Diabetes Management – what every case manager needs to know!
If your clients have type 1 or type 2 diabetes, are their blood glucose levels well managed? How do you know?
Just because someone is under the care of a GP or diabetes team, does not guarantee that the person’s blood glucose levels are well managed. Sometimes advice isn’t adhered to and/or appointments get missed. Other times, physiological changes happen in the body between annual review appointments and insulin or medication needs to be changed sooner.
Case managers can often be the first people to suspect that a client’s blood glucose levels have gone off track.
Symptoms of high blood glucose levels
- Extreme thirst.
- Weeing a lot.
- Feeling weak or tired.
- Blurred vision.
- Unexplained weight loss.
- Wounds healing slowly or becoming infected.
- Recurrent thrush (oral or genital).
- Challenging behaviour (in clients with a brain injury).
If you are worried that a client may have high blood glucose levels, ask the GP to conduct an HbA1c blood test and/or a glucose test (fasting or random).
HbA1c (also known as glycated haemoglobin) is a simple blood test which measures someone’s average blood glucose level over the previous 2-3 months. It does this by measuring the amount of glucose attached to the haemoglobin in red blood cells. The target levels are as follows for non-pregnant adults:
- For a new diagnosis of pre-diabetes – HbA1c must be between 42 – 47mmol/mol.
- For a new diagnosis of diabetes – HbA1c must be 48mmol/mol or higher (or a fasting plasma glucose of 7.0mmol/L or a random glucose level of 11.1mmol/L).
- Existing type 1 diabetes – the goal is to get HbA1c at or below 48mmol/mol (unless otherwise advised by their diabetes team).
- Existing type 2 diabetes – if managed by lifestyle only OR lifestyle plus a single medication – the goal is to get HbA1c at or below 48mmol/mol.
- Existing type 2 diabetes – if on a medication associated with hypoglycaemia – the goal is to get HbA1c at or below 53mmol/mol.
Action is required by the GP (or diabetes team) if anyone has an HbA1c above 58mmol/mol. Medication will need to be added/adjusted and lifestyle factors will need to be reviewed in these situations.
The maximum HbA1c recommended before elective surgery is 69mmol/mol.4
NICE guidelines state that HbA1c should be checked in adults with diabetes at the following intervals:
- Type 1 diabetes – every 3-6 months
- Type 2 diabetes on changing medication/therapy – every 3-6 months until stable.
- Type 2 diabetes once therapy is stable – every 6 months.
The consequences of chronic high blood glucose levels include:
- Damage to the kidneys (e.g. diabetic kidney disease).
- Damage to the eyes (e.g. diabetic retinopathy).
- Damage to the nerves in various parts of the body (e.g. gastroparesis, diabetic neuropathic pain/numbness, foot problems, erectile dysfunction).
- Damage to gums in the mouth (e.g. periodontitis).
People with diabetes should have annual screening for all of the above. The GP can do blood test screening for kidney function and perform a monofilament test on the feet to check for nerve damage. Eye screening will need to be done by an optometrist and a dentist will need to check gums for periodontitis.
For people who want to better control their diabetes and understand how certain food/physical activity/stress impacts their blood glucose levels, they have three options for monitoring this.
Some glucose monitoring options (finger prick testing and Dexcom ONE) are available from the GP, while others (Freestyle Libre 2, Dexcom G6 & G7) are only available through the hospital diabetes team. All options can be purchased privately as well (without a referral or prescription).
1. Finger prick (capillary) blood glucose testing
This is the traditional form of blood glucose monitoring. Someone will need to prick their finger with a special lancet to obtain a drop of blood and this blood is then placed onto a special testing strip and put into a machine that will give a numerical glucose result.
The “healthy” blood glucose range is 4-7mmol/L, although going up to 8-10mmol/L after a meal is generally considered acceptable in people with diabetes.
People with type 1 diabetes are eligible to receive this device (and all required testing strips) free of charge via the NHS. This is IN ADDITION to either a flash glucose monitoring system OR a continuous glucose monitoring system (see below).
People with type 2 diabetes are only eligible to receive this device (and associated testing strips) if they are on insulin, there is evidence of hypoglycaemia, they are pregnant or they are on oral medication that increases their risk of hypoglycaemia while driving or operating machinery.
2. Flash glucose monitoring systems (such as the Abbott Freestyle Libre 2)
Instead of using a finger prick, flash glucose monitoring systems use a sensor placed on the back of the arm to collect glucose data. The person then downloads an app onto their smart phone and scans the sensor using their phone. Blood glucose results can only be seen on the phone/app when the device is scanned, and this must be done at least once every 8 hours. Alarms can also be set to alert the person if their blood glucose level is too low or too high.
Advantages – Painless (as no finger pricks required). Simple to use. Health professionals can access glucose data remotely. One sensor lasts 14 days and the transmitter is built right in. Results can be shared with support workers/family members.
Disadvantages – Only water resistant for 30 minutes in water up to 1 meter. Device must be scanned every 8 hours or data is lost. Sensor is easy to knock off and cannot be reattached.
People with type 1 diabetes are eligible to receive this device (or a continuous blood glucose monitor below) free of charge via their hospital diabetes team.
People with type 2 diabetes are only eligible to receive this device free of charge via the diabetes team, if they are on multiple daily injections of insulin AND are experiencing recurrent or severe hypoglycaemia, have a cognitive impairment, would need help from someone to monitor their glucose levels or have impaired hypoglycaemia awareness. Everyone else will need to self-fund and purchase the device direct from the company.
3. Continuous blood glucose monitoring systems (such as the Dexcom ONE, G6 or G7)
Continuous blood glucose monitoring systems also use a sensor and are similar to the flash glucose monitoring systems mentioned above. The main difference is that this sensor can be placed on either the back of the arm or the abdomen and there is no “scanning” required. The data is automatically transmitted to the phone/app via Bluetooth every 5 minutes. Alarms can be set to alert the person if their glucose level is too low or too high. The ONE is the basic model and the G6 and G7 are the more advanced models. These devices can be submerged in water for longer periods of time (compared to the flash glucose sensor) and are therefore more suitable for clients who swim regularly or participate in hydrotherapy.
Advantages – Painless (as no finger pricks required). Health professionals can access glucose data remotely. Waterproof for up to 24 hours at up to 2.4 meters. One sensor lasts 10 days. Better for tracking sudden changes in blood glucose levels. For G6 and G7 – real-time data can be shared with support workers/family members.
Disadvantages – Sensor is easy to knock off and cannot be reattached. Slightly more complicated to set up (as more options for alerts, etc). The ONE and G6 versions have a separate removable transmitter that inserts into each sensor – this is more costly for short term use, as the transmitter has to be replaced every 90 days. The ONE version does not allow data to be shared with support workers/family.
People with type 1 diabetes are eligible to receive this device (or a flash monitoring system above) free of charge via the NHS.
People with type 2 diabetes will need to purchase this device direct from the company. The NHS does not usually offer this device to people with type 2 diabetes.
How dietitians can help
Dietitians (NHS and private) can help clients with diabetes to:
- manage their blood glucose levels (using dietary and lifestyle changes);
- liaise with the GP/diabetes team to advocate for changes to medication/insulin;
- help clients gain access to glucose monitors as required;
- advocate for annual diabetes checks for kidneys, eyes, nerves of the feet and gums; and/or
- remind the GP (and the client) to complete the HbA1c test every 6 months.
To refer a client for dietetic assessment and advice who has diabetes AND a brain injury, spinal cord injury or complex orthopaedic trauma, contact Specialist Nutrition Rehab at email@example.com or 0121 384 7087.
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