for individuals between 40 and 74. NHS Health Checks includes a diabetes filter, those identified to be at high risk through stage 1 of the filter are offered a blood test to confirm risk.
  • Those who are identified with non-diabetic hyperglycaemia through opportunistic assessment as part of routine clinical care.
  • Individuals can also complete a risk calculation online and self-refer for further evaluation to commence the programme.

The programme runs for nine months and provides support to achieve a healthier weight, improve nutrition and increase physical activity. Delivery of the programme varies by geographical area.

Typically, the programme offers support to participants via:

  • initial 1-2-1 assessment with a health and well-being coach
  • attendance at a local group programme, which consists of nutritional guidance and support, strategies to enable long term progress and physical activity sessions and advice
  • an end of programme 1-2-1 review with a health and well-being coach to celebrate success and consolidate learning.

Nutritional management

Effective management of nutrition is recommended as an integral component of education and clinical care for those at risk of developing or living with any type of diabetes. Input from a registered dietitian should be offered to all people living with diabetes and those deemed to be at high risk of developing type 2 diabetes. The following recommendations are adapted from Diabetes UK. These recommendations can be used to develop individualised nutrition and activity plans.

Nutritional recommendations for the prevention of type 2 diabetes

  • target weight loss of 5%
  • restrict energy intake
  • reduce total and saturated fat intake
  • increase fibre
  • increase physical activity
  • include wholegrains, some fruit, green leafy vegetables
  • reduction in red and processed meat, potatoes, sugar sweetened beverages and refined carbohydrates (CHO)
  • multi component lifestyle interventions which are culturally sensitive to reduce risk in ethnic minority groups.

Recommendations for glycaemic control and type 2 diabetes

  • aim for 5% weight loss in those who are overweight by reducing calories consumed and increasing energy expenditure
  • aim for a Mediterranean style diet or equivalent
  • offer individualised support to identify and quantify CHO intake, encourage low glycaemic index (GI) foods and consider reducing amount of total CHO. Low GI food take longer to breakdown raising blood glucose levels steadily and may be associated with improved HbA1c.

Healthy foods

Recommendations for glycaemic control and type 1 diabetes

  • education to support people with type 1 diabetes should be offered to identify and quantify dietary and CHO intake for glycaemic control specifically
  • adjust insulin to CHO intake in people using multiple daily injections or insulin pumps (carbohydrate counting)
  • aim for consistent quantities of CHO on a day-to-day basis in people on fixed insulin regimes.

Further resources

Diabetic foods

People living with diabetes should avoid foods labelled as ‘diabetic’ / ‘suitable for diabetics’ as there is no role or benefit from the use of diabetic foods. ‘Diabetic’ foods have been a feature in many chocolate, sweets, biscuits, and bakery ranges available in a variety of high street outlets such as supermarkets, pharmacies and “health food shops” as well as being widely available on the internet. As ‘diabetic’ foods can be just as high in calories and fat, continued consumption of these foods can contribute to weight gain and increase an individual’s susceptibility to other health conditions, for example, heart disease and stroke (DUK / European Commission).

Carbohydrate counting

While people with type 2 diabetes are taught to be aware of the size of their carbohydrate intake, people with T1DM need a more exact measure called carbohydrate counting. Carbohydrate counting helps them to optimise their blood glucose control by adjusting their insulin doses. CHO can be counted in two ways, in grams or as CHO portions (CP). One CP is usually equal to 10g of carbohydrate.

Insulin-to-carbohydrate ratios (Insulin-CHO ratio) are different from person to person, depending on age, weight, activity levels and how sensitive the person is to insulin.

The diabetes healthcare team will help the person with T1DM diabetes to work out  their insulin-CHO ratio and, eventually, a different ratio may be set for each meal. They will usually estimate the starting insulin-to-carb ratio and then fine-tune this based on blood glucose control.

Once the quantity of CHO of a meal and the insulin-carb ratio are known, then the insulin bolus dose for that meal can be calculated.

If the meal had 70g of carbohydrate and the Insulin -CHO ratio was 1 unit of bolus insulin for every 10g carbohydrate, then 7 units would be given for that meal.

The amount taken will also depend on other factors such as current blood glucose level, illness or planned physical activity.

See: BERTIE Type 1 Diabetes Education Programme. BERTIE is a diabetes education course that teaches people with type 1 diabetes how to manage insulin doses, matching them to carbohydrate intake, and live life on a day to day basis.

Alcohol

Alcohol in moderate amounts can be enjoyed safely by most people with T1DM and general advice about safe alcohol intake (14 units or less per week) should be applied. However, alcohol intake is associated with an increased risk of hypoglycaemia for those taking insulin. Pragmatic advice for those who wish to continue to consume alcohol would be insulin dose adjustment, additional carbohydrate or a combination of both. Alcohol is contraindicated for those with hypertension, hypertriglyceridemia, some neuropathies, retinopathy and during pregnancy.

For more information, see: Alcohol

Smoking

There is a long established, clear link between smoking and the risk of developing type 2 diabetes due to increasing insulin resistance, caused by cellular damage. Increased insulin resistance caused by smoking, means those with already established type 2 diabetes may require intensification of diabetes medications (including insulin). Persistently elevated blood glucose levels caused by increased insulin resistance, leads to significant long-term complications affecting major organ systems within the body (Joshu and Tibbs, 1999).

People living with diabetes should be encouraged to stop smoking and educated as to the multiple health benefits. People living with diabetes can be referred to the local stop smoking services.

For more information, see: Smoking cessation

Older people with diabetes

Some older persons with diabetes may experience poor nutritional status with physical, social and psychological factors affecting intake. Education should continue to be offered to older persons, including dietary intervention – age should not restrict access. Dietetic input is key to assess nutritional status and formulate individualised care plans which take into account the changes in nutrients that are required as the body ages. Guidelines and care planning should be further adapted for those living with dementia with a focus on maintaining nutritional intake and preventing malnutrition.

Ramadan

Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith. Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The European Association for the Study of Diabetes consensus recommendations emphasise the importance of patient factors and comorbidities when choosing diabetes medications including the presence of comorbidities, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, hypoglycaemia risk, weight issues and costs. Structured education and pre-Ramadan counselling are key components to successful management of patients with diabetes. These should cover important aspects like glycaemic targets, self-monitoring of blood glucose, diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast.

Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycaemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and foetal outcomes. Hypoglycaemia is a common concern during Ramadan fasting. To prevent hypoglycaemic and hyperglycaemic events, the adoption of diabetes self-management education and support principles are recommended. The use of the emerging technology and continuous glucose monitoring during Ramadan could help to recognize hypoglycaemic and hyperglycaemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier (Ibrahim et al, 2020).

Summary guidance for fasting during Ramadan

Structured education programmes

A number of structured education programmes are available for those living with diabetes.

DESMOND

DESMOND - Diabetes education and self-management for ongoing and newly diagnosed is group-based education which aims to support people with a diagnosis of type 2 diabetes and work with them to self-manage their condition, through a structured education programme to target lifestyle modification and behaviour change which can be culturally adapted. These programmes are delivered virtually or in-person over one whole or two half days.

Content includes:

  • thoughts and feelings of the participants around type 2 diabetes
  • understanding diabetes and glucose: what happens in the body
  • understanding the risk factors and complications associated with diabetes
  • understanding more about monitoring and medication
  • how to take control – Food Choices – Physical Activity
  • planning for the future

DAFNE

DAFNE Dose adjustment for normal eating, aims to help adults with type 1 diabetes lead as normal a life as possible, whilst also maintaining blood glucose levels within healthy targets, to reduce the risk of long-term diabetes complications. DAFNE educates people with type 1 diabetes about their condition, insulin use and CHO counting.

Education programmes will vary depending on geographical location.

Reversal of type 2 diabetes

Inspired by the results from the ground-breaking Diabetes Remission Clinical Trial (DiRECT) study, the year-long programme aims to help people recently diagnosed with diabetes lose weight and put their condition into remission.

For three months, people with type 2 diabetes provided with low-calorie total diet replacement products, such as shakes and soups. After this, they’ll be supported to reintroduce solid foods and maintain their weight loss.

Alongside making changes to their diet, people taking part in the programme will also be provided with support to increase their exercise levels. And they’ll be able to take part in virtual one-to-ones and group sessions throughout the year too.

Recommendations for weight management and remission for people living with type 2 diabetes:

  • for overweight or obese people with Type 2 diabetes
  • for remission, aim for weight loss of 15kg as soon as possible after diagnosis – this may be achieved by total diet replacement or meal replacement plans providing 800-1200 Kcal per day for 12 weeks
  • to improve glycaemic control and CVD risk, aim for at least 5% weight loss achieved by reducing calorie intake and increasing energy expenditure.

Physical Activity

Increased physical activity is associated with a 25-40% reduction in the relative risk of developing type 2 diabetes (Aune et al, 2015).

Weight management, physical activity and exercise have numerous benefits for people with type 2 diabetes – improving blood glucose control, cardiovascular risk factors and well-being. Target activity should be at least 150 minutes per week of moderate to vigorous physical activity over at least 3 days.

In type 1 diabetes, physical activity can improve cardiovascular fitness leading to a reduction in CVD and mortality. However, there is limited evidence of improved glycaemic outcomes, and whilst exercise will reduce blood glucose levels, it is also associated with increased hypo and hyper glycaemia. For planned exercise, reduction in insulin is the preferred method to prevent a hypo. For unplanned exercise, additional CHO may be required.

Diabetes UK has produced a number of information prescriptions which assist the health care professional to educated the person living with, or at risk of developing diabetes. 

For more information, see: Physical activity

See also sections on Medication and Wellbeing.

Treatment for diabetes aims to help people with the condition to control their blood glucose levels and minimise the risk of developing complications over time.

Treatment for type 1 diabetes

Lack of insulin production by the pancreas makes type 1 diabetes particularly difficult to control. A management plan defined by the diabetes team that centres around the needs and goals of a person typically includes dietary advice and maintaining a constant health weight, home blood glucose monitoring and exercising regularly. Unfortunately, the treatment cannot eliminate the need for insulin or reverse the disease.

Insulin

All patients with type 1 diabetes will need to have daily insulin injections as their body is unable to produce any insulin. The injections come in the form of a syringe, insulin pen or insulin pump.

Syringe

Insulin syringe

Insulin pens

Insulin pens

Insulin pump

Insulin pump

The reason that insulin is injected is because if it were taken as a tablet, it would be broken down in the stomach and would not enter the blood stream. When a person is first diagnosed, the diabetes team will teach them the correct procedure for their injections. This involves showing them when, where and how to inject themselves and how to adjust insulin doses. They will explain how to store the insulin and safely dispose of the needles.

The team will also discuss the management of diabetic emergencies, such as hypoglycaemia and information relating to sick day rules, and driving a vehicle or operating machinery. The person will be educated about insulin dosing and safety. Each person who is taking insulin may carry an 'Insulin Passport' or 'Insulin Safety Card'.

Insulin passport

Insulin passport

Treatment for type 2 diabetes

It is possible for a person to initially control the symptoms of type 2 diabetes by following a healthy diet, taking regular exercise and keeping their blood glucose levels within an agreed target range. Type 2 diabetes is a progressive condition so they may eventually need to take diabetes medication which will usually be in tablet form. A treatment programme will be tailored to suit the person's needs by the diabetes team and will typically include one or a combination of the following:

  • changing to a healthier diet
  • medication such as metformin
  • injectable GLP-1
  • insulin therapies.

Keeping blood glucose levels under control is vital in reducing the risk of diabetes complications. If a person is overweight, weight loss can often help to reduce the extent of diabetes symptoms. Type 2 diabetes is effectively controlled when a person is involved in the management of their own programme of treatment. Effective 'self-management' is essential to successfully achieving their healthy targets for HbA1c, blood pressure and cholesterol levels. A person with type 2 diabetes may need (or eventually need) medication that reduces high levels of blood glucose. In the first instance this will usually be glucose-lowering tablets (sometimes a combination of more than one type of tablet) and it may also include injectable insulin. Some oral medications for lowering blood glucose levels can cause hypoglycaemia for example, Gliclazide, Glipizide and Glimpiride.

As research in diabetes continues, new and more effective medication are becoming available that assist with weight reduction and improve blood glucose level control in some people with type 2 diabetes without causing hypoglycaemia. Oral medication include: Sitagliptin, Linagliptin and Saxagliptin (Alogliptin and Vildagliptin). Injectable therapies (GLP-1) include: Exenatide, Liraglutide Semaglutide, Dulaglutide exenatide (bydureon), a once weekly preparation.

Further resources

Self-management

Diabetes is one of the few serious medical conditions for which the outcome relies almost entirely on the person’s ability to self-manage. This is why structured group education and individualised care plans are so important to improve peoples ability and confidence to manage their own diabetes.

People living with diabetes need on-going advice and support about maintaining a healthy diet, keeping active and monitoring their health. People living with diabetes spend around three hours per year with a healthcare professional; for the remaining 8,757 hours they must manage their diabetes themselves’. Diabetes can be a burden, but, most people can live relatively normal active and healthy lives and even small adjustments to their lifestyle can make significant improvements. Most diabetes management relies on a person 'self-managing' the condition, so their motivation is a major consideration regarding effective treatment. The health care professional can support the person to identify and set realistic goals and planning smaller steps to achieve and maintain these goals. The health care professional also has an important role in assessing selfcare abilities and referring the person for further support where a gap is identified.

All patients should have their blood glucose levels checked by a health care professional every two to six months. The diabetes health care team should discuss the patient’s blood glucose levels with them and agree a target range with them. Many people with diabetes monitor their blood glucose levels at home using a simple finger prick blood test. They may need to do this several times a day, depending on the type of treatment that they are receiving.

Patients who use insulin – that is all with type 1 diabetes and some with type 2 – should usually test their blood glucose three to ten times per day depending on how difficult their blood glucose levels are to control. This allows them to judge the effectiveness of their previous dose of insulin and helps them to determine the amount of insulin needed for their next dose. Patients with type 2 diabetes should test their blood glucose levels at least once a day, although not all type 2 patients, like those treating their condition through diet or using metformin, need to monitor and it will be down to their own self-management programme which is has been agreed with their diabetes team.

Careful monitoring of blood glucose levels will reveal individual patterns of blood glucose changes. This can help the person with diabetes to see if the treatment programme is working, help plan their meals and activities and to make the necessary amendments if required. Regular testing allows for a quick response to high blood glucose (hyperglycaemia) or low blood glucose (hypoglycaemia). This response could include insulin and adjustments to diet and exercise regimes. It is vital that the patient understands the importance of regular testing. Many patients claim to know when their blood glucose levels are too high but unfortunately this is often not the case. The way that they feel is generally not an accurate guide to what is happening unless their blood glucose levels are very high.

Nurse listening to patient

Emotional well-being and mental health

The impact of diabetes on the person, and the level of self-management required can significantly affect emotional well-being and mental health. As mentioned above people with diabetes spend on average, three hours a year with a health care professional and the remaining 8757 hours managing diabetes themselves. People with diabetes are twice as likely to suffer from depression and are more likely to be depressed for longer and more frequently. Around 40% of people with diabetes struggle with their psychological well-being often because of the demands of the disease. It is important to recognise how cultural and socio-economic factors can increase the burden of diabetes. The NHS spends an extra 50% treating the physical health of someone who has type 2 diabetes and poor mental health compared to someone with type 2 and no mental health problems. For people without diabetes, having depression increases someone’s risk of type 2 diabetes by 60%.

Diabetes specific psychological disorders

  • diabetes distress occurs in 42% in people with T1D, 36% in T2D. Assessment of emotional distress should not be addressed as a separate co-morbid ‘condition’ that is diagnosed and treated only when detected
  • needle phobias, injecting fear
  • eating disorders – affect >30% of women in their early 20’s with T1D
  • 64% of people with diabetes feel down and 1/3rd are interested in counselling from a trained professional.

Factors which impact on emotional wellbeing across type 1 and 2 diabetes

 

Type 1 and 2 

Diabetes distress

Diabetes distress is a natural and rational emotional response to living with a demanding, long-term condition. People feel frustrated, defeated and/or overwhelmed by diabetes. All feelings are focused on diabetes so outwardly an individual may not seem unhappy. It’s not the same as depression - where people feel negative about themselves, others and the future - and it’s not a ‘disorder’. Multi-national studies estimate that at highest levels, diabetes burnout affects 44% of people diagnosed with type 1 or type 2 diabetes. And it’s been consistently linked with higher HbA1c levels. Diabetes ‘burnout’ is a state of physical and emotional exhaustion caused by the continuous stress and efforts to self-manage diabetes. Distress may be a natural reaction to having managed their diabetes over a long period of time - without a single day off.

Distress / burnout may coincide with a particularly demanding time for example relationship difficulties, family stress or bereavement. When these events happen, diabetes may naturally be seen as a low priority. Developing diabetes-related complications can be the motivation some people need, but others find themselves asking ‘What’s the point?’ and wondering why it’s even worth trying.

Diabetes distress / burnout can be indicated by the following symptoms:

  • feeling overwhelmed and defeated by diabetes
  • feeling angry about diabetes and frustrated about the demands of managing it
  • feeling as though diabetes is controlling the person’s life
  • worrying about not taking enough care of diabetes but unmotivated or unwilling to change
  • avoiding parts of the diabetes routine e.g. attending appointments, testing
  • not caring about blood sugar levels
  • reverting to unhealthy behaviours e.g. poor diet
  • feeling alone and isolated with diabetes.

As clinical psychologist, Dr William Polonsky, describes, ‘they are at war with their diabetes – and they are losing it’.

Management of diabetes distress may include:

  • explaining what diabetes distress is and that many people with diabetes experience it
  • explaining the signs and consequences of diabetes distress (e.g. the impact on their daily self-management and well-being)
  • acknowledgement of the significant daily efforts required to manage diabetes – this by itself may reduce the distress
  • 'normalise’ negative emotions about diabetes
  • use a validated tool in line with local policies and procedures
  • explore the most appropriate support for the individual, for example, diabetes education or revising their management plan, advice on lifestyle changes, emotional or social support, or a combination of these
  • if a decision is made to refer, consider a diabetes specialist health professional for difficulties with diabetes management and support or a mental health professional, a psychologist or psychiatrist (preferably with an understanding of diabetes) for stress management or if other emotional problems such as depression or anxiety or more complex psychopathology are underlying the diabetes distress.

Psychological Disorders and Diabetes

People with underlying mental health issues or psychological disorders are at higher risk of diabetes. Medications such as antipsychotics can increase the risk of type 2 diabetes by as much as 60% and many of the atypical antipsychotics have impaired glucose tolerance as a side effect, this is often due to weight gain caused by medications.

As patients get older the risk of diabetes also increases, meaning patients with dementia or Alzheimer's are also often at risk. These conditions can be challenging as patients may lack insight into understanding their diagnosis of diabetes, meaning it is harder to get them to consent to any treatment or to accept treatment on a regular basis leading to increased risk of complications.

Eating disorders and Intentional Insulin Restriction (‘Diabulimia’)

Among people with diabetes, the full syndrome eating disorders are rare. The most common disordered eating behaviours are binge eating and insulin restriction/omission but prevalence is not well established. Eating problems in people with diabetes are associated with sub-optimal diabetes self-management and outcomes, overweight and obesity, and impaired psychological well-being.

Intentional insulin restriction (IIR) or omission for the purposes of weight loss is sometimes referred to a ‘Diabulimia’ – IIR is the preferred clinical term. Estimates of insulin omission have been reported in up to 40% of people with type 1 diabetes. People may also omit or restrict insulin for other reasons than weight loss (e.g. fear of hypoglycaemia). Eating disorders are associated with early onset of diabetes complications and higher morbidity and mortality.

Evidence for the management of eating disorders in combination with diabetes is very limited. Thus, in practise, generally eating disorder treatments are applied to address the needs of people who are living with both conditions.

Healthcare professionals in both primary and secondary care should:

  • consider emotional and psychological support as part of the remit of the whole multidisciplinary team
  • ensure they have adequate training and supervision to identify psychological problems in people with diabetes and deliver an appropriate level of proactive support as part of ongoing diabetes care, including through the care planning process
  • be familiar with the emotional and psychological support services available to their patients both locally and through national organisations such as Diabetes UK.
  • deliver a diagnosis of diabetes without blame or stigma, and give sources of support and information at diagnosis. Time should be allowed to agree a care plan.
    (DUK, 2019a)

Having a quality conversation about emotional health and diabetes 

It’s important to ask people about their emotional health at every appointment. Just because everything may seem okay the first time you ask, this can change over time. Don’t think of this as an added extra. If someone is struggling emotionally, they’re going to find looking after their diabetes much more difficult (Diabetes UK, 2019b)

Top tips

Step 1 – Opening up the conversation

Ask “How are you feeling?”

Step 2 – Making the most of the conversation

Gain insight before the appt, open questions, active listening, reflection, info prescriptions, positive language, use of time, validated scales / tools

Step 3 – Safely closing the conversation

Agreeing actions at the patients pace, ask them to summarise, ‘what questions do you have?’, End on a positive, emphasis on importance of well-being, refer as necessary.

Language matters

The language used by healthcare professionals can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it day-to-day. At its best, good use of language; verbal, written and non-verbal (body language) which is more inclusive, and values based, can lower anxiety, build confidence, educate and help to improve self-care. Conversely, poor communication can be stigmatising, hurtful and undermining of self-care and have a detrimental effect on clinical outcomes. The language used in the care of those with diabetes has the power to reinforce negative stereotypes, but it also has the power to promote positive stereotypes (NHS England,2018).

Top tips

  1. Recognise that some words, phrases and descriptions are potentially problematic, whatever the intention of the user.
  2. Use language (including tone and non-verbal gestures) that is:
    -  free from judgment or negative connotations, particularly trying to avoid the threat of long-term consequences or scolding (‘telling off’); is inclusive and values based          language.
    -  person-centred, (also known as ‘person first’)to avoid labelling a person as their condition.
    -  collaborative and engaging, rather than authoritarian or controlling.
  3. Review the use of common expressions and what underlying attitude they may convey,
    regardless of intention.
  4. Avoid language which attributes responsibility (or blame) to a person for the development of their diabetes or its consequences.
  5. Avoid language that infers generalisations, stereotypes or prejudice, or links one individual with previous experience of others of a similar background or in a similar
    situation.
  6. Use or develop an empathic language style which seeks to ascertain a person’s point of
    view of their condition, rather than assume.
  7. Listen out for a person’s own words or phrases about their diabetes and explore or acknowledge the meanings behind them.
  8. Become alert to the use of language, and non-verbal communication i.e. body language and recognise if it may be creating a negative effect.
  9. Consider how to limit any negative effects from language used, both for yourself and
    with others around you.

Further resources

There are over currently over 30 different insulin preparations available which fall in to the following main types: 

Insulin graphs

 

Insulin is used to manage blood glucose levels in various regimes which can include single insulin types or insulins used in combinations. Typical insulin regimes fall into the following:

Basal

  • Basal insulins are often given once a day, often at night to control pre breakfast blood glucose levels.
  • Insulin Glargine (Lantus), Insulin Detemir (Levemir), Insulin Degludec (Tresiba), and U300 Toujeo 300 Units/mL have the advantage of greater predictability, potentially less weight gain, and lower risk of hypoglycaemia, particularly at night compared to intermediate acting insulin.
  • They can be given as a basal insulin or in a Basal Bolus regimen.
  • Basal insulin alone is suitable for type 2 diabetes. 

Basal plus

  • These regime’s often progress from basal insulin regimes’ and introduce 1 or 2 injections of rapid acting insulin with meals to prevent blood glucose levels rising after food. 

Basal bolus or multiple daily injections (MDI) 

  • MDI is a combination of basal insulin once daily and rapid acting insulin with each meal. 
  • This regime is suitable for people with type 1 and type 2 diabetes. 

Mixed

  • Mixed insulins contain a proportion of rapid or short acting and a proportion of intermediate acting insulin. 
  • The number following the name of the insulin identified the proportion or rapid or short acting insulin (E.g. NovoMix 30 indicates that the proportion of rapid acting insulin with in the mixture is 30%) 
  • This regime is suitable for people with Type 1 and Type 2 diabetes but is more restrictive than MDI. 

Appropriate insulin regimes should be decided in partnership with the person with diabetes, focusing on their lifestyle, considering when they eat, activity levels, occupation and if they are able to self manage or will require support with administration. 

Appropriate training should be provided and should include but is not exclusive to: 

  • insulin type and how it works in relation to meals
  • administration 
  • device
  • storage
  • sharps disposal 
  • driving 
  • management of hypoglycaemia 
  • blood glucose monitoring 
  • self-titration (if appropriate).

High strength insulins

All insulin is available in a concentration / strength of 100 units/ml. This should be the most commonly prescribed insulin strength and always used for new insulin starts.

Some manufacturers have developed insulin with a higher strength formulation e.g. 200 units/ ml & 300 units/ml. These offer the same insulin action but in less volume and can be very useful for patients on doses greater than 40 units to help with insulin absorption and lower the risk of lipohypertrophy (lumpy injection sites).

These insulins only are available in pre-filled pens to ensure that the correct dose: volume concentration is given. The patient still dials to the same dose but a different volume is given.

Biosimilar insulins

Biosimilar insulins are a biological copy that is not identical but demonstrates similarities to the original product in terms of quality, efficacy, cost and safety.

Some of the currently available biosimilar insulins are Abasaglar and Semglee. These are not interchangeable and therefore it is important that insulin is prescribed by brand name.

More biosimilar insulin products are soon to be available in the UK.

Insulin should be initiated and managed by people with suitable knowledge and qualifications. If required you may need to refer people who require insulin to your local Diabetes Specialist Team. 

Further resources

  • Diabetes on the Net. The six steps to insulin safety. An essential module for all those prescribing, managing or administering insulin, with the overall aim of reducing insulin errors in clinical practice. Its focus is on insulin use within the primary-care setting.

Testing and monitoring

Testing and monitoring This section looks at testing and monitoring blood glucose levels.

The measurement of blood glucose provides information on the effectiveness of blood glucose metabolism and guides interventions to achieve optimal glucose control within the body.

Diabetes can be managed by carefully monitoring some key indicators for each individual. NICE (NICE, 2018) recommends that people with diabetes undertake nine annual health checks. It is vital that people with diabetes receive all nine of these key health tests and measures. These checks help to monitor and manage their condition as well as reduce the risk of complications such as stroke, heart disease and amputations.

The nine annual health checks for people with diabetes are:

  • weight and body mass index measurements
  • blood pressure
  • smoking status
  • blood test (HbA1c – blood glucose levels)
  • urinary albumin test (or protein test to measure the kidney function)
  • serum creatinine test (creatinine is an indicator for renal function)
  • cholesterol levels
  • eye check (retinopathy screening)
  • foot check. (NICE 2018)

In addition to the nine annual health checks, Diabetes UK has identified '15 Healthcare Essentials'. These have been highlighted so that people with diabetes and health care workers know what care people with diabetes should expect. These 'Healthcare Essentials' should also be undertaken annually or as required in the case of specialist care needs.

The '15 Healthcare Essentials' can be considered under four categories of:

  • blood tests
  • physical checks
  • advice and support
  • specialist care.

NICE guidelines for the UK currently recommend the following targets (the target blood glucose ranges below are indicated as a guide). See: NICE (updated 2020) Type 1 diabetes in adults: diagnosis and management

Children with Type 1 diabetes 

  • fasting plasma glucose level of 4–7 mmol/l on waking
  • plasma glucose level of 4–7 mmol/l before meals at other times of the day
  • plasma glucose level of 5–9 mmol/litre after meals (NICE 2020)

Adults with Type 1 diabetes 

  • fasting plasma glucose level of 5–7 mmol/L on waking
  • plasma glucose level of 4–7 mmol/L before meals at other times of the day
  • for adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating (NICE 2020)

Type 2 diabetes (Diabetes UK Council of Healthcare Professionals 2015)**

  • before meals: 4–7mmol/l
  • two hours after meals: less than 8.5mmol/l.

Pregnant women with diabetes 

  • fasting plasma glucose below 5.3 mmol/l
  • plasma glucose level below 7.8 mmol/l 1 hour after meals
  • plasma glucose level below 6.4 mmol/ l of 2 hours after a meal (NICE 2020)

Pregnant women on insulin, should also be advised to keep their blood glucose above 4 mmol/litre, because of the risk of hypoglycaemia.

When should blood glucose levels be measured?

The number of times per day the individual with diabetes should measure their blood glucose levels will vary from patient to patient depending entirely on their condition. The following is a useful general guideline however it doesn't apply to everyone and each case should be given individual advice.

Individuals with type 1 diabetes using insulin should check their blood glucose levels before every meal, sometimes as often as ten times per day.

Individuals with type 2 diabetes may measure their glucose levels if they are taking medications that can lead to hypoglycaemia (such as insulin and sulfonylurea). The frequency varies depending on the medication they are taking.

Type 2 diabetes is a progressive condition and even with metformin and diet only, individuals may need to test their blood glucose periodically to observe trends in rising blood glucose.

Wearable glucose monitoring sensors

There are two types of wearable glucose monitoring technologies; intermittently scanned flash glucose monitoring and continuous glucose monitoring which are described in this section. They are only funded by the NHS for people with type 1 diabetes who meet NHS England criteria.

Healthcare professionals who will be working with flash and continuous glucose monitoring are directed to these webinars. It is important you are able to help your patients access wearable glucose monitoring devices appropriately, interpret their data and improve their glycaemic outcomes.

Flash Glucose Monitoring

Intermittently scanned Flash glucose monitoring (flash-GM) is a newer from of blood glucose testing available to people with type 1 diabetes who meet NHS England criteria. Unlike finger-prick blood glucose testing, flash-GM measures a person’s interstitial glucose. This means the glucose levels in the body tissues below the skin. NICE recommends finger-prick testing up to 10 times per day but by scanning their sensor regularly flash-GM can give the person’s continuous glucose results (NICE 2016.)

How does it work

A sensor the size of a £2 coin sits on the back of the arm with a probe just under the skin.

Flash GM and continuous glucose monitoring

An overview of flash-GM

  • Flash-GM requires an interstitial sensor the size of a £2 coin and a receiver. The sensor is self-inserted into the upper arm and lasts up to 14 days. It is attached to the body with clinical adhesives. It transmits glucose data to a receiver when it is scanned. The receiver may be a handset or the user’s mobile phone and it stores and displays their data.
  • By scanning or 'flashing' the sensor with a scanning device or mobile phone the person can observe:
    a) glucose level
    b) a graph of glucose level for the last 8 hours
    c) a direction or ‘trend’ arrow showing if levels are going up or down. The device also stores your data and makes it easy to view patterns over time.
  • Various apps and software are available to present this data to the user and clinician using the cloud. They can then review and respond to glucose patterns.
  • Interstitial glucose lags behind capillary blood glucose by 5-7 minutes. This means that when blood glucose is changing rapidly the measurements will differ. For this reason during episodes of hypoglycaemia patients and clinicians must revert to finger-prick testing.
  • A new version of flash-GM (Libre2)  has an optional alarm connected via Bluetooth to warn the wearer if their blood glucose is going too low. Scanning is still required to see the actual blood glucose level and trend arrow.
There is currently only one flash-GM device licenced in the UK and it can be seen being used here.

Advantages

  • relatively painless insertion
  • reduction in frequency of finger pricking
  • easier to identify trends and improve control
  • ability to test more regularly
  • easier than finger-pricking in lots of situations (on transport, in rain, in cold, during sport, driving)
  • less social stigma than finger pricks
  • modest impact on glucose monitoring costs for people with type 1 using intensive insulin regimes. Flash may even confer savings regarding potential reductions in severe hypogylcaemia
  • some people preferred the arm as a location rather than stomach
  • some people like that it does not alarm, however, this functionality has been added to the updated device – ‘Flash 2’
  • data can be downloaded for the user to view values and trends and uploaded for clinician review of ambulatory glucose profiles
  • has been proven to improve HbA1c
  • in 2019 the DVLA allowed the use of ‘flash’ as an alternative to finger prick testing to check blood glucose levels while driving.

Disadvantages

  • it can give inaccurate readings if blood glucose levels are changing rapidly and is likely to over-estimate hypoglycaemia
  • must be scanned at least every 8 hours to provide an ambulatory blood glucose profile
  • some users have reported reactions to the adhesive
  • costs are around £1300 per year
  • a finger prick blood glucose must still be used to check erroneous readings and also to manage hypoglycaemia if symptoms do not match readings. 

Continuous Glucose Monitoring

Continuous glucose monitoring (CGM) works in a similar way to intermittently scanned flash-GM with a sensor, transmitter and receiver as described above. There are several CGM systems licenced in the UK for example Dexcom G6, Medtronic CGM. The main differences between flash GM and CGM are:

  • CGM systems do not need to be scanned by the wearer. The glucose data is automatically transmitted to the handset and to the cloud in ‘real-time
  • CGM systems have various alarms which can be individualised to alert the person living with type 1 diabetes that they need to take action to adjust their blood glucose – the blood glucose level is displayed in real time alongside the alarm. 
  • some CGM systems are licenced to link to an insulin pump and use the data to adjust some the persons insulin doses for them using an AI algorithm.

CGM is more costly than flash-GM and so funding is reserved for people who have tried all cheaper treatment options but still suffer 1 or more of the conditions listed below (NICE 2016):

  1. cannot avoid serious hypoglycaemia (that means blood glucose so low that another person is needed to help bring it back up to normal)
  2. cannot avoid frequent hypos
  3. have lost their warning signs of low glucose. This means they cannot treat and prevent hypos
  4. cannot get their HbA1c below 75mmol/mol
  5. or suffer from extreme fear of having hypos. This is measured using a validated questionnaire. 

Further resources

What is Diabetic ketoacidosis (DKA)

Diabetic ketoacidosis (DKA) is an acute medical emergency. It is mainly seen in people with T1DM however does occur in type 2 diabetes particularly when SGLT2 inhibitors are being taken. If an individual with diabetes has sustained high blood glucose readings, it is an indication that there is not have enough insulin in their system, or that the insulin that they have is not working properly.

When this happens, it is possible that their body will start breaking down fat and proteins in order to get energy for metabolic processes. As ketones build up in the body, a state of ketoacidosis occurs, or in diabetes, Diabetic Ketoacidosis (DKA). The body cannot function properly in a state of acidosis. The person may initially experience nausea, vomiting and fatigue. As symptoms progress the person may begin to exhibit deep and fast breathing, confusion and the breath may smell of pear drops or nail varnish. Normal levels of ketones are usually considered to be <0.6 and these levels may be seen in people without diabetes eg when fasting for long periods.

If the acidosis is not corrected, this may lead to coma and in rare cases, death. (Diabetes UK) See Diabetes and acute illness, sick day rules section.

Access to ketone testing is recommended for all individuals with type 1 diabetes. NICE (2020) recommends testing for ketones if fasting or premeal blood glucose levels become  unusually high - usually above 11 mmol/l for an unknown reason (such as illness, dehydration or abdominal pain). Ketone testing is also recommended for lower blood glucose if the person feels unwell.

Abnormal ketones can occur in people living with diabetes if:
  • they forget or decide not to take their insulin
  • they are unwell of injured
  • they are using ‘flozin’ (SGLT2) tablets to manage their diabetes

Testing for ketones in this way can help detect the problem at an early stage. This allows for advice and treatment to be given before the level of ketones in the blood becomes dangerous.

The table below gives advice on when you should check for ketones however local policies will vary and should be followed.

Test ketones

Ketones can be measured in two ways:

Urine - This involves dipping a urinalysis test strip in urine and the strip changes colour depending on the amount of ketones detected. It is usually recorded as +, ++, +++ or ++++.

A result of 2+ or more mans there is a high chance of DKA.

Blood – This involves a finger prick and using a blood ketone meter (similar to a blood glucose meter).

Blood Ketone Levels:

< 0.6mmol/l = normal

0.6-1.5 mmol/l - slightly increased risk of DKA – test again in 2 hours

1.6-2.9 mmol/l - increased risk of DKA – contact GP / Diabetes team ASAP

3 mmol/l or more - very high risk of DKA – immediate medical help required.

(NICE, 2020)

Blood ketone testing is considered more accurate because the level of ketones in urine reflects the length of time the urine has been in the bladder.

Urine ketone testing is cheaper. Urine ketone testing might be preferred when a person does not want to have to do another finger prick, for example if they are testing for ketones very frequently.

How to perform a ketone test

1. Assemble the required equipment to perform the urinalysis

- clock or timer or stop watch
- clean surface
- tissue/absorbent paper
- non-sterile gloves (+/- plastic apron)
- urine specimen
- test strips
- clinical waste bag.
 
2. Check the test strips are inside the stated expiry date.

3. Check the urine sample is fresh - observe the colour and odour. Cloudy urine may indicate the sample is contaminated or infection is present. A strong fishy smell may indicate infection and a sweet odour like pear drop sweet may indicate ketones are present.

4. Check the sample is from the correct person and note any medications they are taking (as some medications may affect the result).

5. Wash hands and apply gloves/apron.

6. Remove a test strip from the bottle and replace the lid.

7. Immerse the full length of the test strip in the urine sample, ensuring all the test pads are covered. Remove excess urine on the lip of the sample bottle.

8. Place the test strip on the tissue/absorbent paper to prevent the colours on the pads contaminating each other.

9. Start the timer/note the time.

10. Replace the lid on the urine specimen.

11. When the appropriate amount of time has passed, align the test pads with the corresponding result gauge on the test strip bottle.

12. Be sure to line the pads up with the corresponding test on the container. This is where most errors with urine testing are made!

13. Remove your glove and record the result of the urine test in the person’s medical record. Report any abnormal result to a senior nurse, the diabetes care team or the person’s doctor as appropriate to your role and care setting.

14. Dispose of all equipment in the clinical waste bag.

15. Wash your hands.

Each individual with diabetes in entitled to an 'annual review'.

The following will usually be discussed at the annual review:

  • medical history and general health
  • medication review
  • specific needs or cultural preferences may be discussed
  • advice and support, including details about support groups
  • offering an educational course regarding the management of diabetes
  • diet and lifestyle advice
  • blood pressure monitoring
  • blood glucose monitoring
  • HbA1c check and agreeing individualised
  • explaining about the symptoms, risks and treatment of hypos
  • discussing cardiovascular disease and risk
  • ensuring annual retinal screening is completed
  • foot checks
  • checking for other long-term complications that can be caused by diabetes, such as problems with your kidneys or nerves
  • pregnancy should be discussed (if appropriate) including information about contraception and family planning.

Further resources

Diabetes Prevention Programme

Many cases of Type 2 diabetes are preventable and there is strong international evidence that behavioural interventions can significantly reduce the risk of developing the condition, through reducing weight, increasing physical activity and improving the diet of those at high risk. To help reduce the risk of developing Type 2 diabetes, the Diabetes Prevention Programme has been developed.

Individuals eligible for inclusion have ‘non-diabetic hyperglycaemia’ (NDH), defined as having an HbA1c 42 – 47 mmol/mol (6.0 – 6.4%) or a fasting plasma glucose (FPG) of 5.5 – 6.9 mmol/l. The blood result indicating NDH must be within the last 12 months to be eligible for referral and only the most recent blood reading can be used. Only individuals aged 18 years or over are eligible for the intervention. 

Further resources

Diabetes complications

Diabetes complications This section looks at managing short term and long term diabetes complications.

Short term (acute) complications

Uncontrolled diabetes can cause metabolic imbalance leading to acute complications that may require immediate medical attention. Hyperglycemia (high levels of glucose in blood) sets the stage for protein glycation, which in turn may lead to chronic conditions requiring constant monitoring and treatment. Individuals with diabetes may also develop high cholesterol and high blood pressure, which require medical management.

Acute complications 

Acute complications will require immediate medical intervention.

Hypoglycaemia

Hypoglycaemia occurs when blood glucose levels is below 4mmol/l. A hypoglycaemia episode can happen quickly therefore it is important to understand the signs and symptoms and treat hypoglycaemia correctly. People will experience different symptoms, but the most common symptoms are sweating, feeling shaky, being anxious or irritable, feeling disorientated, blurred vision, headache, palpitation and fast pulse rate.

Diabetes Ketoacidosis (DKA)

DKA is a serious and life-threatening complication of type 1 diabetes caused by absolute or relative insulin deficiency leading to severe hyperglycaemia with ketosis (fat metabolism). Rare cases occur (1:1000) in acutely unwell people with type 2 diabetes taking SGLT2 inhibitors. Patients in DKA require high intensity nursing usually within HDU / ICU. 

Insulin is a peptide hormone secreted by the pancreas which enables cellular uptake of glucose, thus maintaining blood glucose levels and proper cellular function. 

Absolute lack of insulin means, despite high levels of glucose in the blood, it cannot be utilised by the cells of the body to fuel cellular processes. As DKA progresses, levels of glucose in the blood increase, but this glucose cannot be utilised by the cells which need it. 

Cells may also  be deprived of glucose if the amount of food intake is low (such as during illness). 

When cells cannot obtain energy from glucose, cells start using fats as a source of energy. Liver cells produce ketone bodies from fatty acids. When blood glucose levels are low, brain cells can use ketone bodies, but not free fatty acids, for energy. High concentrations of ketones can make the urine acidic and cause fruity-smelling / acetone breath. If not managed, this condition can progress to coma (prolonged unconsciousness) and even death. 

Causes of DKA include: 

  • complete or relative lack of insulin
  • conditions increasing levels of stress hormones e.g. 
    - acute illness 
    - MI 
    - infections 
    - surgical emergencies
    - high dose steroids  
    - pancreatitis.
  • errors of Insulin administration or deliberate omission (30%)
  • new onset of type 1 diabetes (23 %).

Symptoms of Diabetes Ketoacidosis (DKA)

Symptoms of DKA 
Signs of severe DKA include:
 
  • Venous bicarbonate <5mmol/L
  • pH <7.0
  • Ketones > 6mmol/L
  • Hyperventilation
  • Hypotension (systolic BP <90)
  • Depressed conscious level (document GCS) 
  • BLOOD GLUCOSE IS NOT A GOOD GUIDE TO SEVERITY.

Measurement of ketones

Measurement of ketones can provide an effective estimation as to the severity of DKA.

 

Blood ketone advice table

 

All of these must be present to make the diagnosis: 

  • The ‘D’ – a blood glucose concentration of >11.0 mmol/L or known to have diabetes mellitus 
  • The ‘K’ – The ‘K’ – a capillary or blood ketone concentration of >3.0 mmol/L or significant ketonuria (2+ or more on standard urine sticks) 
  • The ‘A’ – a bicarbonate concentration of <7.3

Management of DKA is complex - updated guidelines have been published by the Joint British Diabetes Societies, and endorsed by the RCN. The guidance contains a single page treatment pathway for DKA.

Hyperosmolar hyperglycaemic state

Hyperosmolar Hyperglycaemic State (HHS) occurs in people with Type 2 diabetes who experience very high blood glucose levels (often over 40mmol/l). It can develop over a course of weeks through a combination of illness (e.g.i nfection) and dehydration (Diabetes UK). High blood glucose level triggers increased urination. If liquids are not replaced, the individual can become severely dehydrated. High blood glucose levels can lead to altered mental states, confusion, seizures, coma, and even death.

Further resources

The long term complications of both type 1 and type 2 diabetes are caused by chronic hyperglycaemia. Chronic hyperglycaemia causes both direct and indirect effects to the vascular system. The damaging effects can lead to microvascular complications and macro vascular complications.

Every week diabetes leads to more than 680 strokes, 530 heart attacks and almost 2000 cases of heart failure. A person with diabetes is 2.5 times more likely to have a heart attack and or heart failure and 2 times more likely to have a stroke (Diabetes UK, 2019).

Microvascular complications

Diabetes nephropathy

At least 10,350 people in the UK have end stage kidney failure disease because of diabetes. Diabetes nephropathy or kidney damage develops slowly over many years. High levels of blood glucose can cause the small blood vessels of the kidneys to become leaky and blocked. When this happens the kidneys will work less efficiently. In severe cases this can lead to kidney failure and the need for a kidney transplant. More than one in three people who need kidney dialysis or a transplant have diabetes. One in five people with diabetes will need treatment for kidney diseases during their lifetime.

Diabetes retinopathy

Retinopathy is damage to the retina and is a complication that can affect anyone who has diabetes. Retinopathy is caused by damage to the blood vessels of the light-sensitive tissue at the back of the eye (retina). It is the most common cause of blindness among people of working age in the UK. When a patient is first diagnosed with diabetes they should be offered an appointment for eye screening for retinopathy with a special digital camera. They should then be sent for regular yearly eye tests. As with all complications of diabetes, the sooner any retinopathy problems are detected and treated the greater the chance of the treatment being successful. Treatment consists of laser surgery which will preserve the sight of the patient but will not make it better. The better the blood glucose levels are controlled, the less chance the patient has of developing serious eye problems.

Diabetes neuropathy

Over time, high blood glucose levels, high fat levels such as triglicerides in blood can cause damage to nerves. Hyperglycaemia damages nerves in the peripheral nervous system. Damage to the nerves of the feet can mean that small cuts and breaks in the skin, or damage caused by ill-fitting shoes are not noticed. This can lead to one in ten patients with diabetes developing a foot ulcer, which can ultimately cause a serious infection. Patients should be advised to check their feet every day looking for sores and cuts that aren’t healing along with puffiness, swelling and skin that feels hot to the touch. The patient should be advised to report any changes to a health care professional or podiatrist. They should have a foot examination at least once a year (In patients with diabetes should have their feet inspected on a daily basis and others such as those on renal replacement therapy should have their feet inspected whenever they attend the dialysis unit). High levels of blood glucose can damage the tiny vessels of the nerves. This can cause tingling or burning pain spreading from the fingers and toes and up through the limbs or loss of sensation. If this affects the nerves in the digestive system it could lead to nausea, vomiting, diarrhoea or constipation.

Macrovascular complications

Macrovascular complications affect larger blood vessels, such as those supplying the heart, brain, and extremities. The causes of these complications stem from narrowing of blood vessels due to glycation, inflammation, lipid deposition and other factors. Complications resulting from large vessel damage may lead to cardiomyopathy, stroke, rheumatoid arthritis, osteoporosis, and the degenerative process of aging (Singh et al., 2014). The major concern amongst these complications is myocardial infarction (heart attack). At present, it appears that blood glucose control does not significantly reduce the risks or delay the onset of macrovascular complications. Additional medical management is required.

Coronary artery disease (leading to myocardial infarction /heart attack)

Long term, poorly controlled blood glucose levels increase the likelihood of a person developing atherosclerosis (hardening and narrowing of the blood vessels). This could lead to poor blood supply to the heart, causing angina. The chance that a blood vessel in your heat or brain will become completely blocked, causing a heart attack or stroke is also increased. In addition to atherosclerosis, there is strong evidence of increased platelet adhesion and hypercoagulability in type 2 diabetes that promote platelet aggregation.

Cerebral vascular accident (CVA)

Diabetes is a strong independent predictor of risk of CVA as in coronary artery disease. People with type 2 diabetes have a much higher risk of stroke (Lehto et al, 1996).

Peripheral arterial disease (PAD)

Peripheral arterial disease occurs when fat deposits build up on the walls of the blood vessels of the lower extremities. PAD is a major risk factor for lowr-limb amputation. The most common symptom of PAD is intermittent claudication, cramping or aching in the calves, thighs or buttocks. Diabetes and smoking are the strongest risk factors for PAD. People with diabetes who have PAD are more prone to neuro ischemic ulceration (ADA, 2003).

Other complications

Miscarriage and stillbirth

Pregnant women with diabetes have an increased risk of miscarriage and stillbirth. There is an increased risk of the baby developing a serious birth defect if blood glucose levels are not carefully controlled in the early stages of pregnancy. Antenatal check-ups for pregnant women with diabetes usually take place in hospital or in a diabetic clinic. Here health care professionals can keep a close eye on blood glucose levels. Women planning a pregnancy would need to take a stronger dose of folic acid than is available over the counter. This should ideally be taken three months prior to conception.

Also all women of child bearing age with diabetes need pre-pregnancy counselling on an annual bases – the pregnancy should be planned if possible as diabetes medications may need to be changed pre-pregnancy to optimise diabetes control before conception. Where control is poor, the patient should be advised against becoming pregnant because the risks to the mother and baby are greater. Some blood pressure treatments are contraindicated in pregnancy and would need to be changed or stopped pre-conception.

Gestational diabetes is a type of diabetes, which affects women usually in the second or third trimester. Diabetes is not present before pregnancy and usually goes away after delivery. It is caused by pregnancy hormones affecting insulin use in the body. Women with GD are at an increased risk of type 2 diabetes in later life and should be monitored in order to prevent progression to type 2 diabetes.

Sexual dysfunction

Damage to the nerves and blood vessels can lead to erectile dysfunction in men with diabetes, particularly those who smoke. This can be treated with medication. Sometimes women with diabetes can experience a reduced sex drive, reduced pleasure from sex, lack of vaginal lubrication, reduced ability to orgasm or painful sex. A vaginal lubricant or water-based gel may prove helpful for women experiencing a lack of vaginal lubrication or painful sex. Sexual dysfunction is an often overlook element of the care of people with diabetes and practitioners should address this with their patients during consultations. 

Further resources

References

Diabetes and acute illness

Diabetes and acute illness This section looks at how to manage diabetes when feeling unwell.

People with diabetes are at greater risk of infection and serious complications as a result in comparison to the general population (Diabetes Care, 2018).

Similarly, illnesses and infections affect the blood glucose levels often causing the levels to rise and make their condition worse. Thus it is important for the person with diabetes to recognise the signs and symptoms of underlying illness and seek prompt advice from their GP or local pharmacist to manage this.

Healthcare professionals and others involved need to know what to do and how to monitor blood glucose levels to keep the diabetes under control. Extra insulin is sometimes necessary, so healthcare professionals and people with diabetes need to know how to manage the ‘sick day rules’.

Blood glucose levels may rise even where people are not eating their normal food or drink.

If unsure, always refer to the Diabetes Specialist for advice or seek urgent medical help:

  • if the healthcare professional and/or person with diabetes is not sure what to do
  • if the person with diabetes is persistently vomiting (not able to hold down any food or drink for more than six hours), they can quickly become very dehydrated
  • if blood glucose levels remain high or ketone levels continue to rise despite interventions.

Type 1 diabetes

Key points

  • insulin should never be stopped
  • insulin doses may need to be increased and/or additional doses of fast acting/rapid insulin may be necessary to bring down blood sugars levels. A Diabetes Specialist will be able to prescribe an insulin adjustment table
  • blood glucose levels should be checked at least every two to four hours
  • encourage the person to drink clear sugar free fluids to avoid dehydration
  • food can be taken in alternative forms, for example sugary drinks, boiled sweets, or glucose tablets.

What should be the aim for blood glucose levels when a person with diabetes is ill?

Aim: Blood glucose target between 6-10mmol/L

Testing 

  • if the blood glucose levels stay above 10mmol/L follow the individual prescribed guideline by the Diabetes Specialist for increasing their insulin dose
  • extra blood glucose testing will be necessary. Glucose levels will need to be tested every two to four hours and every two hours if blood glucose levels remain high.

Ketones

  • everyone with type 1 diabetes should have urine ketone testing strips or a ketone meter at home to check high blood glucose levels
  • healthcare professionals working in a hospital ward will be able to perform a simple urine test or use a blood ketone meter to test ketone levels
  • moderate to high urine or blood ketones levels will usually indicate that blood glucose levels are high and extra insulin is needed.

Ketoacidosis - also known as Diabetic ketoacidosis (DKA)

People with diabetes need the correct amount of insulin in their body at all times. The extra demands of illness mean their need for insulin will increase, even if they are not able to eat. If there is not enough glucose getting into the cells of the body, fat stores are used as an alternative source of energy.

Because the body can’t burn up fat very efficiently, by-products known as ketones are given off. Ketones are acids and therefore make the blood “acidic”. Not getting enough insulin at this time and if it is left untreated can result in ketoacidosis, and the person with diabetes may become seriously unwell. If the person doesn’t respond to treatment at home within six hours they may need to be treated in hospital.

Symptoms of ketoacidosis include:

  • blood glucose over 15 mmol/L
  • ketones in your urine or/and blood
  • thirst
  • passing large amounts of urine (this leads to dehydration)
  • tiredness
  • abdominal pain.

A person with diabetes should seek urgent help if they have the following symptoms:

  • vomiting
  • rapid breathing
  • reduced level of consciousness (drowsiness).

When the person has recovered from their illness and their blood glucose levels are back to normal, It is important to remember to reduce the insulin dose back to the usual dose to prevent hypoglycaemia.

Type 2 Diabetes

When blood glucose levels are high a person will usually experience the following symptoms:

  • thirst/dry mouth
  • passing large amounts or urine (this can lead to dehydration)
  • tiredness
  • weight loss.

Type 2 Diabetes on tablets

People with type 2 diabetes on tablets should keep taking their medication unless advised otherwise.

Metformin or/and SGLT2 or/and GLP-1 only

If a person has a severe infection or is becoming dehydrated they need to temporarily stop taking Metformin or/and SGLT2 tablets or/and GLP-1. They should seek advice from their GP or Diabetes Specialist team. They may need a different treatment for their diabetes until they can re-start their Metformin tablets.

Metformin or/and Sulphonylurea

The most commonly used Sulphonylurea tablets are called Gliclazide. Sulonylurea tablets can cause the blood glucose to fall too low. A person with diabetes may have been provided with blood glucose testing equipment to check if their blood glucose has fallen too low, i.e. hypoglycaemia. Recommend delete or clarify They will need to routinely monitor their diabetes. Blood glucose levels can also be checked once in hospital. If the person is ill their blood glucose levels will usually rise. In this instance blood glucose levels will need to be tested more frequently, at least two to four times per day.

Their medication may need to be temporarily increased to control blood glucose levels until they are better.

Type 2 Diabetes and Insulin

People with Type 2 diabetes on insulin must:

  • be provided with equipment to test their own blood glucose levels at home or/and once in the hospital
  • aim to keep their blood glucose levels between 6 and 12mmol/L
  • If their glucose levels remain above 12mmol/L when they are ill, they must follow advice on increasing insulin doses from the Diabetes Specialist
  • extra blood glucose testing will be necessary. Glucose levels will need to be tested every four hours especially if blood glucose levels are high (over 14mmol/L).

Ketones

If the persons blood glucose gets too high, (over 14mmol/L) they may need a urine test for ketones, (hospital policies may vary). People with Type 2 diabetes are not routinely prescribed urine ketone testing strips to test for ketones themselves at home.

Insulin and tablets

If a person with type 2 diabetes has a severe infection or is becoming dehydrated they may need to stop taking Metformin tablets or/and SGLT2 or/and GLP-1 alongside the insulin. They should continue taking the insulin and urgently seek medical advice from the GP or/and Diabetes Specialist team or/and call 111. 

If the person is taking a Sulphonylurea tablet (Gliclazide) they should either continue their normal dose, or increase the dose as advised by the Diabetes Specialist team.

The maximum dose of tablets is:

  • Metformin 500mg, two tablets (1 gram) twice daily 
  • Gliclazide 80mg, two tablets (160 mg) twice daily.

Managing insulin doses during illness for Type 2 diabetes

  • monitor and record blood glucose levels at least four times a day ( at mealtimes event if not eating and at bed time)
  • if blood glucose levels are consistently higher than 14mmol/l the insulin doses may need to be increase, seek immediate advice from the Diabetes Specialist Team/GP.

Further resources

Guidance for patients

What do we know about COVID-19 

  • coronaviruses are a large family of viruses which may cause illness in animals or humans
  • there are many types of human coronaviruses including some that commonly cause mild upper-respiratory tract illnesses
  • COVID-19 (CoronaVIrus Disease - 2019) is caused by a novel (or new) coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
  • SARS-CoV-2 is the seventh coronavirus known to infect humans
  • this is a new disease which has not previously been seen in humans. 

Groups with a greater risk include:

  • people age over 70 and older
  • people who live in nursing homes.

Other high-risk conditions could include:

  • people of any age with severe obesity (BMI >40 kg/m2) or certain underlying medical conditions, particularly if not well controlled, such as those with diabetes, renal failure, or liver disease might also be at risk
  • people with chronic lung disease or moderate to severe asthma
  • people who have serious heart conditions
  • people who are immunocompromised including cancer treatment
  • pregnant women should be monitored since they are known to be at risk with severe viral illness.

Some facts about COVID-19 and diabetes

  1. people with diabetes are not more likely to get COVID-19 than the general population
  2. diabetes is one of the high-risk groups for developing severe illness from COVID-19
  3. people with type 1 diabetes have an increased risk of developing diabetic ketoacidosis if infected with viral or bacterial infections
  4. the risk of mortality remains low under the age of 40
  5. the death rates of people with diabetes doubled during the early phase of the pandemic
  6. people with T1D and T2D, men, BAME ethnicity or living in more deprived circumstances are at a higher risk of mortality
  7. tight glycaemic control and low BMI are also risk factors of mortality with COVID-19
  8. in both T1D and T2D, those with pre-existing kidney disease, heart failure and previous stroke are at a higher risk of mortality
  9. hyperglycaemia and obesity are linked to increased risk of mortality.

Management of people with diabetes infected with COVID-19

  • patients should follow the advice of the GP or/and Diabetes Specialist Team on adjustments to their anti-diabetic medication(s)
  • blood glucose levels should be frequently checked (generally, every 2-4 hours, keeping records)
  • management of COVID-19 infection by patient and HCPs should follow diabetes sick day rules appropriate to any other infections
  • patients should be aware of signs and symptoms of hyperglycaemia. 

General sick day rules

  • patients are advised to drink lots of fluids to stay hydrated. To avoid dehydration, patients should have small sips every 15 minutes or so throughout the day if they are having trouble keeping water down
  • hands should be washed, and injection/infusion and finger-stick sites should be cleaned with soap and water or rubbing alcohol
  • recommendations of local authority should be followed if suspected of COVID-19 symptoms.

Out-patient care

  • prevention of infection in diabetes
  • sensitisation of patients with diabetes for the importance of optimal metabolic control
  • optimisation of current therapy if appropriate
  • caution with premature discontinuation of established therapy
  • tilisation of Telemedicine and Connected Health models if possible to maintain maximal self-containment.

In-patient or intensive care unit

  • monitor for new onset diabetes in infected patients (in-patient care)
  • management of infected patients with diabetes (intensive care unit)
  • plasma glucose monitoring, electrolytes, pH, blood ketones as per local guideline
  • follow local guideline for the indication of early intravenous insulin therapy in severe cases and for the exact titration and management.

Therapeutic aims (follow your local guideline)

  • plasma glucose concentration: 4-8 mmol/L
  • HbA1c < less than 53 mmol/mol (7%)
  • CGM/FGM targets of 4-10 mmol/L
  • preventing Hypoglycaemia <3.9 mmol/L.

Consideration of potential metabolically interfering effects of drugs in suspected or COVID-19 positive patients with type 2 diabetes

Metformin

  • dehydration and lactic acidosis will probably occur if patients are dehydrated, so patients should stop taking the drug and follow sick day rules
  • during illness, renal function should be carefully monitored because of the high risk of chronic kidney disease or acute kidney injury.

Sodium-glucose co-transporter 2 inhibitors (SGLT-2)

  • risk of dehydration and diabetic ketoacidosis during illness, so patients should stop taking the drugs and follow sick day rules
  • patients should avoid initiating therapy during respiratory illness
  • renal function should be carefully monitored for acute kidney injury. 

Insulin

  • insulin therapy should not be stopped
  • regular self-monitoring of blood-glucose ever 2-4 hours should be encouraged, or continuous glucose monitoring
  • carefully adjust regular therapy if appropriate to reach therapeutic goals according to diabetes type, comorbidities, and health status.

Glucagon-like peptide-1 receptor agonists (GLP-1)

  • dehydration is likely to lead to a serious illness so patients should be closely monitored
  • adequate fluid intake and regular meals should be encouraged.

Dipeptidyl peptidase-4 inhibitors (DPP4)

  • these drugs are generally well tolerated and can be continued.

Ongoing support

  • should be used to continue regular reviews and self-management education programmes virtually and ensure patients are adherent to therapy. 

Patients should never stop taking any medication without speaking to their doctor or pharmacist

General preventative measures

  • maintain a good glycaemic control to reduce the risk of infection and the severity
  • special care needed for those with co-existing heart disease or kidney disease to stabilise their cardiac/renal status
  • encourage exercise to stay healthy
  • attention to nutrition and adequate protein intake is important, correcting any nutritional deficiencies where appropriate
  • it is important to take when offered Covid and influenza and pneumonia vaccinations to decrease the chances of secondary infections.

People with diabetes should have ready

  • contact information of health care provider
  • a stock of medications and supplies for monitoring blood glucose
  • enough stock of simple carbohydrates like regular soda, honey, jam, etc. to manage low blood glucose
  • glucagon, blood and/or urine ketone strips.

Summary

  • diabetes is a frequent comorbidity in COVID-19 patients
  • practical recommendations are emerging to help with clinical management and many national and international bodies are continually updating their guidance
  • more data is needed to better define the nature of interaction between diabetes and COVID-19
  • research into potential therapies along with a preventative vaccine is urgently needed
  • guidance and information on COVID-19 is continually evolving so please always refer to the latest guidance in your locality.

Further resources

Guidance for patients

Healthcare professionals – roles and responsibilities

Healthcare professionals roles and responsibilities This section looks at the roles and responsibilities of nursing staff and multi-disciplinary teams when caring for people with diabetes.

The role of Diabetes Specialist Nurses (DSNs)

The DSN role typically involves a high degree of autonomy (especially in community settings) and a range of responsibilities, including clinical care, patient and professional education.

DSNs are fundamental in supporting independence and diabetes self-management for people with diabetes and they play a crucial role in preventing – long-term complications, support patients with complex needs which will otherwise impact on their quality of life, including mental health as well as costly the NHS for preventable complications. DSNs play a key role in supporting primary care teams with specialist expertise to reduce emergency hospital appointments (Diabetes UK, 2011). There is growing body of evidence to support that DSNs are key to cost effective care and improve patient satisfaction (Diabetes UK, 2016). 

Hicks et al (2012) showed that nurse consultant and DSN-led services in the community are clinically effective; patients achieved significant positive clinical outcomes in HbA1c, cholesterol reduction and demonstrated an increased confidence in the patients’ ability to self-manage.

Qualifications, knowledge and skills

New models of care require DSNs to treat, refer, order diagnostic investigations, prescribe medications and create a patient centred care plan. Competencies are crucial to ensure staff are well equipped to manage complex caseloads. 

Career pathways and development in diabetes haven’t been easy to navigate and with a wide range in variety of job titles and job descriptions it has impacted on recruitment to this type role.  (Diabetes UK, 2019; Gosden et al, 2010). 

DSNs should be registered nurses and have practised for a minimum of three years and have proven interests in diabetes management and teaching and counselling. DSNs new to their post are required to undertake have undertaken a diabetes diploma and/ or be working towards or have a related degree.  Senior DSNs should have worked for a minimum of three years as a DSN and are expected to be working towards, or already have a master’s degree.

Diabetes UK (Diabetes UK, 2019)  launched a framework (see Table 1)  to advise on standardising job titles, differentiate levels of practice, inform academic provision and provide a standardise approach to the development of diabetes-specific nursing skills through competency assessment. 

Diabetes professionals roles and responsibilities table

Table 1: Diabetes Specialist Nurse job titles, minimum qualifications & competencies (Diabetes UK, 2019)

A collaborative approach between TREND-UK (Training, Research and Education for Nurses in Diabetes), Diabetes UK, WAND (Welsh Academy of Nurses in Diabetes), and representatives for DSNs and HEIs from England and Wales, has developed the competency framework. It incorporates diabetes-specific nursing outcomes within a clear pathway for career development.

The framework defines the development of knowledge, skills and competence needed to support people living with diabetes. It is recommended that nurses provide evidence to demonstrate their level of knowledge, skill and current practice. It should also link to personal development and support re-validation ensuring it is in line with the Nursing and Midwifery Council view of competence and skills.

From the Diabetes UK DSN workforce survey (Diabetes UK, 2016); 99% said that they have a lot of autonomy in their role, with 89% delivering nurse-led clinics, around half trained as nurse prescribers and a quarter providing professional leadership in the role of lead nurse. The survey (Diabetes UK, 2016) also showed a highly-committed workforce under immense pressure as demand for diabetes services rises without a corresponding increase in DSN numbers. 39% consider their current caseload unmanageable and 78% have concerns that their workload is having an impact on patient care and/or safety. 57% will be eligible to retire from the profession within 10 years or fewer. Over the same time period the number of people in the UK with diabetes is expected to increase by at least 700,000 (Diabetes UK, 2020).

Recommended staffing levels and core responsibilities for DSNs were first stated by the British Diabetic Association (BDA) in 1985. The later recommendations from the BDA (1999) stated that there should be “at least a minimum of four whole time equivalent DSN’s per 250,000 population. This was updated again in 2014 to a minimum of five whole time equivalent DSNs per 250,000 populations in a joint position statement from Diabetes UK, TREND-UK and the Royal College of Nursing (Diabetes UK et al, 2014). It didn’t recommend the banding or skill mix to make up DSN workforce or acknowledge the percentage of people diagnosed with diabetes in that population.

Key messages

  • DSNs work wholly in diabetes care and may be employed in primary or secondary care, or in both.
  • The title of DSN should only be used if a practitioner has the appropriate qualifications, skills and competences aligned to the Knowledge and Skills Framework (NHS Employers 2019)  and specific diabetes competencies in the Career and Competency Framework for Nurses in Diabetes (TREND-UK, 2019).

References

Specialists involved in the delivery of diabetes care must work in multidisciplinary teams for care to be truly effective. They should have received extensive training accredited at a national level.

Specialist teams should comprise of consultant diabetologists, diabetes specialist nurses, diabetes nurse consultants, diabetes specialist dietitians, diabetes specialist podiatrists, Diabetes specialist pharmacists and clinical psychologists who will also collaborate with many other specialists who might be incorporated into the team. 

Specialist teams provide direct care for people with diabetes with complex needs that cannot be met within the skill competencies of the general practice team.

Specialist teams may be based in hospitals or community settings, but will need to provide care, support and education in all locations for the local population. In some teams key members focus on different aspects of the service. 

The way that specialist diabetes services are organised, and the staff leading the delivery of the different aspects of specialist care, will vary from area to area, depending on the skills of local hospital, community and primary care staff. It is recognised that staffing requirements, facilities and resources will vary from area to area. However, providers of specialist diabetes services have a crucial role to play in either delivering or supporting the delivery of all levels of care across the whole integrated diabetes model of care. 

Key contributions of specialist staff include:

  • supporting primary care staff to provide high-quality diabetes care 
  • provision of ongoing education and training in diabetes for primary healthcare professionals
  • direct provision of support to GPs and their staff in the delivery of diabetes care (ie within GPs’ premises) through joint practice-based clinics and virtual clinics 
  • support to GPs in the delivery of care to people living in residential settings and hard-to-reach groups (eg homeless people)
  • support for general practice in the introduction of new therapies and treatment regimens
  • provision of group education for people with diabetes
  • easy access to specialist diabetes podiatry and dietetic services provided in community settings, such as polyclinics (ie as close as possible to where people live)
  • easy access to specialist advice (consultant diabetologist and/or diabetes specialist nurse) on the management of individual patients – including the provision of email/telephone advice to GPs and/or practice and community nurses (the aim would be to enable GPs and their staff to continue, where appropriate, to care for the patient in the community.)
  • training for, and ongoing support to, those GPs and their staff who provide extended primary care services for their own patients and those registered with neighbouring practices, such as insulin initiation, group education and foot clinics.

Suggested diabetes service structure for multi-disciplinary team working

Using the recently published ‘Best Practice in the Delivery of Diabetes Care in the Primary Care Network’(Milne et al 2021) whilst primarily focusing on the development of care within Primary Care Networks (PCNs) it has produced guidance on service delivery at all levels of care and divided primary, community and secondary care services into four tiers. The best practice guide suggests which patients should attend which tier of service and which health professionals should form the multi-disciplinary team (MDT) in that relevant tier. 

Tier 1 diabetes care (GP Practice-based) 

Patient case type examples

Those on oral agents and stable within individualised treatment target ranges. May include care to those needing GLP-1 initiation/titration or insulin initiation/titration. 

MDT

Nominated GP, Practice nurse with a special interest in diabetes, or an RPS advanced level 1 pharmacist.

Tier 2 Diabetes Care at PCN level

The Diabetes Support Team will manage their own caseload and referrals for complex cases unable to be managed at tier 1 care and/or not meeting individualised treatment targets. These practitioners will also provide support and supervision for care homes and will advise others in the community MDT e.g. district nurses/active case managers.

Patient case type examples

Those unable to be managed at Tier 1 care and/or not consistently meeting individualised treatment targets. Injectable therapies: GLP-1 or insulin initiation/titration where extra support is needed. Women of childbearing age, newly diagnosed Type 2 People with painful neropathy, erectile dysfunction, or hypertension. People with diabetes and mental health problems. 

MDT

GP with a special interest (GPWSI), Lead PCN Nurse for diabetes, Community Diabetes Specialist Dietitian and RPS Advanced Level 2 Pharmacist.

Tier 3 Diabetes Care (Integrated Care from Associated Secondary Care Trust or Community Care provider 

Patient case type examples

Referrals for complex cases unable to be managed at Tier2 Diabetes Care Targeted clinics e.g. treatment intensification on 3 oral medications or more and diabetes not controlled, technology (community-managed flash glucose monitoring devices), Frailty, Renal: up to stable Chronic Kidney Disease (CKD) stage 4, Type 1 needing community management (e.g. care home, learning disabilities), GP/PCN support. 

MDT

Community Diabetologist or service level agreement for Diabetologist from local secondary care trust, Senior DSN/Consultant Nurse, Senior Diabetes Specialist Dietitian, RPS Mastery Level Consultant Pharmacist.

Tier 4 Diabetes Care (Secondary Care Trust) 

Patient case type examples

patients with complications cardio- and peripheral vascular disease, retinopathy and neuropathy (especially those with uncontrolled neuropathic pain or autonomic neuropathy)
Inpatient diabetes Foot diabetes MDT, Type 1 diabetes , unstable/rapidly deteriorating CKD 4 and 5, those on renal replacement therapy, Antenatal diabetes, Children and young people, people with uncertain diagnosis, bariatric surgery, islet cell transplantation.

Care Providers: Consultant Diabetologist, Registrar, Senior DSN/Consultant Nurse, DSN, Senior Diabetes Specialist Dietitian, Diabetes Specialist Dietitian, Pharmacists, health care assistants.

Reference

Milne N, Avery L, Ali SN, Alicea S, Beba H, Kanumilli N (2021) How to deliver best practice in diabetes care across Primary Care Networks. Diabetes & Primary Care 24: Early view publication

Advanced preparation of insulin syringes for adult patients to administer at home - RCN guidance for nurses 

The RCN views the practice of pre-loading insulin as necessary for the small minority of  patients unable to use insulin pen devices, and should only be considered after all other options have been exhausted.

There are potential legal and safety complexities associated with the practice of pre-loading insulin syringes in order to enable people to self-administer in their own homes that health care practitioners must be aware of.

Firstly, the preparation of pre-loaded syringes represents a form of secondary dispensing which, under the terms of the Medicines Act (1968), is classified as an unlicensed activity in all four UK countries. Consequently, health care organisations and practitioners must take full responsibility for the safety of this activity.

Secondly, the safety of individuals using preloaded insulin syringes, as well as the storage, stability and sterility of insulin once drawn up in the syringe, is of paramount importance (Rosindale, 2014).

For this reason the RCN recommends that nurses should operate within the framework of a local pre-loaded insulin syringe clinical policy which details the responsibilities of every individual involved in the practice (employing organisation/patient/GP/community nurse) and standardises how nurses perform the preparation of syringes (essential to assure vicarious liability protection for nurses undertaking this practice). Health care organisations and practitioners are also directed to review the Royal Pharmaceutical Society’s Professional Guidance (2018).

An overview of the local framework requirement is outlined in Rosindale (2014) and an example insulin syringe clinical policy document can be found in the appendix on page 29 of this publication.

The policy, which should be regularly updated by a local diabetes lead nurse and the medicines management team, should contain a clearly defined standard operating procedure to guide and support local health care practitioners.

Vicarious Liability

Guidelines

Introduction

This guidance has been updated and replaces previous guidance. Developed for nursing practitioners working in a variety of settings, this publication highlights the professional,  organisational and safety issues that must be addressed when pre-loading insulin syringes for later use by a person with diabetes.

Professional consensus statements

Prior to updating these guidelines, the RCN working group undertook an exercise to evaluate the views of senior diabetes nurse specialists and draw on their professional  expertise in the development of these recommendations.

The findings of the consensus statement exercise revealed a significant variation of understanding in relation to the professional risks and legal issues surrounding the practice of pre-loading insulin syringes: just 20 per cent of respondents knew the practice of pre-filling an insulin syringe was outside the Medicines Act, and only 20 per cent were aware that pre-loading insulin syringes is not considered to be best practice.

The consensus participants were, however, clearly in agreement on the imperatives relating to patient safety.

They agreed strongly that:

  • only registered nurses should be involved in pre-loading insulin syringes
  • patients must have capacity for this practice to be considered
  • full patient training and education must be provided
  • nursing staff cannot undertake this practice if there is no organisational policy in place.

The consensus statement exercise provided the group with an invaluable snapshot of the state of knowledge on this topic, highlighting why the re-issue of this updated guidance is both timely and necessary. The responses revealed how the practice of pre-filling insulin syringes has become so embedded in every day practice that it is often considered normal by many health care organisations and their employees.

It is hoped that these guidelines will prompt a reevaluation and discussion of the issues involved while ensuring that appropriate steps are taken to protect all concerned: patients, nursing staff, and employers.

Insulin syringe

Context: a growing issue

In recent years the arrival of innovative insulin delivery devices means more people with diabetes have been able to find an insulin pen that suits their needs, reducing the number of people requiring pre-loaded insulin syringes. 

However, there remains a small number of people who will not or cannot use an insulin pen for a variety of reasons: poor manual dexterity; visual impairment; an inability to find a pen device that suits their needs; or a reluctance to make the change from the standard insulin injection syringe they are familiar with (Rosindale, 2014).

As a result, these patients will be unable to autonomously inject once or twice a day and, consequently, will require nursing support to pre-load the insulin syringes they use in order to maintain their independence. The RCN is aware that the potential number of people requiring such support in the community is likely to increase for two reasons: 

  • the number of people with Type 2 diabetes that require insulin treatment is growing: over the past two decades the number of people with diabetes in the UK has more than doubled, from 1.4 million in 1996 to 4.5 million in 2016 (Diabetes UK, 2016)
  • Diabetes UK estimates that by 2025, 5.2 million people will have diabetes: most of these cases will be Type 2 diabetes because of the ageing population and the rapidly rising number of overweight people (Diabetes UK, 2016).

The preparation of insulin injections by community nurses for patients to administer in their own homes at a later time has been the practice for many years. Preserving an individual’s convenience and independence, the practice reduces the risk of hypoglycaemia and, by enabling people to administer their insulin at the correct time in relation to meal times, releases nursing time and resources.

Anecdotally, the practice of pre-loading insulin syringes for people with diabetes to administer themselves has taken place satisfactorily for decades. However, there are no national guidelines currently in place to support this practice (Rosindale, 2014).

The RCN believes the practice of pre-loading insulin syringes should only be considered when all other options to enable patients to self-manage have been exhausted – such as the introduction and use of an insulin pen device.

This guidance outlines the key considerations and essential elements that should be in place when the only alternative is to undertake the advanced preparation of insulin syringes for adult patients to administer at home.

Issues relating to prescribing and medicines management are a leading cause of cases being referred to the NMC for consideration of fitness to practise proceedings against nurses and midwives. Following these guidelines should ensure that nurses avoid finding themselves in a position where they are referred to the NMC for inadvertent or deliberate breaches of medicines management standards. These guidelines therefore provide an essential tool for nurses who work in the treatment of adult diabetics.

Insulin syringe

Summary of professional issues

The act of pre-loading an insulin syringe is considered a form of secondary dispensing which is not covered by the terms of the Medicines Act (1968). In essence, the act of pre-loading an insulin syringe creates an unlicensed product.

This is an important legal consideration that needs to be taken into account by health 
care professionals and employers. If something were to go wrong, it is the nurse who 
prepares a preloaded insulin syringe outside the bounds of the Medicines Act that would 
be liable (Rosindale, 2014).

These points have significant implications for community nurses. While the pre-loading of insulin syringes is considered to be common practice, ultimately, it is the nurse who is professionally accountable for this action.

For this reason the RCN recommends that, for their own legal protection, nurses must  operate within the requirements of a local policy/protocol for the pre-loading of insulin syringes for patients to administer at home. Therefore, a local policy must be in place to ensure that nurses benefit from vicarious liability, in which the employer takes full responsibility for the safety of this activity.

The pre-loading of insulin syringes should only be undertaken by registered nurses; this 
activity cannot be devolved to health care assistants.

Protecting the safety of an individual with diabetes is of paramount importance. In 2010, the National Patient Safety Agency (NPSA) issued two rapid response reports (NPSA, 2010a; NPSA 2010b) highlighting the potential errors that can occur in relation to insulin  administration: omitted doses, delayed doses and inappropriate use of non-insulin syringes. However, no harm to patients was reported between 2005 and 2013 as a result of using this method (Rosindale, 2014).

Before preparing to pre-load insulin syringes for adults with diabetes to administer at home, the RCN therefore recommends the following:

Ensuring that there is an organisation-wide policy in place covering the use of pre-loaded insulin syringes; this is essential for your protection and the protection of patients (see Appendix 1 for an example policy document).

  • Patients must be assessed and have full capacity for this practice to be considered and patient capacity must be routinely and frequently re-assessed (as per local policy).
  • A senior diabetes specialist nurse (SDSN) must be involved in the initial patient assessment; this risk assessment should be updated on a regular basis (as per local policy).
  • Comprehensive training on pre-drawn insulin for self-administration must have been undertaken.
  • A patient care plan must be in place.
  • A quality assurance plan must be in place (as per local policy) which is overseen by your local SDSN.
  • The patient’s GP is aware, understands and is in agreement that prescribing pre-loaded insulin syringes has associated medical-legal issues, and that there is a policy in place to support this process.

Patient requirements

A number of essential elements need to be checked when assessing an individual with diabetes who requires pre-loaded insulin syringes. At a minimum the patient must:

  • have Level 3 mental capacity, as defined by the Mental Capacity Act (2005)
  • accept full responsibility for the storage and administration of the insulin-filled syringes
  • be assessed to confirm they cannot use any other first-line licensed alternative (such as an insulin pen device)
  • receive full training and education in their specific medication (dose, frequency of injections, time/action profile), resuspending the pre-loaded syringe, injection technique and rotation of relevant injection sites
  • be able to describe the signs, symptoms and treatment of a hypoglycaemic event
  • know who to contact should they encounter any problems between visits.

Registered nurse requirements

To benefit from vicarious liability protection, the registered nurse must adhere to the requirements of their local policy for the pre-loading of insulin syringes.

At a minimum, the nurse must:

  • always involve the senior diabetes specialist nurse (SDSN) in each patient case
  • undertake an initial, and regularly update, a patient risk assessment (as per local policy)
  • never delegate the pre-loading of insulin syringes to a health care assistant
  • ensure syringes and storage boxes are clearly labelled with content (drug name, dose), time and date of preparation, and patient’s name (as per local policy)
  • ensure the patient is educated on their medication, what they are taking and why they are injecting insulin
  • ensure patients understand that pre-loaded syringes are their responsibility and are not the responsibility of their carer
  • ensure the patient is trained in the correct injection technique (and is still capable of self-injecting), the rotation of sites, the safe storage of insulation and the disposal of sharps
  • ensure the patient has a contact number for any problems between visits.

Storage conditions for pre-loaded insulin

In relation to the storage, stability and sterility of pre-loaded insulin syringes in the home, studies have shown these can remain stable and sterile at refrigerator temperatures for up to 28 days (Rosindale, 2014).

Pre-loaded insulin syringes should be stored in the main part of the refrigerator at between 2ºC and 8ºC, and should not be placed in the freezer or at the back of the refrigerator. The needle should point upwards in mixtures containing isophane insulin to prevent blockage by suspended substances in the insulin (Rosindale, 2014).

Lantus (Glargine) or Abasglar (biosimilar Glargine) are unsuitable for use in pre-loaded syringes as it will become turbid (cloudy). Tresiba and Toujeo are also not suitable and should not be drawn from the cartridge or the pre-filled pen into a syringe as it is available in different doses and can overdose the patient.

Syringes should be stored in a sealable container, and both syringes and container should be clearly labelled. If the patient is required to administer insulin more than once per day (for example, prior to eating breakfast, and again, before the evening meal) there should be a separate container for each administration time – even if the doses that are utilised are the same.

Syringe label

The syringe label should contain the following information:

  • date and time of preparation
  • patient’s name
  • name of insulin
  • the dose (in number of units)
  • the time the insulin injection should be administered
  • initials of the registered nurse who prepared the syringe.

Sealable container label

The sealable container label should contain the following information:

  • date and time of preparation
  • patient’s name and address
  • the name of the insulin preparation
  • the dose (in number of units)
  • administration instructions; for example, just before or 30 minutes before food, at times 
  • agreed with the patient and documented in the nursing notes
  • the number of syringes prepared and left in the container
  • the signature of the registered nurse who prepared the syringes.

Separate containers should be used for insulin that is to be delivered at different times of the day.

Whether to re-suspend pre-loaded insulin before injection 

If the pre-loaded dose contains isophane insulin or is a cloudy insulin, the syringe should be gently rotated ‘back and forth’ between the hands at least 20 times until the insulin is uniformly suspended before injection. This also warms the insulin, which is important because injecting cold insulin can be painful and is less effectively absorbed.

Potential patient problems

If morning and evening doses are different, it is possible that the two doses may become confused, particularly if the patient has poor vision.

This should be addressed by the community nurse when assessing a patient’s capabilities and circumstances. Ways of overcoming this risk include the use of different shaped boxes for storage, which should be clearly marked to differentiate each dose.

A further potential problem is the accidental wastage of insulin through spillage or the dropping of a syringe, and community nurses should ensure that patients know who to contact if this happens.

Finally, doses could be self-administered at too close or too long an interval. To minimise this risk, the community nurse should regularly assess the patient’s understanding of their regimen and routine.

Nursing professionals are responsible for overseeing every aspect of patient safety, which should include the provision of education, support and insulin safety awareness training (including infection control and how to test blood glucose levels).

Disposing of syringes after use

Patients should be provided with yellow sharps boxes to dispose of syringes. These are available on prescription or through the local council, and should be returned in accordance with local guideline on clinical waste management.

Summary of key points

Community nurses are under increased pressure to undertake the pre-loading of insulin syringes for people with diabetes to administer at home.

The rising numbers of people with Type 2 diabetes, combined with an ageing population demographic, means the number of people unable to utilise a pen device due to dexterity or other reasons, is growing. Furthermore, in the current economic climate, there is also a potential for the use of pre-loaded insulin syringes to be abused in an attempt to generate perceived efficiencies by reducing community nurse visits/time.

The RCN considers the pre-loading of insulin syringes not to be best practice, and recommends that the use of licensed first-line injection devices (such as an insulin pen) should be promoted to enable patient self-management.

The RCN advises that:

  • the pre-loading of insulin into a syringe for use by the patient at a later date must be seen as the final option, and should only be considered when all other options have been exhausted
  • pre-preparing insulin syringes is an unlicensed activity that falls outside the Medicines Act (1968): practitioners and health organisations must take responsibility for the safety of this activity
  • an organisation-wide policy/protocol on the pre-loading of insulin syringes for patients must be in place; this is essential to ensure patient safety and provide nurses with legal protection through vicarious liability
  • the policy/protocol must set out responsibilities for all parties concerned and set out an agreed standard operating framework for every aspect of the practice (patient education, storage, labelling, monitoring of diabetes control and wellbeing etc)
  • the specialist diabetes service/a senior diabetes specialist nurse lead must be involved in the preparation of the organisational policy, the initial patient risk assessment, and ongoing quality assurance to ensure policy adherence.

Consensus statement and methodology

View the Consensus statement and methodology.

References

  • Diabetes UK (2016) Annual report 2016
  • National Patient Safety Agency (2010a) Rapid response report: reducing harm from omitted and delayed medicines in hospital, London: NPSA.
  • National Patient Safety Agency (2010b) Rapid response report: safer administration of insulin, London: NPSA.
  • Parliament (1968) Medicines Act 1968, London: Stationery Office.
  • Parliament (2005) Mental Capacity Act 2005, London: Stationery Office.
  • Rosindale S (2014) Pre-loading of insulin syringes for people with diabetes to administer at home: new solution to an old practice, Diabetes and Primary Care, 16 (3), pp.137-142.
  • Royal Pharmaceutical Society (2018) Professional guidance on the safe and secure handling of medicines

Acknowledgements

The RCN would like to thank everyone who contributed to the review and development of this fourth edition.

Samantha Kelly (nee Rosindale), lead author, Diabetes Nurse Consultant for Merton & Wandsworth, Central London Community Healthcare NHS Trust.

Jo Reed, reviewer, Renal Diabetes Specialist Nurse, Imperial College Healthcare NHS Trust

Samantha and Jo are both committee members of the RCN Diabetes Forum.

Case studies

Case studies Three case studies providing examples of the treatment and management of diabetes.

Case study 1 - Mrs Patel

Case study one

Mrs Patel is an 89-year-old widow. She has been living in a nursing home for the past two years because her family have been unable to cope with her nursing needs following a stroke in 2012, which has affected her right side and her speech. Mrs Patel is unable to manage the normal activities of daily living. She was diagnosed with type 2 diabetes 20 years ago. Mrs Patel had taken a great interest in her diabetes when she was able to but since having the stroke and the death of her spouse in 2013, she has not been able to participate in her own personal and diabetes care.

Over time Mrs Patel has become increasingly frustrated because she is unable to communicate how she is feeling, or what her needs are. Mrs Patel is on Gliclazide 80 mgs twice daily and metformin 1gm twice daily. You notice that Mrs Patel is off her food and has had very little to eat that day. The nurse in charge has given Mrs Patel her medication as prescribed at 10 am. At 2pm you notice Mrs Patel is sweating profusely, she is pale and appears to be drowsy but responds to her name.

You consider the signs and symptoms you are faced with and wonder whether Mrs Patel’s blood glucose level is ok. You inform the nurse in charge of Mrs Patel’s condition and confirm with her that you will do a blood glucose test (based on your level of competence) and take the 'hypo' kit to the bedside in case the blood glucose is less than four.

Following the capillary blood glucose test you discover that Mrs Patel’s blood glucose is 2.4mmols.

What steps do you take next?

  1. Record the blood glucose level on the Mrs Patel’s chart and report the result to a registered member of the staff when you have finished with your other patients
  2. Record the blood glucose level on the Mrs Patel’s chart and report the result to a registered member of the staff immediately
  3. Immediately inform a registered member of staff.

The correct answer is Option 2.

Feedback: You need to write down the glucose level so that there is a record, but this is an emergency so you must act very quickly to prevent Mrs Patel’s lapsing into a hypoglycaemic coma. Inform a registered member of staff immediately.

What is the clinical term for a low blood glucose?

  1. Hypoglycaemia
  2. Hyperglycaemia

The correct answer is Option 1.

Feedback: Hypoglycaemia (hypo) is described as a blood glucose < than 4 mmols. Glucose is a sugar carried in the blood stream that your body uses for energy. Blood glucose can be erratic at times, sometimes becoming very low when medication is taken and food is restricted or the patient is off their food.

As Mrs Patel is still conscious and responding to her name, and her swallowing reflex is intact you would aim to treat her hypo following the guidelines for the management of hypoglycaemia in the nursing home. Can you remember what the recommended treatments for hypoglycaemia are?

Feedback: Recommended treatments for hypoglycaemia:

  • 10-20g glucose give by mouth
  • or five jelly babies,
  • or three glucose or dextrose tabs,
  • or a small glass of sugary (non-diet) drink
  • or a small carton of pure fruit juice
  • or two tubes of a glucose gel such as GlucGel®.

If Mrs Patel does not feel better and the blood glucose is still less than than 4 mmols after 10-15 minutes repeat one of the above treatments again. When Mrs Patel starts to feel better it is advisable to give some longer-acting carbohydrate such as 1 slice of bread or 2 biscuits. Providing sustained carbohydrate will minimise further falls in blood glucose.

What was the cause of Mrs Patel’s hypoglycaemia?

  1. she has not eaten because she was off her food
  2. she had a sickness virus that meant she was not eating
  3. she was given her Gliclazide tablets at 10 am but she had not eaten because she had reduced appetite. Gliclazide stimulates the pancreas to produce insulin thus causing Mrs Patel to have hypoglycaemia.

The correct answer is Option 3.

Feedback: Mrs Patel was given her Gliclazide tablets at 10 am but she had not eaten because she had no appetite. Gliclazide stimulates the pancreas to produce insulin thus metabolising more glucose, reducing the circulating blood glucose levels, causing Mrs Patel to have hypoglycaemia.

You also need to be aware that Mrs Patel needs to be assessed to identify the reason for her reduced appetite. She may require a medication review because Gliclazide may not be the best medication for an elderly woman. Her kidneys may not be functioning properly, reducing the excretion of the medication beyond what the manufacturer’s specifications.

The signs and symptoms of hypoglycaemia were that Mrs Patel was sweating heavily and appeared pale.

The other signs and symptoms of hypoglycaemia are feeling anxious, trembling and shaking, tingling of the lips, hunger and palpitations

How would you prevent Mrs Patel from getting hypoglycaemia in the future?

  • monitor and record Mrs Patel's fluid and food intake
  • report and record any changes in eating habits to nurse in charge
  • Mrs Patel may need feeding as she has difficulty with the activities of daily living
  • test and record Mrs Patel’s blood glucose as prescribed by the team
  • report any abnormal readings to nurse in charge
  • be aware that Mrs Patel will need further assessment as to the reasons why she has a reduced appetite. For example, Mrs Patel may be feeling depressed and lonely because she lost her husband
  • she may feeling generally unwell for other reasons
  • Mrs Patel may require a medication review.

Feedback: All of these ways are correct.

What other factors may you consider when caring for Mrs. Patel that are relevant to management of her diabetes?

  • fear and anxiety of hypoglycaemia
  • hypoglycaemia unawareness
  • lack of mobility and exercise
  • always have glucose at Mrs. Patel’s bedside
  • reasons for poor eating habits
  • constipation or obstruction
  • illness
  • ill fitting dentures or poor oral hygiene.

Feedback: All of these ways are correct.

Case study 2 - Mary

Case study two

Mary, 74 years old, lives in a nursing home. She has had type 2 diabetes for 15 years and in addition to Metformin and Gliclazide takes insulin before bed to control her diabetes.
You have worked at the home for six months and have got to know Mary fairly well. Usually when her blood glucose levels are taken they range between 7 and 13mmol/l.

You are aware that the GP responsible for Mary's care is anxious to improve her blood glucose as much as possible because Mary has leg ulcers that are slow to heal. You have recently been trained to monitor blood glucose levels and have been assessed as competent. On this particular evening you monitor Mary's blood glucose level before her evening meal and the result is 21.4 mmol/l.

What do you do?

  1. You know that this reading is unusually high for Mary and wonder what the cause could be. In order to reassure yourself that the test is accurate you check that the blood glucose meter had had the quality assurance check that it should have each day that it is in use as stated in the homes policy. You check the record book and find that the meter had indeed been checked and was reading within the expected target range. You know that you had washed Mary's hand before you had performed the test and so you are certain that the result is as accurate as can be.
  2. You know that it is important to keep Mary's levels as good as possible in order to help her leg ulcers to heal. When dealing with Mary you are aware that she is her usual chatty self. There is nothing unusual about her appearance in this particular evening and she has not complained about feeling unwell. You ask her how she is feeling and she reports nothing that would suggest her high blood glucose result is a problem.

The correct answer is Option 1.

Feedback: You should make sure that this meter has been checked each day that it has been used and in line with local policy. If the meter is functioning correctly, then you would report this reading to the nurse in charge as it is outside the normal range. You would also report that Mary is her usual self and not reporting any of the symptoms of high glucose levels. The nurse in charge should then go and review Mary herself.

The symptoms of a high blood glucose level are:

  • increased thirst
  • feeling tired and unwell
  • skin rash
  • vomiting
  • passing lots of urine.

Mary reports none of these symptoms.

You ask Mary if her day had been unusual in any way that may have led to this high result. Mary tells you that it was her Granddaughter’s birthday and that she had been taken out for lunch by her family. The lunch was much larger than she would usually have eaten and she had had a small piece of birthday cake.

Below are some causes for high blood glucose level. Which do you think explains Mary's increase in her blood glucose level?

  1. more food than normal
  2. illness
  3. infection
  4. less exercise than usual
  5. forgotten medication.

Feedback: Mary had more food than normal, some of which was sugary.

What are the consequences of a high blood glucose level?

If blood glucose levels are consistently high over a period of time they can leads a person to feeling unwell with the symptoms listed above. In addition they can delay healing if as in Mary’s situation, there are leg ulcers or wounds for example if the person was recovering from surgery. If glucose levels remain high in the very long term they can lead to the development of diabetes complications for example, eye disease, kidney disease, heart disease, peripheral vascular disease, neuropathy and increase your risk of a heart attack, stroke or amputation.

The reason for the raised blood glucose result here is the change in Mary’s daily routine. She does not feel unwell from this high glucose level. You report the high result to the nurse in charge and explain what you feel the reason for it may be. The nurse in Charge decides to re check Mary’s glucose levels during the evening and before bed. This additional testing is to monitor that the levels are returning to more normal limits for Mary and to check that the levels are not rising further. At this point, because Mary is not feeling the effects of this raised result, the nurse in Charge makes the decision not to inform the GP at this point but to continue monitoring the situation. The GP will be informed if the glucose levels rise further or if they do not return to levels more usual for Mary.

Case study 3 - Jason

Case study three

Jason is 19 years old and lives in student accommodation in the city. He comes into the surgery without having booked an appointment and asks to see the doctor or practice nurse because he is feeling unwell. The doctor is on visits and will be back soon, and the practice nurse is doing the baby vaccine clinic so is really busy. The receptionist asks if you can see him while he is waiting.

You can see that Jason looks unwell. He is a little flushed, looks very skinny and says he is a little breathless. He tells you that over the past couple of weeks he has been really thirsty and has lost over a stone in weight. He was underweight before he became unwell and is now worried because his clothes don’t fit anymore. Jason gets up at night to pass urine almost every hour but attributes this to the fact he is drinking copious amounts of water as he is so thirsty and his vision is blurred.

You wonder what could be the matter and in order to reassure Jason about his weight you decide to weigh him. You check his records and find that when he registered at the surgery when he started college his weight was 11 stone 10 lbs he now weighs 10st 9 Ibs.

What do you suspect could be the cause?

  1. he is not eating healthily
  2. he is probably drinking too much
  3. urine Infection.

The correct answer is Option 3.

Feedback: His symptoms and his frequency of micturition could be due to a urine infection.

What tests can you do to confirm this?

  1. urine test
  2. blood pressure test
  3. blood test.

The correct answer is Option 1.

Feedback: A dip stick urine test will show if there is blood present and quantify it and it will show if there are leukocytes present, these are white blood cells and are high when infection present, as we make white blood cells specifically to fight infections.

You decide to do a urine test in case his frequency of micturition is due to a urine infection. You ask him to provide a urine sample which you dip test using a urine test strip. This shows that he has a very high level of glucose and ketones in the urine and he is not known to have diabetes.

What do you do next?

  1. You have been trained to use this and regularly help out in the diabetic clinic so you think he probably has undiagnosed diabetes.
  2. You explain to Jason that as the nurse is still busy it might be useful to check his blood glucose reading as the urine has shown positive to glucose. He agrees so you do a quality control test on the meter first as you know it should be checked on a daily basis. He washes his hands to ensure there is no glucose on the fingers and then you do the test. The reading shows a blood glucose of 28.3 mmol/l.

The correct answer is Option 2.

Feedback: Yes, if you have been trained to do a blood glucose test, then you can test Jason to confirm your suspicions. A trained nurse may confirm their suspicions - an unregistered nurse should not discuss the implications of the test with Jason.

What is the diagnostic level for the confirmation of diabetes?

  1. Fasting plasma glucose of more than 7.0 mmol/l or a random plasma glucose of more than 11.1 non fasting
  2. Fasting plasma glucose of less than 7.0 mmol/l or a random plasma glucose of less than 11.1 non fasting
  3. Fasting plasma glucose of more than 5.0 mmol/l or a random plasma glucose of more than 9.0 non fasting.

The correct answer is Option 1.

Feedback: The diagnostic level for confirmation of diabetes is a fasting plasma glucose of more than 7.0 mmol/l or a random plasma glucose of more than 11.1 non fasting. Usually 2 laboratory tests need to be done but as Jasons blood glucose is very high and he has some of the common symptoms of type 1 diabetes there cannot be any doubt about the diagnosis ( see Diabetes UK for information on the diagnosis of diabetes).

What is the relevance of ketonuria in diabetes?

  1. Ketones show that the patient is not following the correct diet and he should be given advice about how to correct this
  2. Ketones can show which form of diabetes the patient has.
  3. Ketones cause the body to become acidotic which can lead to critical illness. If insulin is not received in the next couple of hours his condition will deteriorate.

The correct answer is Option 3.

Feedback: Ketonuria is a sign of either an absolute or relative lack of insulin and confirms the diagnosis of type 1 diabetes when seen with heavy glycosuria. His breath may smell of ketones (pear drop or nail varnish aroma) but not all people can detect this. Ketones are toxic and if the patient does not receive insulin in the next couple of hours his condition will deteriorate quickly and he could become very nauseated or vomit. High levels of ketones can cause the individual to become acidotic so his breathing could become laboured and he could go into coma.

What is the relevance of his thirst and polyuria?

  1. His body is trying to quickly remove the excess glucose by filtering it through the kidneys, so he passes copious amounts of urine. He also becomes really thirsty but will be unable to maintain his fluid balance so he has become extremely dehydrated
  2. It is the concentration of certain osmolites, such as salt. If the water volume of the body falls below a certain threshold or the osmolite concentration becomes too high, then the brain registers a need 'thirst'. His body has excess salt which has triggered his thirst and he needs to increase his intake of fluids to balance the levels.

The correct answer is Option 1.

Feedback: His body is trying to quickly remove the excess glucose by filtering it through the kidneys, so he passes copious amounts of urine. He will be unable to maintain his fluid balance so will become extremely dehydrated.

What should do you do next?

  1. He needs to be given glucose immediately and told to rest.
  2. He needs to be given insulin immediately.

The correct answer is Option 2.

Feedback: The young man will need to be given insulin as soon as possible will need to be admitted to hospital as an emergency for initial management and may even require intravenous insulin and intravenous fluids to correct the acidosis and dehydration. Report your findings to the registered nurse immediately – she should call the GP straight away and explain the situation.

Resources

This section will signpost you to RCN resources, guidance and further resources on diabetes.

  • Joint British Diabetes Society. This offers an array of practical guidelines that can be adopted/adjusted to meet local need.
  • NICE diabetes guidance. This webpage includes everything NICE has produced on the topic of diabetes: related NICE guidelines; pathways; quality standards and advice. There is guidance for adults, children and young people, diabetes in pregnancy, footcare; type 1 and 2 diabetes and preventing type 2 diabetes. (England and Wales)
  • NICE guideline (updated 2021) Type 1 diabetes in adults: diagnosis and management. This guideline covers care and treatment for adults (aged 18 and over) with type 1 diabetes. It includes advice on diagnosis, education and support, blood glucose management, cardiovascular risk, and identifying and managing long-term complications. In July 2021, NICE reviewed the evidence and updated the recommendations on long-acting insulin therapy.
  • SIGN (2010) Management of Diabetes. This guideline provides recommendations based on current evidence for best practice in the management of diabetes.

Reflection on learning and onward development

(Adapted from and maps to the NMC's reflective accounts form)

Once you have reviewed the Diabetes Essentials resource, you can complete the reflective form.

The form contains the following sections and is mapped to the Nursing and Midwifery Council's (NMC) reflective accounts template and the hours spent reviewing the resource can map to the NMC CPD log template (non-participatory hours).

Reflective Account – Diabetes Essentials Resource

Date Undertaken:

Details of Sections completed within Diabetes Essentials: 

Total time completed (Non participatory – map to NMC CPD log template):    (hours)

What sections of the Diabetes Essentials resource were reviewed and how does this relate to your area of nursing practice? 

What did you learn from the sections you reviewed and how does this impact on your area of practice? 

How have you changed / improved your practice as a result? 

How is this relevant to the NMC code? (select one of more themes: Prioritise People – Practise Effectively – Preserve Safety – Promote Professionalism and Trust

 

RCN Diabetes Forum Committee (2021)

Development team

The original learning area was developed by Louise Cox, and original illustrations were developed by John Heseltine BSc (Hons) and George Reith.

The RCN Diabetes Forum

Webpage updates:

Claire Constable - Digital Resources Coordinator, RCN

Jay Musson - Digital Resources Coordinator, RCN

This updated and refreshed resource was supported by:

The RCN Diabetes Forum

Page last updated - 12/11/2021