Diabetes – Management

Initial Management Plan

1. Patient Education and Individualized Targets

• Tailor management goals based on:
  • Age, concurrent illness, and life expectancy.
  • Lifestyle preferences and psychological well-being.
• Blood glucose stabilization:
  • Relieve symptoms of hyperglycemia (e.g., polyuria, polydipsia, fatigue).
  • Prevent acute complications like diabetic ketoacidosis and hyperosmolar hyperglycemia.
  • Avoid hypoglycemia.
  • Reduce risk of chronic complications.

2. Multidisciplinary Team (MDT) Approach

• Utilize the Enhanced Primary Care Program and Team Care Arrangement to fund 5 allied health services per year.
• Key members of the team:
  • Diabetes educator: Provides patient education and self-management support.
  • Dietitian: Develops tailored nutrition plans.
  • Podiatrist: Manages foot care and prevents complications.
  • Endocrinologist: Specialist management of complex diabetes.
  • Ophthalmologist/Optometrist: Eye exams at diagnosis, then at least every 2 years.
  • Pharmacist: A formal Home Medicines Review (HMR) can be arranged by GPs to optimize medication use.
  • Psychologist: Manage common comorbidities like depression; referrals can be arranged through a Mental Health Care Plan (MHCP).

3. Non-Pharmacological Management

• Lifestyle modifications:
  • Nutrition: Consult with a dietitian for a diabetes-friendly diet plan.
  • Physical activity: Aim for 30 minutes of moderate-intensity exercise every second day (or more), as guided by a physical therapist.
  • Smoking cessation: Strongly encouraged.
• Regular screening and treatment:
  • Eyes: Regular eye exams to detect retinopathy.
  • Kidneys: Monitor kidney function through eGFR and UACR.
  • Feet: Regular foot checks to prevent ulcers and neuropathy.
  • Cardiovascular health: Monitor and manage cardiovascular risk factors.
• Psychosocial and mental health:
  • Screen for and address underlying mental health conditions, such as depression and anxiety.
  • Pay special attention to adolescent and mental health comorbidities.

4. Lifestyle and Cardiovascular Risk Reduction

• Diet: Follow a heart-healthy, diabetes-friendly diet as per the dietitian’s advice.
• Physical activity: 30 minutes of moderate-intensity exercise on alternate days.
• Lipid and blood pressure management:
  • Set individualized targets and consider medications such as statins and ACE inhibitors for cardiovascular risk reduction.

5. Ongoing Reviews and Monitoring

Quarterly Review: 

1. SNAP intervention, review self monitoring, review sx, check weight / waist circumference, BP, foot exam. HbA1c at least 6 monthly. 

Yearly Review: 

1. Review goals of management
2. Check for diabetic complications – P/E cardio, peripheral nervous system, eyes, feet
3. Immunisations – influenza yearly, pneumococcal, tetanus (booster 50yrs)
4. Investigations – lipids, ACR/microalbuminuria, UEC, ECG 2^nd yearly if >50 w other CVD risk
5. Referrals – ophthalmologist/optometrist 2^nd yearly, allied health

The Blood Glucose Profile in Type 2 Diabetes

In type 2 diabetes, the blood glucose profile consists of three main components:

1. Fasting Blood Glucose (FBG):
   • This sets the flat baseline for the day’s glucose levels.
2. Daytime Baseline Changes:
   • Typically, there is an increase in preprandial blood glucose (pre-meal glucose levels) from breakfast until the evening meal.
   • In some cases, this baseline may decrease over the course of the day.
3. Prandial Blood Glucose (post-meal):
   • Blood glucose rises above baseline after meals, peaking within 1–2 hours.
   • It typically returns to baseline 3–4 hours after eating.

Setting Glycemic Targets

General targets for glycemic control include:

• HbA1c ≤7% (53 mmol/mol)
• Average blood glucose (avBG) of 8 mmol/L
• Preprandial blood glucose (prepBG) of 7 mmol/L

Average Blood Glucose (avBG):

• Represents glucose levels over 24 hours.
• The formula:
  avBG (mmol/L) = 2 × HbA1c (%) – 6

Preprandial Blood Glucose (prepBG):

• Measured before breakfast, lunch, and dinner.
• Typically 1 mmol/L lower than the avBG.
• Reflects both basal and prandial glucose levels.
• The formula:
  prepBG (mmol/L) = 2 × HbA1c (%) – 7

For example:

• With an HbA1c of 6% (42 mmol/mol), the avBG would be 6 mmol/L, and the prepBG would be 5 mmol/L.

RECOMMENDED (HbA1c) TARGETS
Condition	HbA1c target
General target	≤53 mmol/mol (7.0%)
Diabetes of short duration and no clinical cardiovascular disease
Lifestyle modifications ± metformin	≤42 mmol/mol (6.0%)
Requiring any antidiabetic agent other than metformin or insulin	≤48 mmol/mol (6.5%)
Requiring insulin	≤53 mmol/mol (7.0%)
Pregnancy or preconception	≤42 mmol/mol (6.0%)
Diabetes of longer duration or clinical cardiovascular disease	≤53 mmol/mol (7.0%)
Severe hypoglycaemia or hypoglycaemia unawareness	≤64 mmol/mol (8.0%)
Major comorbidities likely to limit life expectancy	Symptomatic treatment of hyperglycaemia, aim for blood glucose level <15 mmol/L

Glucose monitoring in specific populations

Self-Monitoring of Blood Glucose (SMBG) in Type 2 Diabetes

SMBG is recommended in the following situations for patients with type 2 diabetes:

• On medications that may cause hypoglycemia, such as insulin or sulfonylureas.
• When HbA1c results are unreliable, such as during intercurrent illness or conditions that affect red blood cell turnover.
• During intercurrent illness, to monitor for hypo- or hyperglycemia.
• In pre-pregnancy and pregnancy management, especially in individuals with established diabetes.

If HbA1c measurements are deemed inaccurate, glycemic control should be assessed using:

• Self-Monitoring of Blood Glucose (SMBG)
• Continuous Glucose Monitoring (CGM)

Special Considerations

Renal Failure

• In patients with renal failure, alternative glycemic markers such as fructosamine and glycated albumin may be used when HbA1c is unreliable. However, their utility is limited in low protein and low albumin states.
• Assessment of an SMBG diary over time is likely more useful, and CGM may also be considered.

Pregnancy

• For diagnosing diabetes in pregnancy, a 75 g Oral Glucose Tolerance Test (OGTT) should be used instead of HbA1c.
• SMBG should be used for glucose monitoring and medication adjustments during pregnancy.
• CGM is another option, particularly for individuals with type 1 diabetes.

Type 1 Diabetes Considerations

Puberty

• During puberty, natural increases in insulin resistance occur due to hormonal changes, such as elevated growth hormone, cortisol, and sex hormones. This makes it more challenging to maintain stable blood glucose levels.

National Diabetes Services Scheme (NDSS) Subsidy for CGM

Under the NDSS, CGM is subsidized for certain eligible individuals with type 1 diabetes. The eligibility criteria are as follows:

1. Children and Young People with Type 1 Diabetes (up to 21 years):
   • Must be under 21 years of age.
   • Must have a valid NDSS registration.
   • Must have a diagnosis of type 1 diabetes.
2. People with Type 1 Diabetes Aged 21 Years and Older with Certain Clinical Needs:
   • Must be 21 years or older.
   • Must have a valid NDSS registration.
   • Must meet specific clinical criteria, such as:
     • Frequent severe hypoglycemia without warning.
     • Significant fear of hypoglycemia that affects quality of life.
     • Impaired awareness of hypoglycemia.
     • Need for intensive management due to frequent and severe hyperglycemia.
3. People with Type 1 Diabetes Who Are Pregnant, Planning Pregnancy, or Immediately Postpartum:
   • Must be planning pregnancy, currently pregnant, or up to 6 weeks postpartum.
   • Must have a valid NDSS registration.
4. People with Type 1 Diabetes and Additional High Clinical Needs:
   • Special consideration is given to individuals with additional high clinical needs not covered by other categories.
5. Carers of Children and Young People with Type 1 Diabetes:
   • Carers of eligible children may receive subsidized CGM if they meet the criteria.

NDSS Registration Eligibility

To register with the NDSS, individuals must:

• Be a resident of Australia.
• Have a Medicare card or Department of Veterans’ Affairs card.
• Have a diagnosis of diabetes confirmed by a doctor or a credentialed diabetes educator.

Clinical Management Goals

Nutrition in Type 2 Diabetes Management

In more than 50% of individuals with type 2 diabetes, reducing energy intake, increasing physical activity, and achieving weight loss can initially normalize blood glucose levels. However, medication may be required later.

• Goal: Aim for a BMI between 18–24.9 or use waist circumference as an alternative measure.
  • While achieving an ideal body weight may not always be feasible, a 5–20% weight loss can significantly improve glycemic control.
  • Aim for a calorie intake of approximately 2000 kJ/day, targeting a weight loss of 0.5 kg per week.
• Dietary Recommendations:
  • Include low glycemic index (GI) and high-fiber foods at every meal, such as wholegrain breads, rolled oats, low-fat/sugar cereals, pasta, beans, lentils, and temperate fruits.
  • Ensure fats account for less than 30% of total daily energy intake.
    • Avoid saturated fats, commonly found in processed foods, meats, and takeaway snacks.
    • Recommend consuming 5g of fish oils per day for heart health benefits.
  • Limit alcohol intake to ≤2 standard drinks (20g) per day for both men and women, following Australian guidelines.
  • Avoid added salt in cooking to reduce cardiovascular risks.
• Non-Alcoholic Fatty Liver Disease (NAFLD):
  • Common in people with type 2 diabetes and associated with abnormal liver function tests (particularly ALT) and ultrasound findings of a “bright liver.”
  • NAFLD can progress to cirrhosis, and the main treatment is lifestyle modification.

Referral to a dietitian is strongly recommended for individualized nutrition advice.

Physical Activity in Type 2 Diabetes Management

• Aim for at least 150 minutes per week of moderate-intensity physical activity, such as walking.
• For individuals over 50 years old with at least one vascular risk factor, consider a biannual ECG as silent myocardial infarction (MI) is common in this population.
• If the patient is on insulin, adjust carbohydrate intake or insulin doses around physical activity to prevent hypoglycemia. Delayed hypoglycemia can occur 6–12 hours after exercise.

Lifestyle and Monitoring Recommendations

• Smoking: Advise complete cessation – target zero cigarettes per day.
• Alcohol: Limit consumption to ≤2 standard drinks (20g of alcohol) per day for both men and women.
• Blood Glucose Monitoring:
  • Target 4–7 mmol/L for fasting blood glucose and 5–10 mmol/L for postprandial levels.

 

Driving with Diabetes

Austroads Guidelines Overview:

• Provides a flowchart (Figure 10) for managing diabetes in drivers seeking a commercial licence.
• Drivers must notify authorities of significant health changes affecting driving.
• In some regions (e.g., SA and NT), doctors are mandatory notifiers for diagnosed conditions.