Download Diagnosis of Diabetes, Impaired Glucose Tolerance and

Diabetes Workbook – Level 1
Diabetes
Workbook
Level 1
Bronwyn Henderson
Diabetes Nurse Specialist
Manaia Health PHO
July 2008
Page .1
Diabetes Workbook – Level 1
Pre Workbook Questionnaire
Diabetes Knowledge Questionnaire
(please complete prior to starting workbook)
1. How would you rate your general knowledge around diabetes?
0
1
2
limited
3
4
5
6
7
average knowledge
8
excellent knowledge
2. How confident are you in providing Diabetes education to patients?
0
1
2
3
Not at all confident
4
5
6
7
slightly confident
8
very confident
3. How confident are you to complete an Annual Free Diabetes Check? (Get Checked)
0
1
2
3
Not at all confident
4
5
6
7
slightly confident
8
very confident
4. Characteristics of Type 2 diabetes include:
a.
b.
c.
d.
e.
relative insulin deficiency
insulin resistance
decline in beta cell function
All of the above
Only b and c





5. Diabetes Ketoacidosis only occurs in Type 1 diabetes:
a. True
b. False


6. The first line in medication treatment for Type 2 diabetes is:
a.
b.
c.
d.
Metformin
Glipizide
Diamicron
Actos




Page .2
Diabetes Workbook – Level 1
7. If a patient has just been prescribed a sulphonylurea what is the most important thing to discuss
with them:
a.
b.
c.
d.
What and when to eat
When to take the medication
How to recognize and treat hypoglycaemia
When to visit the doctor again




8. Which food does not contain carbohydrate
a.
b.
c.
d.
Milk
Bread
Chicken
Apple




9. Blurred vision is a common symptom of retinopathy
True
False


10. Complications of diabetes usually arise after:
a.
b.
c.
d.
10 years of diabetes
5 years of diabetes
15 – 20 years of diabetes
1 – 5 years of diabetes




Page .3
Diabetes Workbook – Level 1
Introduction
The purpose of this workbook is to highlight key knowledge required to assess and provide
education, care and support to Diabetes patients seen in general practice.
The level one workbook is based on a basic level with further levels expected to provide more
specialised knowledge.
This workbook is designed for self directed learning however the Manaia Health PHO Diabetes
Resource Nurse is available to discuss aspects you are unclear about.
There are various worksheets, questions etc throughout this workbook, they are designed to assist
you to reinforce learning and at the completion of the workbook the correct answers will be
forwarded to you.
The Ministry of Health New Zealand Guidelines Group ‘Management of Type 2 Diabetes’ is a key
document for you to read and understand.
In order to gain a certificate of completion for this workbook you will need to complete all sections
and arrange for the Diabetes Resource Nurse to complete an audit of a Get Checked consultation.
Once completed forward the book to:
Bronwyn Henderson
Manaia Health PHO
17 Norfolk St
Whangarei
The book will be returned to you with the correct answers to the worksheets for you to mark yourself
and a certificate of achievement.
Page .4
Diabetes Workbook – Level 1
Contents
Pre workbook questionnaire…………………………………………………
pg 2
Introduction ……………………………………………………………........
pg 4
Overview of diabetes anatomy ……………………………………………..
pg 6
Basics of diabetes physiology ………………………………………………
pg 9
Type 1 diabetes ………………………………………………………………
pg 10
Type 2 diabetes ………………………………………………………………
pg 11
Diagnosis ……………………………………………………………………..
pg 17
Management ………………………………………………………………….
pg 19
Testing ………………………………………………………………………...
pg 21
Medications …………………………………………………………………..
pg 23
Insulin ………………………………………………………………………….
pg 25
Exercise ……………………………………………………………………….
pg26
Nutrition ……………………………………………………………………….
pg 29
Acute complications ………………………………………………………….
pg 39
Long term complications …………………………………………………….
pg 40
Microvascular complications ………………………………………………..
pg 42
Macrovascular complications ……………………………………………….
pg 46
Diabetic Foot ………………………………………………………………….
pg 47
Annual Free Check …………………………………………………………..
pg 49
Annual Free Check Audit ……………………………………………………
pg 50
Post workbook questionnaire ……………………………………………….
pg 53
Evaluation ……………………………………………………………………..
pg 55
Page .5
Diabetes Workbook – Level 1
Overview of Diabetes Anatomy & Physiology
Definition
Diabetes is a disorder that affects the way your body uses food for energy.
Normally, the carbohydrates you eat are digested and broken down to a simple sugar, known as
glucose. The glucose then circulates in your blood where it waits to enter cells to be used as
fuel. Insulin, a hormone produced by the beta cells in the islets of langerhans in the pancreas,
helps move the glucose into cells. A healthy pancreas adjusts the amount of insulin based on the
level of glucose. In diabetes however, this process breaks down, and blood glucose levels
become too high.
There are two main types of full-blown diabetes. People with Type 1 diabetes are completely
unable to produce insulin. People with Type 2 diabetes can produce insulin, but their cells don't
respond to it. In either case, the glucose can't move into the cells and blood glucose levels can
become high. Over time, these high glucose levels can cause serious complications.
Page .6
Diabetes Workbook – Level 1
Cause
Type 1 diabetes Type 1 diabetes develops when the body's immune system destroys pancreatic
beta cells, the only cells in the body that make the hormone insulin that regulates blood glucose.
This form of diabetes usually strikes children and young adults, although disease onset can
occur at any age. Type 1 diabetes accounts for 5% to 10% of all diagnosed cases of diabetes.
Risk factors for type 1 diabetes may include autoimmune, genetic, and environmental factors.
In type 1 diabetes, the destruction of the insulin-producing beta cells is usually an autoimmune
process in people with a genetic susceptibility. The trigger for type 1 diabetes is not fully
understood although many things are thought to be precursors, such as a coxsackie B4 virus or
rubella.
Type 1 diabetes generally develops more quickly than Type 2 diabetes and generally is
diagnosed because of acute symptoms:
Energy Crisis:
The insulin production drops off suddenly when the beta cells are destroyed and the person is
very quickly in crisis. When there isn't any insulin, the glucose in the blood just keeps circulating
and building. The cells don't get any fuel and the body tries to get rid of the excess glucose by
excreting it through the kidneys, taking water with it. This causes excessive thirst and urination.
Diabetic Ketoacidosis:
The body becomes fatigued because the cells aren't getting the glucose they need for energy.
The person may suffer a condition called diabetic ketoacidosis, which means that the body starts
to break down fats to make energy, fatty acids are converted to ketones in the liver as another
source of fuel, these ketones however also need insulin to enter our bodies cells, which means
the ketones also build up in our blood making the blood increasingly acidic, this added to the
dehydration will eventually lead the person to go into a diabetic coma and possibly even die.
Small amounts of ketones will appear in the blood and urine if a person is starved, however as
people with Type 2 diabetes and those without diabetes are still producing insulin, these will
generally not be seen in large quantities, therefore a large amount of ketones in the urine is often
the first indication that the person has Type 1 diabetes.
People with Type 1 diabetes must always take insulin for the rest of their lives in order to live
with the disease.
Page .7
Diabetes Workbook – Level 1
Type 2 diabetes
Type 2 diabetes accounts for about 90% to 95% of all diagnosed cases of diabetes. It usually
begins as "peripheral insulin resistance" (declining insulin sensitivity in the body, especially
skeletal muscles) a disorder in which the cells do not use insulin properly. As the need for insulin
rises, the pancreas gradually loses its ability to produce insulin.
Type 2 diabetes is associated with older age, obesity, family history of diabetes, history of
gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity. Maori
and Pacific Island people are at particularly high risk for type 2 diabetes.
Type 2 diabetes is increasingly being diagnosed in children and adolescents.
Latent Autoimmune Diabetes in Adults (LADA) is one of several names currently applied to
people diagnosed with diabetes as adults who are often not overweight and have little or no
insensitivity to insulin. When special laboratory tests are done, people with LADA are found to
have antibodies – especially GAD65 antibodies – that attack their beta cells. About 15% to 20%
of people diagnosed with type 2 diabetes in fact have LADA.
Gestational diabetes is a form of glucose intolerance that is diagnosed in some women during
pregnancy. It is also more common among obese women and women with a family history of
diabetes and is more common in specific ethnic groups (Maori/Pacific Island).
During pregnancy, gestational diabetes requires treatment to normalize maternal blood glucose
levels to avoid complications in mother and infant.
After pregnancy, 5% to 10% of women with gestational diabetes are found to have type 2
diabetes. Women who have had gestational diabetes have a 20% to 50% chance of developing
diabetes in the next 5-10 years.
The other specific types of diabetes are relatively rare. Underlying pathology needs to be
considered when deciding on management strategies.
•
Maturity onset diabetes of the young (MODY) refers to a number of rare hereditary
forms of diabetes due to defects of insulin secretion
•
Inherited defects in the action of insulin
•
Diseases of the pancreas include cystic fibrosis, pancreatitis, and haemochromatosis
•
Endocrine disorders – often called a ‘hormone imbalance’, technically known as an
‘endocrinopathy’ or ‘endocrinosis’, includes acromegally and Cushings syndrome
•
Drug- or chemical-induced diabetes might arise from the use of steroids, diazoxide,
thiazides or pentamadine
•
Infections associated with the development of diabetes include congenital rubella,
coxsackie, citomegalovirus (CMV), and mumps
Page .8
Diabetes Workbook – Level 1
Basics of Diabetes Physiology
The beta cells in the pancreas detect fluctuations in blood glucose and other nutrients. A rise
in blood glucose results in the release of insulin. The insulin helps to reduce blood glucose
at three levels: muscle, fat and liver.
Insulin acts to make the cell membrane receptive so that:
• Muscle tissue can take up glucose; any excess glucose is stored as glycogen
• Fat can take up glucose; any excess glucose is stored as fat.
In the liver, insulin stops the production of new glucose (gluconeogenesis), decreases the
break-down of glycogen into dextrose (glycogenolysis), and promotes glycogen synthesis
from glucose.
Insulin also reduces the release of free fatty acids.
Diagnosis and types
Insulin and glucose disposal
Curriculum Module II-1
Slide 8 of 48
Gluconeogenesis
Glycogenolysis
Glycogen synthesis
Insulin
Blood glucose
Glycogen
synthesis
Glucose uptake
Free fatty acid release
Slides current until 2008
Page .9
Diabetes Workbook – Level 1
Type 1 Diabetes
In type 1 diabetes, there is severe to total insulin deficiency.
This results in the following:
• A decrease in glucose uptake by the muscle cells
• The breakdown of muscle into amino acids – then taken up by the liver and converted into
new glucose (gluconeogenesis)
• An increase in the breakdown of triglycerides, leading to an increase in the release of free
fatty acids – also taken up by the liver and converted into a usable energy form, ketones
(ketosis).
• A reduction in the uptake of glucose by the liver and an increase in the breakdown of
glycogen (glycogenolysis).
Diagnosis and types
Insulin deficiency in
type 1 diabetes
Curriculum Module II-1
Slide 9 of 48
Glucose uptake
Glycogenolysis
Gluconeogenesis (amino acids)
Ketone production (fatty acids)
Blood glucose
Glucose uptake
Protein degradation  amino acids
Triglyceride degradation  fatty acids
Slides current until 2008
Page .10
Diabetes Workbook – Level 1
Type 2 Diabetes
Diagnosis and types
Curriculum Module II-1
Slide 10 of 48
Insulin insensitivity in
type 2 diabetes
Glucose uptake
Glycolysis
Gluconeogenesis (amino acids)
Blood glucose
Glucose uptake
Protein degradation  amino acids
Slides current until 2008
Some 80% of people with type 2 diabetes have insensitivity to insulin. This means that they
require significantly more circulating insulin in order to lower their blood glucose levels.
People with type 2 diabetes therefore have a relative – rather than total – insulin deficiency.
This results in reduced glucose uptake from muscle tissue and the liver. The breakdown of
protein can occur in type 2 diabetes, but is significantly less pronounced than in type 1
diabetes.
The liver contributes to the hyperglycaemia seen in people with type 2 diabetes by breaking
down and releasing stored glucose (glysolysis) and, to a lesser extent, making new glucose
(gluconeogenesis).
Page .11
Diabetes Workbook – Level 1
Diagnosis and types
Curriculum Module II-1
Slide 11 of 48
Insensitivity to insulin in
type 2 diabetes
Glucose uptake
Glycolysis
Gluconeogenesis (amino acids)
Blood glucose
Glucose uptake
Protein degradation  amino acids
Glucose uptake
Slides current until 2008
As illustrated in the diagram, some of the excess glucose is taken up by the fat cells.
Diagnosis and types
Effect of insulin resistance in
type 2 diabetes
Curriculum Module II-1
Slide 12 of 48
Glucose uptake
Glycolysis
Gluconeogenesis (amino acids)
Blood glucose
Converted to triglycerides
Glucose uptake
Protein degradation  amino acids
Glucose uptake
Slides current until 2008
or taken up by the liver and converted to triglycerides.
The storage of these triglycerides in the liver leads to the ‘fatty liver’ associated with insulin
insensitivity.
Page .12
Diabetes Workbook – Level 1
Unlike type 1 diabetes, people with type 2 diabetes still have some insulin production. In
fact, they may have higher blood levels of insulin than their counterparts without diabetes –
albeit in response to higher-than-usual blood glucose concentrations.
However, it is now understood that type 2 diabetes does not occur without beta-cell
destruction.
Excess body fat – particularly abdominal or visceral adiposity – is thought to contribute to the
insulin insensitivity that is characteristic of this type of diabetes. It has been shown that
people who carry excess weight around their abdomen are at higher risk of diabetes.
Type 2 diabetes tends to develop slowly such that the symptoms of this condition, and
therefore, the diagnosis, are often missed. Longstanding undetected hyperglycaemia – as
often precedes the diagnosis of type 2 diabetes – may lead to the development of long-term
diabetes complications. Complications therefore can be present at the time of diagnosis.
There are multiple genes associated with type 2 diabetes. Some people with the condition
may have a single gene defect, while others have multiple gene defects. This may explain
why some people’s diabetes is easier to treat than others.
In the early stages of insulin insensitivity, the pancreas produces more insulin than usual in
an effort to overcome the insensitivity. Levels of insulin in the blood become excessively
high (hyperinsulinaemia). Eventually the beta cells become ‘exhausted’ and the amount of
insulin produced decreases.
Some recent studies have shown that poor fetal nutrition may cause a decrease in beta-cell
formation, provoking diabetes in later life. Poor fetal nutrition is marked by low birth weight
followed by rapid growth – with sufficient nutrition – within the first 12 months of life.
The ‘thrifty gene’ theory hypothesises that humans are genetically programmed to survive
periods of famine. However, in times of abundance, particularly in the context of sedentary
lifestyles and high-energy diets, these genes contribute to the excessive accumulation of
fatty tissue, leading to insulin insensitivity and diabetes.
There is a natural loss of beta-cell function as we age – approximately 1% per year. In
people with type 2 diabetes, this loss is accelerated to 7% per year.
Page .13
Diabetes Workbook – Level 1
Diagnosis and types
Curriculum Module II-1
Slide 21 of 48
The natural history of
type 2 diabetes
Beta-cell loss
Primary
failure
Insulin
requirements
 Insulin
requirements
with age
Endogenous
insulin
Age (years)
Slides current until 2008
Insulin requirements increase as part of the normal aging process. The aging process also
results in the loss of beta cells.
Blood glucose levels will rise when insulin requirements exceed insulin production. This is
known as ‘primary failure’. In some people this does not occur until very late in life. However,
other people are born with insensitivity to insulin and their pancreas produces more insulin
than usual in an effort to overcome this insensitivity, the beta-cells loss, relative insulin
deficiency and resulting rising blood glucose levels occur at an earlier stage of life.
Diagnosis and types
Curriculum Module II-1
Slide 23 of 48
The natural history of
type 2 diabetes
Beta-cell loss
Hyperinsulinaemia
Insulin
requirements
Secondary
failure
Effect of
oral drugs
Insulin
insensitivity
 Insulin
requirements
with age
Endogenous
insulin
Age (years)
Slides current until 2008
Page .14
Diabetes Workbook – Level 1
As noted previously, people with type 2 diabetes lose 7% of their beta-cell function each
year.
Therefore, type 2 diabetes is a progressive condition; the insulin deficiency will worsen over
time and it is now well known that around 50% of people with type 2 diabetes will require
insulin therapy in addition to oral blood-glucose lowering drugs to maintain near-normal
blood glucose levels. This is known as ‘secondary failure’.
The number of people affected by diabetes is increasing dramatically. This is thought to be
due to a complex interplay of genetic, environmental and social factors. The prevalence of
type 2 diabetes increases with age.
Excess weight – abdominal fat in particular – increases insulin requirements and compounds
the problem of insensitivity to insulin. Therefore, disturbing increases in the prevalence of
type 2 diabetes reflect the rising prevalence of obesity.
There are particularly disturbing trends in adolescents – thought to be exacerbated by
decreased exercise and increased calorie and fat intake. Research has shown that some
ethnic groups are at higher risk than others. Maori and Pacific Island communities, for
example, show higher rates of type 2 diabetes and appear to suffer more in terms of
diabetes complications – such as kidney failure – compared to Caucasian populations.
In the 1990s, children with type 2 diabetes represented only 1% to 4% of patients cared for
in paediatric units. By the late 1990s, in some units they represented nearly 50% of children
and adolescents with diabetes.
Key Patient Messages:
 Type 1 diabetes is an autoimmune condition meaning that they no longer produce insulin.
 Type 2 diabetes usually develops later in life, starting with insulin resistance then gradual loss of
beta cell function.
 Generally, because of the loss of beta cell function most people with type 2 diabetes will need a
change in treatment approximately every 5 years, with the majority of people needing insulin at
approximately 10 – 15yrs post diagnosis, being careful with diet and exercise however can put less
strain on the pancreas meaning beta cell function can be preserved for longer.
 It is important that people are aware that needing to go on insulin does not mean they have failed in
their management, and if frightened of the thought of insulin, discussion and demonstration of the
insulin pens can ease some of this fear.
Page .15
Diabetes Workbook – Level 1
Across
Down
3. excessive thirst
1.
High Blood Sugar
5. sign of early renal impairment
2.
after a meal
10. a simple sugar – the end product of CHO metabolism
4.
the conversion of glucose into glycogen for storage in the liver
11. Disease of the nervous system due to degenerative
6.
Low Blood Sugar
12. an organ of the body that produces insulin
7.
chemicals which occur as a result of fat catabolism or
breakdown
13. Term for fat in the body
8.
A type of cell in an area of the pancreas called the islets of
langerhans which make and release insulin
15. Hormone produced by the alpha cells in pancreas,
insulin antagonist and increases blood glucose by
stimulating glucose production in the liver
9.
Disease of the kidneys caused by degeneraltion of small blood
vessels or glomeruli (kidney units that filter blood
changes of the sensory motor & autonomic nerves.
14. A hormone produced by the pancreas that helps the body use
Page .16
Diabetes Workbook – Level 1
glucose for energy
Diagnosis
Diagnosis of Diabetes, Impaired Glucose Tolerance and
Impaired Fasting Glucose
WHO diagnostic criteria for diabetes, impaired glucose tolerance, and impaired fasting glucose.
Fill in the gaps highlighted.
Blood test
Diabetes mellitus
Impaired glucose
tolerance
Impaired fasting
glucose
Result
Venous plasma glucose
concentration (mmol/L)
Fasting
>
OR 2-hour post glucose load
OR both
Fasting (if measured)
>
AND 2-hour post glucose load
7.0
<
>
, and <
>
, and <
<
For clinical purposes, the diagnosis of diabetes should always be confirmed by repeating the test on
another day, unless there is unequivocal hyperglycaemia or obvious symptoms together with a
positive test.
Differentiation between Type 1 and Type 2 Diabetes
Several tests can assist in a differential diagnosis of type 1 diabetes and type 2 diabetes.
The presence of ketones in the urine indicate insulin deficiency and point towards the diagnosis of
type 1 diabetes.
Likewise, the presence of the antibodies associated with beta-cell destruction (islet-cell
antibodies/GAD antibodies) can be used for differential diagnosis. Insulin assays are unable to
distinguish endogenous versus injected insulin.
C-peptides are a by product of the production of insulin, if C-peptide levels are low or absent it
means insulin production is reduced or absent pointing to a diagnosis of Type 1 diabetes.
Page .17
Diabetes Workbook – Level 1
Activity
1. What are the most common risk factors for Type 2 Diabetes:







_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
2. The pathogenesis for type 2 diabetes includes:
a. Insulin deficiency and insulin insensitivity
b. Insensitivity to insulin and autoimmune beta-cell destruction
c. Autoimmune beta-cell destruction and glucagons deficiency
d. Insulin deficiency and glucagon deficiency
3. A person with thype 2 diabetes, recently started on insulin, asks if there is a way to measure
if he/she is still producing any insulin. The correct response would be:
a. Islet cell antibody tests
b. C-peptide test
c. HbA1c test
d. Serum insulin test
4. type 1 diabetes is usually caused by:
a. Injury to the pancreas
b. An autoimmune reaction
c. Insulin insensitivity in the cells
d. Hypersensitivity to insulin
.
Page .18
Diabetes Workbook – Level 1
Management
Education
Education for people with diabetes is known to be effective and improve outcomes. These results are
based on multiple meta-analyses of educational studies, however we need to be aware that often,
psychological, spiritual, and socio-economic aspects have a strong impact on diabetes outcomes and
may be more important than the level of diabetes knowledge of the person with the condition.
Although we expect people with diabetes to make multiple lifestyle modifications, we rarely provide
information about strategies for behavioural change. Providing this information is most effective if it is
incorporated into each content area so that people can apply the information in context.
We need to acknowledge that people with diabetes are the experts in their own lives. While we know
about diabetes, we cannot and do not know what is best for their diabetes or their lives. It takes our
shared expertise to create a plan that will work. If this does not work, it does not reflect a failure by
anyone; we need to continue trying until the optimum plan is identified.
People with diabetes do not view the psychosocial and behavioural aspects of diabetes care as
separate from the therapeutic aspects. They view their diabetes in its totality.
For example, when teaching about blood glucose monitoring, how to test, interpret and act on the
results, a number of other areas can be addressed i.e:
• Do you have the funds to pay for the meter/ strips?
• How often do you need to test to manage your diabetes effectively?
• What will help you remember to test?
• How will you feel and respond if the numbers do not reflect your efforts?
• How will you use the results to help you manage your diabetes?
There are always advantages and disadvantages for all therapeutic options. People with diabetes
need to know how to weigh up the pros and cons, based on their personal goals and values. It is
important to realise that ultimately people have the right and responsibility to make the final decision.
Several studies have shown that people who test their blood glucose more often will have better
HbA1c. We also expect that people will assume the role of decision-maker in their own care, but we
rarely make this explicit. It is important that we let them know that their outcomes largely depend on
their own efforts. In order to assume responsibility, people with diabetes need both initial diabetes
education and ongoing self-management support.
People with diabetes cannot do things that they do not know how to do. However, it is rare that
knowledge alone is enough to sustain behavioural changes for a lifetime of diabetes.
Page .19
Diabetes Workbook – Level 1
Activity
1. It would be useful to do some research around the theories of behaviour change such as : health
belief, transtheoretical/ empowerment theories.
2. In assessing John’s need to learn about diabetes, which of the following would you ask
about?
a. His family history of diabetes
b. His perception of the seriousness of the disease
c. His ability to attend teaching sessions
d. All of the above
3. John comes to see you after a consultation with the doctor and says in a surprised tone:
“The doc says I have diabetes – what do I do now?”. What would be the your best answer?
a.
b.
c.
d.
Go on a diet and lose that extra weight you are carrying.
Buy a meter so you can test you own blood sugar.
How much do you already know about diabetes?
Take the medication she/he prescribed and you’ll feel better.
Page .20
Diabetes Workbook – Level 1
Testing
There are currently two funded meters available in NZ (Optium, Advantage) these are available free
of charge if patients have a community services card, are on insulin or a sulphonylurea. The optium
meter is available through Diabetes Supplies, Advantage meters can be obtained both through
Diabetes Supplies or by taking a completed form to a local pharmacy. Strips for both of these meters
requires a prescription.
Testing is most beneficial if the patient is aware of how to use the results to monitor and assist and
manage their diabetes, some ways to do this include:





If someone says they know what their blood glucose is, ask them to guess their level and write it
down before doing a test. People are usually quite surprised at the difference!
How often a person should test is defined by the individual and what information is required. People
on insulin for example need to test daily prior to each meal and before bed to monitor insulin
requirements, if on basal bolus insulin or an insulin pump they may also need to test 2 hours after
meals to assess the effect of their bolus insulin. People with Type 2 diabetes may only need to
test 1 – 3 times per week fasting and before bed and 2 hours post a meal to gain a trend.
People should be taught how to look for patterns or trends in their results, and what to do when one
is found.
They should also be encouraged to learn from experience, testing before eating and then testing 2
hours later will show the effect of that particular meal. This can help the person decide whether to
eat the food again, or perhaps to have a smaller serving or different type of food next time.
People should be encouraged to test at least once a week even if glycaemic control is stable to
monitor their diabetes, they should also be encouraged to test more often during periods of stress or
illness.
Blood glucose targets
The HbA1c result gives an average of the blood glucose over the past three months but is weighted to
the last 4 to 6 weeks, meaning that the more recent glucose levels impact the result more. The person
with diabetes does not have to fast for this test.
People with diabetes often get confused between their HbA1c and their blood glucose results. They
can think the numbers mean the same. Therefore, it is important to explain the difference.
Target for people who
can achieve it (without
too much
hypoglycaemia)
Target for most people
with diabetes
IDF Global Guideline for
Type 2 diabetes
HbA1c
< 6%
Pre-meal
4 – 6 mmol/L
2 hours post-meal
5 – 8 mmol/L
< 7%
4 – 7 mmol/L
5 – 10 mmol/L
< 6.5 %
< 6.0mmol/L
< 8.0 mmol/L
Page .21
Diabetes Workbook – Level 1
Key patient messages:


Self monitoring of blood glucose levels (SBGM) gives the person the ability to learn about and
manage their condition.
Writing down their results and looking at several days gives them the opportunity to look at patterns,
rather than focusing on individual results.

Case Study
Mr N is a 50yr old man with Type 2 diabetes who comes into clinic for a routine visit, he is currently on
Metformin 500mg 1 tab BD. What picture are you able to gather from this information and what advice
would you give him.
Before
Breakfast
After
Breakfast
6.5
8.3
Wednesday 6.2
9.2
Monday
Before
Lunch
After
Lunch
Before
Dinner
After
Dinner
Before
Bed
7.8
7.2
Tuesday
5.5
6.0
Thursday
Friday
Saturday
7.3
9.0
6.0
Sunday
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Page .22
Diabetes Workbook – Level 1
Medications
Evidenced-based guidelines suggest that when diet and exercise therapy has not successfully
achieved target blood glucose levels within 2-3 months, medication should be started.
It is suggested that if the HbA1c is less than 9% and the person is overweight (a BMI over 25),
biguanides (Metformin) should be the first choice.
Achieving target blood glucose levels is important to delay or prevent the development of the longterm complications of diabetes.
Diabetes should be treated aggressively. If the targets are not being achieved (HbA1c >7.0%)
medication should be increased, or medication from a different class added.
There should not be a delay in moving to insulin if this is needed.
Blood glucose-lowering medicines
Mechanisms of action
Curriculum Module III-2
Slide 5 of 41
GLP-1 (incretins)
improve response to
glucose level
Biguanides and thiazolidinediones
reduce glucose production
Insulin secretagogues: sulphonylureas
and meglitinides increase insulin
production
Alpha-glucosidase
inhibitors slow
absorption of sucrose
and starch
Thiazolidinediones and biguanides reduce
insulin resistance
Slides current until 2008
Page .23
Diabetes Workbook – Level 1
When caring for people with diabetes you need to have a thorough understanding of drug
therapy.
Completing the following tables will assist you to reinforce this knowledge.
Tablet
size
Daily
Dose
Range
Approx Frequency
Duration of
Admin/day
Most common side effects
Gliclazide
(Diamicron)
Glipizide
(Minidiab)
Pioglitazone
(Actos)
Rosiglitazone
(Avandia)
Metformin
(Metomin,
Glucophage
Glucomet)
Acarbose
(Glucobay)
Page .24
Diabetes Workbook – Level 1
Insulin
Indications for insulin therapy:




Type 1 diabetes
Women with diabetes who become pregnant or are breastfeeding
Transiently in type 2 diabetes in special situations
In Type 2 diabetes, inadequately controlled on maximum doses or glucose lowering medication
(secondary failure)
Nutrition in diabetes
Insulin action profiles
Curriculum Module III-5
Slide 13 of 59
Rapid-acting analogue insulin
Onset: <0.5 hr Peak: 1 hr Duration: 3-4 hr
Soluble insulin
Onset: 1/2 hr Peak: 1-3 hr Duration: 6-8 hr
Lente insulin
Onset: 2 1/2 hr Peak: 7-15 hr Duration: 24 hr
NPH insulin
Onset: 1 1/ 2 hr Peak: 4-12 hr Duration: 24 hr
Biphasic insulin
Onset: 1/2 hr Peak: 2-8 hr Duration: 24 hr
Biphasic analogue insulin
Onset: <0.5 hr Peak: 1-4 hr Duration: 24 hr
Long-acting analogue insulin
Onset: 2-3 hr Peak: none Duration: 24 hr
Slides current until 2008
Insulin initiation
All patients with newly diagnosed Type 1 diabetes should be referred to the Diabetes Centre for
insulin initiation.
For those with Type 2 diabetes see Care pathway for insulin initiation appendix 1
Page .25
Diabetes Workbook – Level 1
Exercise
Physical Activity has many benefits for people with diabetes including lowering blood sugars by assisting in
weight loss, improving insulin sensitivity and increasing glucose uptake. It is has also been shown to
improve psychological wellbeing reducing the possibility of depression.
Sport Northland has lists of various exercise providers in the area, they also have lists of walking tracks
and can provide one on one support to patients via Green Prescription.
Physical Activity recommendations are similar as for the general population however there are some
specific safety considerations particularly for those with Type 1 diabetes and those with diabetes
complications. (see: Management of Type 2 Diabetes – Ministry of Health Guidelines page 18 – 19)
Safety Considerations

Patients should be reminded to drink adequate water to avoid becoming dehydrated, especially if
exercising in a hot climate.
• They should be reminded to check their footwear. Feet should be protected from the environment.
Shoes and socks should keep the feet as dry as possible and not cause reddened areas or
blisters.
• People with diabetes who take any kind of blood glucose-lowering medicine should be advised to
wear some form of identification. In case of a hypoglycaemic episode while exercising, a bracelet
or some identification indicating the person has diabetes might result in faster and more
appropriate help being given. If a person has regular exercise partners, they should be made
aware of the signs and symptoms of hypoglycaemia and how to treat it.
• If blood glucose is >14mmol/L strenuous exercise is not recommended as it may cause the blood
glucose to increase. If there is not enough insulin in circulation, the liver will respond to exercise by
releasing more glucose. In type 1 diabetes, it may also lead to accelerated fat catabolism, ketone
formation and dehydration, this is especially relevant if ketones are already present in the urine.
• To reduce the risk of hypoglycaemia, people on oral agents or insulin should eat before exercising
if the blood glucose is <6mmol/L , more food may be needed during the exercise. It is essential
patients on Sulphonylureas or insulin are aware of how to treat hypoglycaemia appropriately
Page .26
Diabetes Workbook – Level 1
• Special precautions need to be taken when treating hypoglycaemia would prove difficult. Physical
activity under water would be an example. People at risk of hypoglycaemia should plan very
carefully when undertaking activities of this kind.
• People with cardiac history should be taught to exercise within the cardiac comfort zone.
Considerations also need to be given to other co-morbidities such as arthritis and diabetic
complications.
• People with peripheral neuropathy should not undertake weight-bearing exercise. They should be
advised to undertake non-weight-bearing exercise such as exercise bike, swimming etc.
• Exercise that increases blood pressure, and therefore renal perfusion, is contraindicated in people
with nephropathy.
• Caution needs to be taken to avoid a bleed in people with significant diabetic retinopathy.
Key patient messages:
•
Exercise is an integral part of diabetes management.

Recommendations are as for the general population with a minimum of 30 minutes of
moderate activity daily.

The 30 minutes activity can be broken down into smaller blocks with the same benefits as
long as the activity is moderate (ie breathing changes, you can talk but not sing or your body
heat increases)

It is important that people with diabetes are aware of safety considerations.
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Diabetes Workbook – Level 1
Activity
1. A benefit of physical activity specific to type 2 diabetes is that it:
a.
b.
c.
d.
Builds strong bones
Increased insulin sensitivity
Lessens stress
Decreases risk of injury
2. What advice would you give to your friend Alice, who has type 1 diabetes, prior to starting a
game of squash when her blood glucose measures 4.4mmol/L. should she:
a.
b.
c.
d.
Administer 5 units of insulin, wait 5 to 10 minutes then test again
Start her squash match, and stop if she develops symptoms of hypoglycaemia
Eat an easy to digest carbohydrate snack, wait 5 to 10 mins and test again
Warm up properly, stretch and ease into her match
3. When should a patient with diabetes be advised to have a medical check prior to starting an
exercise regime:
a. If they are overweight
b. If they have a history of migraine
c. If they have had diabetes for more than 10 years or have diabetes complications
d. If they have foot problems
Page .28
Diabetes Workbook – Level 1
NUTRITION
Carbohydrates
Carbohydrates should be the main source of energy for the body. Aim for 42 – 50% of total energy
During digestion, complex carbohydrates are broken down to simple sugars like glucose and fructose.
It is important to note that not all complex carbohydrates are broken down at the same rate due to the
glycaemic index of the carbohydrate. The amount and source of carbohydrates should be considered.
It is recommended that carbohydrates come from whole grains, potatoes, pulses, fruit and vegetables
and milk rather than from large amounts from sucrose or other refined sugars.
Carbohydrates are found almost exclusively in plant foods, such as cereals, potatoes, pulses, fruits,
vegetables. Pulses belong to the legume family – peas, beans, lentils.
Milk and milk products, though rich in protein, also contain significant amounts of carbohydrates.
A number of studies regarding the effect of the source of carbohydrates on blood sugar levels show
little or no variation (when adjusted gram for gram). This means that sucrose may be included as a
moderate part of the carbohydrate component in a planned diet, however it is recommended that
sucrose and refined carbohydrates are consumed within the context of a healthy meal to prevent
obesity and dental caries and to optimise nutritional intake.
Fibre
There are two types of fibre: soluble and insoluble and for people with diabetes, there are various
benefits of fibre. Soluble fibre helps slow down the absorption of glucose and reduces the absorption
of dietary fats. Insoluble fibre provides bulk to food and therefore limits the amount of calories
ingested as high-fibre foods – generally, have lower calories. Generally 70g/day is recommended.
Protein
Recommended Daily Intake for protein for adults is 0.8 g high-quality protein/kg body weight/day. 1020% of total energy per day is acceptable (similar to general population) however, 10-15% is a safer
level for people with diabetes. For a person weighing, for example, 70 kg this would give a
recommended daily intake of 56 g of protein/day.
Fats
Fat is a concentrated source of energy. It is an essential macro nutrient and plays several vital roles:
•
•
•
•
•
It provides oil for the skin
It regulates body functions by forming hormones
It insulates and protects internal organs
It carries fat-soluble vitamins throughout the body
It helps repair damaged tissue and helps to fight infections.
Page .29
Diabetes Workbook – Level 1
Total dietary fat should provide < 35% of daily caloric intake. However, important distinctions are made
between the different types of fat in the diet:
•
•
•
Polyunsaturated fats (PUFA) should only be present in up to 10% of total fat intake
Saturated fats and trans-fatty acid intake should be carefully controlled < 7% of total fat intake
Monounsaturated fats (MUFA) should generally be preferred, as they enhance cardiovascular
health.
• Hydrogenated (trans) fats should be avoided.
Fish
Eating at least 1 - 2 portions of fish per week is recommended, one portion of which should be oily fish.
However, care should be taken not to detract from the beneficial effects of eating fish by cooking it in an
unhealthy way, like deep frying or dressing with rich sauces. Oily fish (mullet, kahawai,mackerel, herring,
sardines, trout, salmon) are known to be rich in omega-3 fatty acid – polyunsaturated fatty acids containing
EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). Omega-3 fatty acids are good for the heart
and help to lower mortality rates from heart attack.
Alcohol
Advice for people with diabetes is the same as for the general population: drink alcohol in moderation.
However they do need to be aware of the risk of hypoglycaemia if on sulphonylureas or insulin.
Unfortunately, in many societies, people drink alcohol late in the evening along with rich snacks or a late
dinner – increasing the risk of weight gain and delayed hypoglycaemia. Delayed hypoglycaemia can occur
up to 14 hours after alcohol consumption.
To prevent delayed hypoglycaemia, alcohol should only be consumed with meals containing
carbohydrates.
What are the New Zealand recommended guidelines for alcohol consumption?
For men: __________________________________________________________
For women: ________________________________________________________
Energy
• Both kilocalories (kcal) and kilojoules (kJ) are common units used for describing the amount of energy
liberated by foods
The distribution of calories from carbohydrate and monounsaturated fats can vary depending on the
nutrition assessment and treatment goals: together they should provide 60-70%. Corresponding doses of
glucose-lowering medicines and/or insulin therapy need to be taken to optimise blood glucose levels.
The amount of kcal or kJ intake recommended will vary according to the weight and activity of the
individual and their desire to lower or gain weight, for a specific diet plan a dietitian referral is
recommended.
Page .30
Diabetes Workbook – Level 1
Plate Balance
This is a very useful model to help people increase their non-starchy vegetable intake, and balance
out their carbohydrate and protein intake. Half the plate should consist of non-starchy vegetables.
Non-starchy vegetables have a very low energy density, low levels of carbohydrate, and contain fibre
and many nutrients. They are a healthy food, and have little effect on weight and blood glucose levels.
Non-starchy vegetables include salad vegetables, green asparagus, beetroot, broccoli, brussel
sprouts, butter and green beans, cabbage, carrot, cauliflower, celery, choko, cucumber, egg plant,
kamo kamo, leeks, lettuce, marrow, mushrooms, onion, peas, peppers, puha, pumpkin, silverbeet and
spinach, swede, taro leaves, tomato, watercress, and zucchini.
Starchy vegetables are potato, kumara, swetcorn, parsnip, yams, green banana, taro, cassava and
breadfruit. Include these in the carbohydrate portion of the plate.
One quarter of the plate should be starchy carbohydrate foods which are preferable wholegrain, high
fibre and low G.I. the other quarter should be lean protein (a palm size amount that is the thickness of
the index finger).
If portion sizes are larger than recommended, encouraging the use of a smaller dinner plate will help
reduce portions, while giving the illusion of a larger meal.
Page .31
Diabetes Workbook – Level 1
Label Reading
Label reading is a practical way to assess the nutritional value of food and all people with diabetes should
be given information on this. There is information available on the Diabetes New Zealand website
www.diabetes.org.nz
And The DNZ pamphlet on diabetes and healthy food choices is a good resource for people to take away.
There are also free supermarket shopping tours available through Diabetes Northland & the PHO and as
part of the Diabetes Self Management Course provided through Manaia Heath PHO.
Key patient messages:
•
•
•
•
•
•
•
The DNZ pamphlet on diabetes and healthy food choices is an excellent resource.
There is no such thing as a diabetic diet, the recommended diet is the same as the general
population ie low fat, low sugar, moderate carbohydrate and increased fibre, however people
with diabetes need to be more conscious of the carbohydrate portion of our diet:
Carbohydrates are the only source of glucose directly from our diet and therefore the only part
of our diet directly impacting on blood glucose levels.
Having consistant amounts of carbohydrates (1/4 of our meal) will help keep blood glucose
levels stable.
Carbohydrates include: sugar, fruit, milk, yoghurt (unless sweetened with artificial sweeteners),
cereals, bread, pasta, rice, flour.
Better carbohydrate choices are those lower in fat and with a low glycaemic index (G.I) as Low
G.I foods cause a slower rise in blood glucose levels and also keep you full longer.
Label reading is an important part of dietary management.
Activity
On the following pages assess which of the items would be the best choice out of the various food groups,
and give one reason why you made this choice.
Page .32
Diabetes Workbook – Level 1
A 
B 
C 
D 
Reason for choice _________________________________________________________________
Page .33
Diabetes Workbook – Level 1
A 
B 
C 
D 
Reason for choice _________________________________________________________________
Page .34
Diabetes Workbook – Level 1
A 
B 
C 
D 
Reason for choice _________________________________________________________________
Page .35
Diabetes Workbook – Level 1
A 
C 
B 
D 
Reason for choice _________________________________________________________________
Page .36
Diabetes Workbook – Level 1
A 
B 
C 
D 
Reason for choice _________________________________________________________________
Page .37
Diabetes Workbook – Level 1
A 
B 
C 
D 
Reason for choice _________________________________________________________________
Page .38
Diabetes Workbook – Level 1
Acute Complications
Hyperglycaemia
Any illness can cause hyperglycaemia in patients with Diabetes.
If not managed appropriately this can lead to dehydration and ultimately Diabetic Ketoacidosis
(DKA) in Type 1 diabetes and Hyperosmolar Non Ketotic Acidosis (HONK) in Type 2 diabetes;
both conditions are potentially life threatening.
Acute hyperglycaemia can also be an indication of other conditions such as MI or infection.
Management of Hyperglycaemia is particularly important with Type 1 diabetes and the unwell
elderly because of the higher risk of DKA / HONK.
See Manaia Health PHO hyperglycaemia policy and sick day management advice - appendix 2
Hypoglycaemia
Hypoglycaemia is defined as a blood sugar below 3.5mmol/L
Hypoglycaemia is only problematic if a person is on a sulphonyurea or insulin.
Activity
1. What is the first line of treatment for hypoglycaemia (person is conscious)
____________________________________________________________________________
Give examples: ________________________________________________________________
2. How long after the initial treatment should you retest and give complex carbohydrate?
___________________________________________________________________________
3. How many gram of complex carbohydrate should you give once blood glucose levels are back
over 4.0?
__________ g
Give examples_________________________________________________________________
_____________________________________________________________________________
Page .39
Diabetes Workbook – Level 1
Long Term Complications
Prevention of diabetes complications
Diabetes can affect many parts of the body and can lead to serious complications such as blindness,
kidney damage, and lower-limb amputations. Working together, people with diabetes and their health care
providers can reduce the occurrence of these and other diabetes complications by controlling the levels of
blood glucose, blood pressure, and blood lipids and by receiving other preventive care practices in a timely
manner.
Glucose control

Research studies have found that improved glycemic control benefits people with either type 1 or
type 2 diabetes. In general, for every 1% reduction in results of A1C blood tests (e.g., from 8.0% to
7.0%), the risk of developing microvascular diabetic complications (eye, kidney, and nerve disease)
is reduced by 40%. Keeping blood glucose levels in the recommended range (HbA1c <7.0%)
reduces the risk of complications to similar the non diabetic population.
Blood pressure control


Blood pressure control can reduce cardiovascular disease (heart disease and stroke) by
approximately 33% to 50% and can reduce microvascular disease (eye, kidney, and nerve disease)
by approximately 33%.
In general, for every 10 millimeters of mercury (mm Hg) reduction in systolic blood pressure, the risk
for any complication related to diabetes is reduced by 12%.
Control of blood lipids

Improved control of cholesterol or blood lipids (for example, HDL, LDL, and triglycerides) can reduce
cardiovascular complications by 20% to 50%.
Preventive care practices for eyes, kidneys, and feet

Detecting and treating diabetic eye disease with laser therapy can reduce the development of
severe vision loss by an estimated 50% to 60%.
Diabetes is associated with retinal, renal, neurological and cardiovascular complications. It causes 24,000
new cases of blindness annually. Diabetes is the leading cause of end-stage renal disease and increases
the risk for cardiovascular disease fourfold. Many of the complications of diabetes are associated with
breakdown of the microvasculature.
Page .40
Diabetes Workbook – Level 1
DCCT Study
These vascular-related complications are preventable through tight control of diabetes. The Diabetes
Control and Complications Trial (DCCT) showed that sustained reduction in glucose levels result in
striking risk reduction (Figure below). Even more dramatic reductions are expected from the nearperfect glycemia provided by the Islet Sheet.
Page .41
Diabetes Workbook – Level 1
Microvascular Complications
Retinopathy
Diabetic retinopathy is a complication of diabetes that results in damage to the network of capillaries
that supply the retina.
Background Retinopathy occurs when normal blood vessels develop tiny bulges. If retinopathy
worsens & becomes proliferative, new weak blood vessels form outside the retina.
Healthy Eye
Proliferative Retinopathy
In its initial stages diabetic retinopathy is a silent condition. People can often see well until they have a
bleed in the eye. When symptoms do occur the disease is generally quite advanced. This makes
treatment much more difficult and the outcome much poorer. Therefore, regular screening to look for
retinopathy is a cornerstone for diabetes assessment.
Blurred vision is a common symptom in diabetes. People experience osmotic changes in the lens due
to fluctuating blood glucose levels, in other words the lens changes shape, and the vision becomes
blurred. This terrifies many people as they fear it is the beginning of blindness. They have to be
reassured that the blurred vision will improve several weeks after the blood glucose levels have settled.
Also they should be advised not to get spectacles (glasses) during this period.
Page .42
Diabetes Workbook – Level 1
Nephropathy
Risk factors:

Poor glycaemic control

Hyperlipidaemia

Hypertension

Genetic predisposition

Glomerular hyper-filtration during early period

Ethnicity

Long disease duration

Smoking
Diabetic nephropathy
Curriculum Module III-7b
Slide 5 of 37
Natural history of diabetic nephropathy
Acute renal hypertrophy-hyperfunction
Normoalbuminuria
10 to 15 years
Microalbuminuria
(incipient diabetic nephropathy)
Proteinuria
(clinical overt diabetic nephropathy)
Chronic renal failure
Slides current until 2008
Diabetic nephropathy
Protein, microalbuminuria and
macroalbuminuria
Curriculum Module III-7b
Slide 6 of 37
• Protein
Albumin
Albumin Excretion Rate
• Microalbuminuria:
30-300 mg/24 hr
20-200 µg/min
2.5-25 mg/mmol (men)
3.5-35 mg/mmol (women)
• Macroalbuminuria:
>300 mg/24 hr or
>200 µg/min
>25 mg/mmol (men)
>35 mg/mmol (women) Slides current until 2008
Page .43
Diabetes Workbook – Level 1
The glomerular capillary wall normally limits the filtration of macromolecules by size selective
properties.However, when the kidney is damaged, one of the warning signs is that its filtering system is
affected and molecules like protein are leaked into the urine. One of these proteins is called albumin. If
small amounts of albumin are leaked this is called microalbuminuria.Once more than 300 mg per day of
albumin, this is called macroalbuminuria.
Macroalbuminuria just means that more protein is leaked by the kidney than in microalbuminuria.
Particularly at levels less than 70 mg/day, microalbuminuria can be transient.
If a person has low levels of microalbuminuria, it is important to take into consideration some factors that
may affect albumin levels, if any of these are present, another test will have to be carried out at a later
date:
 Exercise
 Menstruation
 Pregnancy
 Poor glycaemic control
 Urinary Tract Infection
 Hypertension
 Cardiac failure
Once patients have microalbuminuria, intensive interventions such as improving control and treatment with
an anti-hypertensive medication should be undertaken.
In type 1 diabetes, microalbuminuria is a sign of developing diabetic nephropathy.
In type 2 diabetes, it may even be present at diagnosis and is more a marker for increased risk for
cardiovascular morbidity and mortality.
People with type 2 diabetes and microalbuminuria have a 20-fold increased risk of a macrovascular event.
Microalbuminuria can be reduced and the progression slowed by tight glycaemic control.
Unfortunately once the person has developed overt proteinuria, improving glycaemic control has little
benefit in slowing the progression of disease. What is far more important is intensive blood pressure (BP)
treatment. Guidelines suggest a target BP <130/80 mmHg.
It is also important to reduce salty foods in the diet. There is evidence that the antihypertensive drugs are
more effective when salt intake is reduced. The principle is to improve overall health and well-being of
people with renal failure. Adequate intake of calories is important; these give the body energy and maintain
a healthy weight. A balanced diet with carbohydrates, protein, fat, fibre, vitamins and minerals, and calcium
is recommended. Fluid may be limited in chronic kidney disease (CKD) but not at the earlier stage. The
evidence base for protein restriction in diabetes is weak but some clinicians suggest limiting protein intake
to 0.8 g/kg daily if the person is proteinuric.
In summary, diabetes is a common cause of CKD. It is important to remember that there are grades of
diabetic nephropathy. We should try to find changes early; interventions are most effective early in the
course of the disease.
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Diabetes Workbook – Level 1
Neuropathy – Damage to nerve fibres
The damage occurring to nerve fibres is thought to occur when high blood glucose levels cause
chemical changes in nerves. These changes impair the nerves ability to transmit signals. High blood
glucose levels also damage blood vessels that carry oxygen and nutrients to the nerves.
Diabetic neuropathy involves disturbance of function & pathological changes in the peripheral &
autonomic nervous system.
Peripheral Neuropathy is the most common type which mainly affects the feet and is often worse at
night. Symptoms may include:
 Diminished sensation (inability to feel 10g monofilament is an early test)
 Burning, tingling or prickling sensation
 Numbness oo insensitivity to touch, even light touch
 Loss of balance & coordination (reduced proprioception)
Autonomic Neuropathy
- Affects the nerves that serve the heart & internal organs, which may result in:
- Postural hypotension
- Erectile Dysfunction
- Diarrhoea
- Urinary retention
- Predisposition to cystitis
Cardiovascular Neuropathy
Associated with abnormalities of heart rate control and vascular response.
Patients with this may have an abnormal response to exercise & may fail to increase their
cardiovascular output or vascular tone with exercise resulting in hypotension. Aerobic exercise should
then be avoided.
Genitourinary Neuropathy
Neurogenic bladder develops insidiously & progresses slowly. Overflow incontinence & recurrent
UTI’s may occur.
Sexual dysfunction in men often involves changes in libido, erectile ability and ejaculation. Impotence
may be related to autonomic neuropathy but other causes should not be excluded. Women may also
have sexual difficulties including arousal, painful intercourse and nonorgasmic response.
Gastro-intestinal
Upper gastro intestinal motility disorders may cause symptoms of dysphagia, heartburn, reflux,
anorexia, bloating, early satiety, upper abdominal pain, nausea and vomiting. Constipation and
diarrhea can also be associated with longstanding autonomic neuropathy.
Treatment of gastroparesis includes improvement of glycaemic control & dietary modification with
small, low fat, low fibre and liquid meals. Pharmacological treatment may also be necessary.
Sweating disturbances
Can involve diminished or absent sweating in the feet or increased sweating over the upper body.
Gustatory sweating involving the face, scalp, neck and shoulder can occur while eating certain foods.
Hypoglycaemic unawareness
The metabolic response to hypoglycaemia is largely mediated from the autonomic nervous system.
Autonomic neuropathy may result in a loss of hypoglycaemic warning signs.
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Diabetes Workbook – Level 1
However other factors may contribute to this (regular frequent hypoglycaemia may result in temporary
unawareness which can be regained by a 2 – 4 weeks of higher blood sugars with no hypoglycaemia).
Patients who do not recognise hypoglycaemia need extensive education and support and may require
adjustment of their glycaemic goals.
Activity
1. How often should someone with diabetes be screened for retinopathy?
a.
b.
c.
d.
Annually
On diagnosis and every 2 years
Whenever they have vision problems
Every 5 years
2. When should someone newly diagnosed with Type 1 diabetes have their first eye
screen?
a.
b.
c.
d.
Within 5 years
On diagnosis
When they have vision problems
2 years after diagnosis
Macrovascular Complications
Cardiovascular Disease
Macrovascular disease is a very serious complication of diabetes and is the most common cause of
increased morbidity and mortality in diabetes.
It is very important to recognise that diabetes is much more than a blood glucose disease and to learn
about how the macrovascular risk factors that contribute to this increased risk of morbidity and
mortality can be identified and reduced.
The underlying abnormality is atherosclerosis.
The definition of hypertension is when the blood pressure is greater than 140/90 mmHg. However, the
target in diabetes is tighter than this and a blood pressure of less than 130/80 mmHg is
recommended.
Achieving this can be difficult and it is common that three or more anti-hypertensive agents are
required. However, common practice is that when the blood pressure is not reduced with one drug,
the person is taken off that medication and a new one is tried. In reality what is needed is to keep
adding antihypertensive agents to the regimen until the target blood pressure is achieved.
Peripheral Vascular Disease
Peripheral vascular disease (PVD) is a disease of the peripheral blood vessels characterised by
narrowing and hardening of the arteries that supply the legs and feet with resulting decrease in blood
flow.
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Diabetes Workbook – Level 1
Diabetic Foot
Diabetes foot complications involve both microvascular and macrovascular disease often involving both
neuropathy and peripheral vascular disease.
Complications usually arise after 10 years of elevated blood sugars
It can affect the blood supply to the foot (peripheral vascular disease )leading to ulceration and the
nerves in the feet (neuropathy) leading to trauma, foot deformity and ulceration.
Diabetes is the most common cause of non-traumatic amputation.
It is estimated that 15% of people with diabetes will develop a foot ulcer in their lifetime and even more
will have wounds unrelated to their diabetes which will be complicated by their condition.
What to look out for:
1. Poor blood supply to feet – (Peripheral Vascular disease / PVD) can be macro or
microvascular
Macrovascular (large vessels – leg):
 Change in colour
 Diminished foot pulses
 Pain – cramps on exercise, foot pain when resting can be
an indication
 Hair loss
 Thickened toenails/ nail loss
 Ulcers
 Skin cool to touch
 Shiny appearance of skin
 Gangrene
Microvascular











Change in colour to toes
Pain/ numbness in toes
Slow capillary refill time
Slow healing wounds
Nerve Damage (Neuropathy)
Numbness and pins and needles in feet
Foot pain – sharp/ stabbing/ burning
particularly at night.
Foot deformity
Change in gait
Poor proprioception
Callus/corns
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Diabetes Workbook – Level 1
The High Risk Foot
People with diabetes who have peripheral vascular disease + neuropathy or who have history of previous
ulceration or amputation or have a foot deformity are considered to be High Risk, these people should be
referred to the NDHB podiatrist for funded podiatry care and regular assessment.
Unfortunately people not considered high risk are unable to have funded podiatry care at this time,
however some may be eligible for podiatry care under a disability allowance.
See foot assessment and podiatry referral criteria – appendix 3
Activity
You have a patient visit for their annual diabetes check.
As part of the foot assessment you find they have good protective sensation with the monofilament, good
blood supply and apart from some callus around the heel they have no obvious foot pathology.
What foot care advice would you give them?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Diabetes Workbook – Level 1
Annual Diabetes Free Check (AFC)
The free annual check is the foundation for diabetes services. It is designed to improve the
co-ordination of services delivered by all health care providers.
AFC Objectives:
• Screen for risk factors and complications
• Promote early detection and intervention
• Agree on an updated treatment plan
• Update information on diabetes register – basis for clinical audits and to plan for diabetes
improvements in the area
• Prescribe treatment and refer on to specialists or other providers
What needs to be included:
• Review of symptoms and concerns of the person and whanau
• Examination for risk factors, must include foot check and advice on foot care
• Fasting blood test – HbA1c, cholesterol and urine test for nephropathy
• Prescription for meds, test strips, meters (as required)
• Information for the person and their consent for the use of information
• Treatment plan or equivalent (ie careplan in association with Careplus) should be provided in writing
and verbally to the person with diabetes as well as other providers of diabetes support (ie Whanau)
Currently in Manaia Health PHO Medtech practices, the Diabetes Get Checked is completed using the
TIM template which when complete is automatically sent to the Kaipara Database for information
collection and payment to the practice, Profile practices currently will need to complete and fax a
manual form.
Page .49
Diabetes Workbook – Level 1
Diabetes Annual Check – Audit
Date: ____________________
Name of nurse being reviewed: ______________________________________________
What should be covered
Assure patient is aware of the Get Checked
process and the reasons for it and consent
gained for use of the information gathered.
Comments
Patient assessment:
Assess the patients:
- understanding of diabetes, glycaemic
control, medical history, modifiable risk
factors, support network, current medications
and safety are assessed
Blood Glucose Control:
 Does the patient test blood sugars, if
so how often and how do they use the
information.
 Check patients record book/meter and
look for trends, ask if patient has any
symptoms/concerns ( thirst, polyuria,
tiredness, infection, blurred vision)
 Check recent HbA1c – when last
done, does patient understand what it
shows.
Diabetes Medication:
 Assess current medications
 Are their any barriers to taking them
as prescribed.
 Are they aware what the medication is
for, when they should take it, side
effects.
 Is the medication effective?
 Arrange prescription if needed.
Blood Pressure (should be 130/80 or less)
 If higher than recommended, what
medications is the patient on, are they
taking them correctly, do they have
side effects, are they aware of the
implications of high blood pressure?
Page .50
Diabetes Workbook – Level 1
 Discuss with GP
Blood Cholesterol: (aim: TC <4mmol,
LDL <2.5mmol, HDL < 1.0mmol, TC/HDL
ratio<4.5mmol, Triglycerides <1.7mmol)
 When did the patient last have a lipid
profile done?
 Has it changed since previous test?
 Does the patient understand what
cholesterol is and dietary
management?
Kidney Function:
 Check serum creatinine + MSU for
microalbumin
 If newly elevated suspect renal
disease notify GP ? ACE inhibitor if
not already on this.
Weight: Height/weight to ascertain BMI
Retinal Screening:
 Has patient had retinal screening in
the last 2 years, if not refer to Diabetes
Service
 Assess patient understanding of retinal
screening is and why it is important?
Foot Check:
 Physical check – pulses, foot colour,
monofilament, check for foot
deformity signs of pressure
(callus/corns/redness/bruising), any
wounds.
 Assess if patient has any foot pain or
cramps
 Assess patient understanding of how
to check and care for their feet, give
verbal and written information if
required
 If foot pathology refer to podiatrist
Food Choices:
 Assess patients understanding of
healthy eating and any barriers to
eating well.
 Give verbal/written information of
required
 If patient would like further or more
complex dietary information refer to
dietitian
Page .51
Diabetes Workbook – Level 1
Physical Activity:
 Assess patients current activity
 Are they aware of the benefits of
activity
 Would a green prescription be of
benefit to them?
Smoking:
 Does the patient smoke and if so how
much.
 Are they aware of the risks?
 Do they wish to stop, if so consider
referral to smoking cessation
programme.
Alcohol:
 Is the patient aware of recommended
guidelines and safety aspects of
alcohol and diabetes?
Care planning:
 A plan of care is made with the patient
which is individualised, based on the
assessment and realistic and
achievable
 Care plan is clearly documented and a
copy given to the patient
Documentation
Assessment documented on Get Checked
template and summary in patient notes
Ensure annual recall is set up
Diabetes Nurse Specialist ___________________________________________________________
Page .52
Diabetes Workbook – Level 1
Diabetes Knowledge Questionnaire
(please complete when workbook is finished)
1. How would you rate your general knowledge around diabetes?
0
1
2
3
limited
4
5
6
7
average knowledge
8
excellent knowledge
2. How confident are you in providing Diabetes education to patients?
0
1
2
3
Not at all confident
4
5
6
7
slightly confident
8
very confident
3. How confident are you to complete an Annual Free Diabetes Check? (Get Checked)
0
1
2
3
Not at all confident
4
5
6
7
slightly confident
8
very confident
4. Characteristics of Type 2 diabetes include:
a.
b.
c.
d.
e.
relative insulin deficiency
insulin resistance
decline in beta cell function
All of the above
Only b and c





5. Diabetes Ketoacidosis only occurs in Type 1 diabetes:
a. True
b. False


6. The first line in medication treatment for Type 2 diabetes is:
a.
b.
c.
d.
Metformin
Glipizide
Diamicron
Actos




7. If a patient has just been prescribed a sulphonylurea what is the most important thing to
discuss with them:
a.
b.
c.
d.
What and when to eat
When to take the medication
How to recognize and treat hypoglycaemia
When to visit the doctor again




Page .53
Diabetes Workbook – Level 1
8. Which food does not contain carbohydrate
a.
b.
c.
d.
Milk
Bread
Chicken
Apple




9. Blurred vision is a common symptom of retinopathy
True
False


10. Complications of diabetes usually arise after:
a.
b.
c.
d.
10 years of diabetes
5 years of diabetes
15 – 20 years of diabetes
1 – 5 years of diabetes




Page .54
Diabetes Workbook – Level 1
Evaluation
It would be appreciated if you could take a moment to complete an evaluation of this workbook.
1. The workbook met my expectations..
0
1
2
Strongly disagree
3
4
disagree
5
6
7
agree
8
strongly agree
2. I have gained knowledge that will benefit my practice …
0
1
2
Strongly disagree
3
4
disagree
5
6
7
agree
8
strongly agree
3. The information was …
0
1
2
Difficult to understand
3
4
5
6
moderately clear
7
8
easy to understand
4. The length of the workbook was…
0
1
Just right
2
3
4
5
too short
6
7
8
too long
5. I am interested in a more advanced workbook..
Yes 
No 
Comments:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Thank you!
Page .55
Diabetes Workbook – Level 1
Page .56
Diabetes Workbook – Level 1
APPENDIX 1
Page .57
Diabetes Workbook – Level 1
Page .58
Diabetes Workbook – Level 1
Care pathway for initiation of insulin therapy in Type 2 Diabe
Blood Glucose targets not reached.
HbA1c >8%
Prior to Insulin Initiation:
 Consider dietary and lifestyle interventions
 Maximise Oral therapies including possible use of
Glitazone therapy
Patient is willing and able to start insulin therapy:
 Discuss target blood glucose levels
 Prescribe insulin:
- Penmix 30 or Humulin 30/70
- Usual starting dose 0.2 – 0.3 units/kg body wt/bd
- Titrate dose up depending on blood glucose results
- Usually stop Sulphonylurea, Glitazone, may
continue Metformin
If Patient is reluctant to start insulin, consider continuing
with oral therapies and adding intermediate acting insulin
once daily. (0.2 – 0.3 units/kg body weight)
Refer to Manaia PHO Diabetes Nurse
Specialist for:


Insulin initiation/support & education
Insulin dose titration until blood glucose
targets reached :
(fasting < 6.0, post prandial < 8.0 – 10.0 mmo
:
Unable to initiate
insulin in Primary Care
Refer to Secondary Diabetes Service
Page .59
Diabetes Workbook – Level 1
Page .60
Diabetes Workbook – Level 1
APPENDIX 2
Page .61
Diabetes Workbook – Level 1
Page .62
Diabetes Workbook – Level 1
Hyperglycaemia
Standard
All patients referred to the Manaia Health PHO Diabetes Resource Nurse who present at clinic with hyperglycaemia
(defined as capillary blood sugar above 15.0) will be managed appropriately.
Rationale
Any illness can cause hyperglycaemia in patients with Diabetes, if not managed appropriately this can lead to
dehydration and ultimately Diabetic Ketoacidosis (DKA) in Type 1 diabetes and Hyperosmolar Non Ketotic Acidosis
(HONK) in Type 2 diabetes; both conditions are potentially life threatening.
Acute hyperglycaemia can also be an indication of other conditions such as MI or infection.
Management of Hyperglycaemia is particularly important with Type 1 diabetes and the unwell elderly because of the
risk of DKA / HONK.
Method
Treatment of Hyperglycaemia
Type 1 Diabetes
1. Assess significance:












How severe are the symptoms
Any obvious reason for loss of control
Has the patient omitted therapy
Is the insulin degraded from freezing or direct sunlight
Are the insulin pens functioning properly
Is there a history of poor glycaemic control
Are there signs of infection, chest, wound, UTI
Are there features of acute myocardial infarction
Recent steroids
Recent major emotional trauma
Any evidence of depression or eating disorder
Don’t assume nausea and vomiting secondary to gastro-enteritis
2. Carry out a full physical assessment including urine for ketones, capillary
glucose and assessment of mental alertness.
3. Admission to Hospital Emergency Dept is advised in collaboration with the
patients GP in the following circumstances:
Page .63
Diabetes Workbook – Level 1
- Heavy Ketonuria (2+ or more) and/or:
The patient is:
- vomiting and dehydrated
- drowsy
- hypotensive
- Clearly very ill but the cause is not apparent
- Not able to care for self
- Has a major acute infective or vascular episode
4. If small to moderate ketones and not vomiting recommended care for patient
at home:







Deal with any immediate medical issues before going home
Initiate hourly short acting insulin SC (4 – 6 units per hour) in consultation with patients GP.
Patient to maintain fluid intake – 1 glass low joule fluid hourly
Patient to monitor symptoms, blood glucose hourly and urine for ketones
Patient to maintain contact with Diabetes Resource Nurse or GP/ practice nurse per phone minimal 2
hourly
If blood sugars remain consistently over 15.0 or the patient is increasingly unwell, the patients GP should
be notified and the patient referred to the Hospital Emergency Dept.
If successful the patient is to continue until glucose < 10 then revert to usual insulin doses.
Type 2 Diabetes
1. Assess significance (as in Type 1 Diabetes above)
2. If patient is well and hx of high blood glucose levels:

Consider possibility of lifestyle change or medication change in consultation with GP
3. If patient is unwell :





Advise patient to test blood sugars 2 – 4 hourly
If blood sugars remain > 15 for more than 24 hours or blood sugars continue to climb, patient to return to GP.
If nausea and vomiting – continue sulphonylurea/ insulin, Metformin should be discontinued because of
increased risk of Lactic acidosis.
Patient to maintain fluid intake 1 glass low joule fluid hourly
If on medication – if possible eat small amounts of low fat foods eg dry toast, soup to prevent hypoglycaemia
Nursing Considerations


Medical team – General Practitioner/ Practice Nurse needs to be aware of hyperglycaemic events. It may be
necessary to investigate cause or review management plan.
Once patient is stabilised they should be contacted per phone by the Diabetes Resource Nurse or Practice
Nurse within one week to assess glycaemic control.
Page .64
Diabetes Workbook – Level 1
APPENDIX 3
Page .65
Diabetes Workbook – Level 1
Page .66
Diabetes Workbook – Level 1
PODIATRY ASSESSMENT
Medications:
__________________________________________________
__________________________________________________
Wound: No
□
Yes
□
Date of wound occurance: ____________________________
Aetiology: _________________________________________
Site: ______________________________________________
Neurological
Label diagram with a + in the circled area of the foot if the patient can feel the 10G monofilament and – if they
cannot feel 10G monofilament.
Neuralgia: No
□ Yes □
intermittent
□ continuous □
Vascular
Page .67
Diabetes Workbook – Level 1
Dorsalis Pedis:
Posterior Tibial:
□ Reduced □ Absent □
Normal □ Reduced □
Absent □
Normal
Capillary refill time ____________ secs
Hair Loss: No
Cramps:
No
□ Yes □
□ Yes □
on exercise
a rest
□___ metres/mins
□
Biomedchanical / orthopaedic
Location
Description
Deformity
Skin lesion
Cellulitis
Other
Skin Condition
Location
Hyperhydrotic
Anhydrotic
Maceration
Infection: Bacterial
Fungal
Nail Condition
Normal:
Thickened:
Ingrowing:
Page .68
Diabetes Workbook – Level 1
Criteria for Secondary Services Podiatrist NDHB
1. Neuropathy
Evidenced by:
+ PVD
Evidenced by:
 Inability to feel monofilament
in more than 3 areas
+ 2 of following:




Dry skin
Poor proprioception
Callous formation
Parathesia







Foot pulses not palpable + 2
or more of following:
Capillary refill > 5 secs
Poor colour of foot
Shiny appearance of foot
Hair loss on feet and toes
Intermittant claudication &
rest pain
Blanching on elevation
2. Foot Ulcer/ Past history of ulceration
3. Past history of amputation
Page .69