Managing diabetes

Diabetes can be managed by carefully monitoring some key indicators for each individual. NICE 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)
  • feet check.

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.

Explore the interactivity below to see how the '15 Healthcare Essentials' fit into these four categories.

What is a good blood glucose level?

NICE guidelines for the UK currently recommend the following:

The target blood glucose ranges below are indicated as a guide.

Children with Type 1 diabetes (NICE 2015)

• on waking and before meals: 4–7mmol/l
• after meals: 5–9mmol/l.

Adults with Type 1 diabetes (NICE 2015)

• on waking: 5–7mmol/l
• before meals at other times of the day: 4–7mmol/l
• 90 minutes after meals: 5–9mmol/l.

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 (NICE 2015)

• fasting: below 5.3mmol/l and

• 1 hour after meals: below 7.8mmol/l or
• 2 hours after meals: below 6.4mmol/l

  • a normal pre-prandial (before meal) blood glucose level will be between 4 and 7 mmol/l
  • after eating (post-prandial) levels should be below 9 mmol/l when tested 2 hours after a meal
  • when going to bed for the night, levels should be no more than 8 mmol/l.

When should blood glucose levels be measured?

The number of times per day the patient 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

  • Type 1 diabetes patient using insulin should check their blood glucose levels before every meal, sometimes as often as ten times per day
  • some type 2 diabetes patients may measure their glucose levels and would normally test daily
  • type 2 diabetes is a progressive condition and even with metformin and diet only, patients may need to test their blood glucose periodically to observe trends in rising blood glucose.

Self-management of blood glucose levels by the patient

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 ‘normal’ level 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 patient and the 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.

Flash monitoring

Flash monitoring is an exciting new technology that has become popular amongst people with diabetes, despite not yet being available on the NHS

Flash Glucose Monitoring is an alternative to finger-prick testing. Abbott’s Freestyle Libre is the only device of its kind on the market.

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. By scanning or 'flashing' the sensor with a scanning device you get a) glucose level b) a graph of glucose level for the last 8 hours c) a direction arrow showing if levels are going up or down. The device also stores your data and makes it easy to view patterns over time.

Advantages:

Painless insertion; reduction in finger pricking; easier to identify trends and improve control; ability to test more regularly; easier than finger-pricking in lots of situations (on tube, in rain, in cold, during sport, driving); less social stigma than finger pricks; inexpensive compared to CGM and strips; some people preferred the arm as a location rather than stomach; some people like that it doesn't alarm; data accessibility is better than some other devices.

Disadvantages:

It can gave inaccurate readings it blood glucose levels are changing rapidly. Some users have reactions to the adhesive; and costs around £1300 per year; the device (and educational support for it) are not currently available on the NHS. The DVLA do not allow it to be used before driving. A finger prick blood glucose must be used.

Blood glucose testing (HbA1c)

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. The HbA1c test is usually done in hospital or a GP clinic and then sent to a laboratory and is usually checked at 6 monthly intervals. The HbA1c test is carried out by a health care professional. It primarily measures the levels of HbA1c in the blood to identify the average plasma glucose concentration over the previous six to twelve weeks. Different HbA1c scores show good, fair, poor and bad control of diabetes. Increasing levels of HbA1c indicate a greater risk of complications.

A high HbA1c level indicates that the patient’s blood glucose level has been consistently high over recent weeks, and means that their diabetes treatment plan may need to be changed. The diabetes health care team should work with the patient and help them set a target HbA1c level to aim for. Generally this will be less than 53 mmol/l HbA1c (7%) but it can be as low as 48mmol/l (6.5%) for some people. HbA1c targets will be individual for each person as an HbA1c of below 53 mmol/l (7%) may not be appropriate for some people for example the elderly where the risk of hypoglycaemia is greater and may lead to a fall.

Ketone levels

If a patient, with type 1 diabetes, has sustained high blood glucose readings it is an indication that they either don’t 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 protein in order to get some energy. In these circumstances ketone testing is crucial. The body finds a way to keep going where it has no other way to gain energy. Ketones are made when the body breaks down proteins. As the ketones build up in the body, this can be damaging, and is referred to as a state of ketoacidosis, or in diabetes, Diabetic Ketoacidosis (DKA). Most people with type 2 diabetes will not develop ketonuria but people with type 1 diabetes are at risk of DKA.

The urine test to detect ketones is quite simple and involves dipping a chemical test strip in urine or wetting the test strip in a stream of urine. A blood test can also be carried out in similar way to blood glucose testing. Ketone testing is recommended for patients with type 1 diabetes. Diabetes UK recommends testing for ketones if blood glucose levels become high - usually above 15 mmol/l. 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.

Blood pressure

The blood pressure of a person without diabetes should be no higher than 140/85. However, when a person has diabetes their blood pressure should be no higher than 130/80. This is also the case if they have had a heart attack, stroke or coronary heart disease. In England, although over 90% of patients with diabetes have their blood pressure checked, only 50% are achieving their target blood pressure.

The patient’s blood pressure should be checked at least once a year as part of an annual diabetes review. This helps to ensure that their blood pressure is within the target range and not increasing their risk of developing diabetes complications which include cardiovascular disease (CVD). You can find more details on how to take a blood pressure on the 'first steps' link in the useful resources section of this course.

Blood fats

The lipids (or fats) in a person’s blood are made up of cholesterol and triglycerides. These lipids are found in all of us. A simple blood test can be carried out to determine blood lipid levels. Not all cholesterol is bad. High Density Lipoprotein (HDL) cholesterol can protect against heart disease. Low levels of HDL can increase the risk of cardiovascular disease (CVD). Low Density Lipoprotein (LDL) cholesterol is the bad form of cholesterol in the blood. High levels of this type of cholesterol are linked with an increased risk of CVD.

Triglycerides are another type of fat in the blood. If a patient has raised cholesterol and raised triglycerides they have an increased risk of CVD.

The recommended blood lipid levels are:

  • total cholesterol level should be below 4.0mmol/l
  • HDL levels should be 1.0mmol/l or above in men and 1.2mmol/l or above in women.
  • LDL levels should be less than 2.0mmol/l
  • Triglyceride levels should be 1.7mmol/l or less

Targets for people with diabetes are lower than for the rest of the population as they are at increased risk of CVD. It is always wise to check your patient's records to confirm their correct targets. Although most patients with diabetes have their cholesterol checked, less than 40% (in England) achieve their target (Source: State of the Nation). Try to encourage your patient to adopt a more healthy lifestyle, including making changes to their diet, increasing their exercise and seeking advice from their GP for medication that can help. You can find out more information in the section on Treatments for Diabetes.

What happens if good blood glucose control is not maintained?

If diabetes is not diagnosed and treated it can lead to many different health problems. A slightly raised glucose level that does not produce any symptoms can prove damaging in the long term. High levels of glucose can cause damage to blood vessels, nerves and organs. This can result in:

• heart disease (Myocardial Infarction i.e heart attack)

• cerebral Vascular Accident (CVA or stroke)

• peripheral vascular disease (PVD

• nerve damage (neuropathy)

• vision damage (blindness due to retinopathy)

• kidney disease (nephropathy)

• foot problems (limb amputation)

• sexual (erectile dysfunction) and fertility problems.

Explore the animated body images below to see the extent of the health complications that can arise from long term, poorly controlled diabetes. Note: all the conditions described on the body images can affect men and women.

Blood glucose levels

The level of blood glucose literally refers to the concentration of glucose in the blood, sometimes called the serum glucose level. This figure is expressed as millimoles per litre (mmol/l). In people without diabetes this amount usually remains stable at around 4-7mmol/l. Blood glucose levels will usually be at their lowest in the early mornings with spikes occurring following meals. Blood glucose levels fluctuate more widely in people with diabetes. Over a sustained period of time high levels of glucose present in the blood will damage the blood vessels. Poorly controlled blood glucose levels can increase a patient’s chances of developing diabetes complications including nephropathy, neuropathy, retinopathy and cardiovascular diseases. These complications usually develop over years rather than days or months. It is especially important to be vigilant for the signs of diabetes as type 2 diabetes is often not diagnosed until a relatively late stage.


A ‘normal’ blood glucose level would be one that is within the range of those of a person who does not have diabetes. Opinions differ about the ideal range to aim for in a patient with diabetes as this is individual to each person. For this reason the target levels will need to be agreed between the patient and the diabetes team. View the interaction below to learn more about the key factors of: normal blood glucose levels; when blood glucose should be measured; self-management of blood glucose levels; blood glucose testing; ketone levels; blood pressure; and blood fats.

What is a good blood glucose level?

NICE guidelines for the UK currently recommend the following:

The target blood glucose ranges below are indicated as a guide.

Children with Type 1 diabetes (NICE 2015)

• on waking and before meals: 4–7mmol/l
• after meals: 5–9mmol/l.

Adults with Type 1 diabetes (NICE 2015)

• on waking: 5–7mmol/l
• before meals at other times of the day: 4–7mmol/l
• 90 minutes after meals: 5–9mmol/l.

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 (NICE 2015)

• fasting: below 5.3mmol/l

and

• 1 hour after meals: below 7.8mmol/l or
• 2 hours after meals: below 6.4mmol/l

  • a normal pre-prandial (before meal) blood glucose level will be between 4 and 7 mmol/l
  • after eating (post-prandial) levels should be below 9 mmol/l when tested 2 hours after a meal
  • when going to bed for the night, levels should be no more than 8 mmol/l.

When should blood glucose levels be measured?

The number of times per day the patient 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

  • Type 1 diabetes patient using insulin should check their blood glucose levels before every meal, sometimes as often as ten times per day
  • some type 2 diabetes patients may measure their glucose levels and would normally test daily
  • type 2 diabetes is a progressive condition and even with metformin and diet only, patients may need to test their blood glucose periodically to observe trends in rising blood glucose.

Self-management of blood glucose levels by the patient

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 ‘normal’ level 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 patient and the 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.

Flash monitoring

Flash monitoring is an exciting new technology that has become popular amongst people with diabetes, despite not yet being available on the NHS

Flash Glucose Monitoring is an alternative to finger-prick testing. Abbott’s Freestyle Libre is the only device of its kind on the market.

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. By scanning or 'flashing' the sensor with a scanning device you get a) glucose level b) a graph of glucose level for the last 8 hours c) a direction arrow showing if levels are going up or down. The device also stores your data and makes it easy to view patterns over time.

Advantages:

Painless insertion; reduction in finger pricking; easier to identify trends and improve control; ability to test more regularly; easier than finger-pricking in lots of situations (on tube, in rain, in cold, during sport, driving); less social stigma than finger pricks; inexpensive compared to CGM and strips; some people preferred the arm as a location rather than stomach; some people like that it doesn't alarm; data accessibility is better than some other devices.

Disadvantages:

It can gave inaccurate readings it blood glucose levels are changing rapidly. Some users have reactions to the adhesive; and costs around £1300 per year; the device (and educational support for it) are not currently available on the NHS. The DVLA do not allow it to be used before driving. A finger prick blood glucose must be used.

Blood glucose testing (HbA1c)

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. The HbA1c test is usually done in hospital or a GP clinic and then sent to a laboratory and is usually checked at 6 monthly intervals. The HbA1c test is carried out by a health care professional. It primarily measures the levels of HbA1c in the blood to identify the average plasma glucose concentration over the previous six to twelve weeks. Different HbA1c scores show good, fair, poor and bad control of diabetes. Increasing levels of HbA1c indicate a greater risk of complications.

A high HbA1c level indicates that the patient’s blood glucose level has been consistently high over recent weeks, and means that their diabetes treatment plan may need to be changed. The diabetes health care team should work with the patient and help them set a target HbA1c level to aim for. Generally this will be less than 53 mmol/l HbA1c (7%) but it can be as low as 48mmol/l (6.5%) for some people. HbA1c targets will be individual for each person as an HbA1c of below 53 mmol/l (7%) may not be appropriate for some people for example the elderly where the risk of hypoglycaemia is greater and may lead to a fall.

Ketone levels

If a patient, with type 1 diabetes, has sustained high blood glucose readings it is an indication that they either don’t 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 protein in order to get some energy. In these circumstances ketone testing is crucial. The body finds a way to keep going where it has no other way to gain energy. Ketones are made when the body breaks down proteins. As the ketones build up in the body, this can be damaging, and is referred to as a state of ketoacidosis, or in diabetes, Diabetic Ketoacidosis (DKA). Most people with type 2 diabetes will not develop ketonuria but people with type 1 diabetes are at risk of DKA.

The urine test to detect ketones is quite simple and involves dipping a chemical test strip in urine or wetting the test strip in a stream of urine. A blood test can also be carried out in similar way to blood glucose testing. Ketone testing is recommended for patients with type 1 diabetes. Diabetes UK recommends testing for ketones if blood glucose levels become high - usually above 15 mmol/l. 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.

Blood pressure

The blood pressure of a person without diabetes should be no higher than 140/85. However, when a person has diabetes their blood pressure should be no higher than 130/80. This is also the case if they have had a heart attack, stroke or coronary heart disease. In England, although over 90% of patients with diabetes have their blood pressure checked, only 50% are achieving their target blood pressure.

The patient’s blood pressure should be checked at least once a year as part of an annual diabetes review. This helps to ensure that their blood pressure is within the target range and not increasing their risk of developing diabetes complications which include cardiovascular disease (CVD). You can find more details on how to take a blood pressure on the 'first steps' link in the useful resources section of this course.

Blood fats

The lipids (or fats) in a person’s blood are made up of cholesterol and triglycerides. These lipids are found in all of us. A simple blood test can be carried out to determine blood lipid levels. Not all cholesterol is bad. High Density Lipoprotein (HDL) cholesterol can protect against heart disease. Low levels of HDL can increase the risk of cardiovascular disease (CVD). Low Density Lipoprotein (LDL) cholesterol is the bad form of cholesterol in the blood. High levels of this type of cholesterol are linked with an increased risk of CVD.

Triglycerides are another type of fat in the blood. If a patient has raised cholesterol and raised triglycerides they have an increased risk of CVD.

The recommended blood lipid levels are:

  • total cholesterol level should be below 4.0mmol/l
  • HDL levels should be 1.0mmol/l or above in men and 1.2mmol/l or above in women.
  • LDL levels should be less than 2.0mmol/l
  • Triglyceride levels should be 1.7mmol/l or less

Targets for people with diabetes are lower than for the rest of the population as they are at increased risk of CVD. It is always wise to check your patient's records to confirm their correct targets. Although most patients with diabetes have their cholesterol checked, less than 40% (in England) achieve their target (Source: State of the Nation). Try to encourage your patient to adopt a more healthy lifestyle, including making changes to their diet, increasing their exercise and seeking advice from their GP for medication that can help. You can find out more information in the section on Treatments for Diabetes.

What happens if good blood glucose control is not maintained?

If diabetes is not diagnosed and treated it can lead to many different health problems. A slightly raised glucose level that does not produce any symptoms can prove damaging in the long term. High levels of glucose can cause damage to blood vessels, nerves and organs. This can result in:

• heart disease (Myocardial Infarction i.e heart attack)

• cerebral Vascular Accident (CVA or stroke)

• peripheral vascular disease (PVD

• nerve damage (neuropathy)

• vision damage (blindness due to retinopathy)

• kidney disease (nephropathy)

• foot problems (limb amputation)

• sexual (erectile dysfunction) and fertility problems.

Explore the animated body images below to see the extent of the health complications that can arise from long term, poorly controlled diabetes. Note: all the conditions described on the body images can affect men and women.

1.Starting image

2. Heart disease and stroke

A person with diabetes is up to five times more likely to have a stroke and develop heart disease than someone without diabetes. Long term, poorly controlled blood glucose levels increase the likelihood of a person developing atherosclerosis (furring 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.

3. Kidney disease

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, although this is rare.

4. Nerve damage

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. If this affects the nerves in the digestive system it could lead to nausea, vomiting, diarrhoea or constipation.

5. Retinopathy (damage to the retina at the back of the eye)

Retinopathy is damage to the retina and is a complication that can affect anyone who has diabetes. 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 is laser surgery which will preserve the sight of the patient but will not make it better. The better the blood sugar levels are controlled, the less chance the patient has of developing serious eye problems.

6. 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 aren’t 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 their 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 changing or stopping pre-conception.

7. Sexual dysfunction


Damage to the nerves and blood vessels can lead to erection problems 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.

8. Foot problems


Nerve damage to the nerves of the feet can mean that small cuts and breaks in the skin 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 bases and others such as those on renal replacement therapy should have their feet inspected whenever they attend the dialysis unit).

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