Last partial update: May 2019 - Please read disclaimer before proceeding

(Back to top)

Why do Australians need to worry about diabetes?

1. Diabetes is relatively common

In Australia today, the incidence of diabetes is rising rapidly and in 2015 the number of adult Australians affected is about 7.5%. (In 1980 it was only about 2%.) In the elderly the figure is closer to 20%. This is a huge number of people and the cost of treating them is about $3 billion per year! In 2011, diabetes caused about 2.3% of the total burdnen of illness in Australia. Unfortunately, because early diabetes has few symptoms, about 50% of these with diabetes are unaware they have the disease.

In addition, another 16% of adults have impaired glucose handling by the body, a ‘pre-diabetes’ condition that itself increases cardiovascular disease risk. This impaired glucose handling is also appearing at much earlier ages (even in adolescents) than has previously been the case due to increasing obesity and reducing physical activity levels. This means Australia may be headed for an even worse diabetes epidemic than it is already experiencing.

This is because early diabetes has few symptoms.

2. Diabetes is a dangerous disease

Loss of vision and kidney failure: Diabetes is the second most common cause of both blindness and kidney failure in Australia. Up to 50 per cent of people with type 2 diabetes have chronic kidney disease.

Heart attacks: Diabetes increases the risk of coronary artery disease (heart attacks) by two to three times with the increase in risk being greater for women. Seventy per cent of people who have heart attacks have either glucose intolerance (‘pre-diabetes’) or diabetes itself. A person with diabetes has the same chance of having a heart attack as a person who has already had one.

Diabetic complications start early in the disease and because diagnosis is often delayed, 50 per cent of those with diabetes already have significant complications from the disease at the time of diagnosis.

3. Disabiltiy from diabetes can be prevented / reduced in severity by maintaing a healthy weight

An appropriate diet, adequate physical activity and maintaining a healthy weight can help by preventing the disease, delaying its onset or reducing the severity of its complications. Early diagnosis and treatment reduces death and ill health from all types of diabetic complications, especially those associated with the eyes and the kidneys.

 

A recent study (2017) looked at people who had type 2 diabetes for less than six years to see whether a closely monitored intensive weight loss program could cure their diabetes. It was found that the program achieved a 46% remission rate (off medication), with the highest success being attained by people who lost 15kg of weight or more.

(Back to top)

 

What is diabetes? Types of diabetes

Diabetes is a condition in which blood glucose (blood sugar) levels remain chronically higher than normal. The hormone insulin (produced in the pancreas) is the main regulator of body's blood glucose level; although other hormones have a role also. Its main task is to faciliate the passage of glucose carried in the blood into body cells, where it is used as an energy source or is stored for later use. In doing this it acts to reduce the blood glucose level. Insulin is needed most when glucose from ingested food enters the blood from the intestine (i.e. after a meal). Diabetes can be due to the body producing less insulin than normal and / or an inability of the body to use insulin properly.

There are several types of diabetes and several conditions that can lead to diabetes.

 (Back to top)

(A) Type 1 diabetes

In this condition, people produce very little or no insulin. It mainly starts in the children, although occasionally cases occur in adults, and it is responsible for about ten per cent of diabetes overall (but about 90% of diabetes in children and adolescents). Most caes are diagnosed early on in the disease as the onset is typically associated with a relatively abrupt and large drop in insulin secretion due to destruction of insulin-secreting cells in the pancreas. (This destruction is caused an auto-immune process i.e. the body's immune system malfunctions and attacks and kills the cells. Other auto-immune diseases are commonly associated with the disease, especially auto-immune thyroid disorders.) As the cells die quickly, significant symptoms occur early on in the disease. These include weight loss, excessive urine production (which leads to passing urine more often and at night), thirst, blurred vision, generally feeling unwell, and sometimes drowsiness and even loss of consciousness.

The risk of developing type 1 diabetes is about 10 times higher in people with a first degree relative with Type 1 diabetes but this disease is relatively uncommon and thus the risk is still small. If the relative has type 2 diabetes the risk is only slightly higher but Type 2 diabetes is much more common than Type 1.

 (Back to top)

(B) Type 2 diabetes

Type 2 diabetes accounts for 90 per cent of Australians with diabetes. It is a condition that tends to come on very slowly over years and is usually associated with no symptoms in the early stages. Thus, about 50% of people with the condition do not know they have it. Symptoms when they do occur (later in the disease) are often mild and include excessive urine production (which leads to having to pass urine more often and at night), thirst, blurred vision, generally feeling unwell, skin infections, slow healing, tiredness and numbness in the feet.

The major cause of type 2 diabetes is that the insulin produced does not work as well at removing glucose from the blood. The body can copmhensate for this to some extent by producing extra insulin but eventually the body's insulin requirement exceeds the maximum amount it can produce and blood glucose levels start to rise. This abnormality is termed ‘insulin resistance’.

In Australia about 25% of the adult population have problems with producing adequate insulin, with increasing age being an important contributing factor. In 2006 type 2 diabetes was thought to cause about 3% of deaths and contribute to another 6% of deaths.

Older people - Insulin production decreases in all people as they age

The body's ability to produce insulin decreases in all people with age. While almost all younger adults can produce adequate insulin, there is considerable variation in the amount of insulin that individuals require and some young people are only able to produce just enough. As they age, these young people find that their insulin requirements start to exceed their reducing insulin production and their blood glucose levels begin to increase.

Pre-diabetes states: Impaired glucose tolerance and impaired fating glucose. (See Diagnosing diabetes table later in this section). The first indication that a problem exists is that blood sugars become abnormal some of the time. This is especially likely when the body is presented with an increased glucose load i.e. food containing sugar. At such times the body can not move the extra glucose entering the blood from the ingested food into the body tissues quickly enough to maintain a normal blood glucose level. Such people are termed to have impaired glucose tolerance, a ‘pre-diabetes’ condition. (It is diagnosed when the person has a mildly abnormal fasting or non-fasting blood sugar level or a mildly abnormal glucose tolerance test. This is a test used for diagnosing diabetes.) About 16 per cent of adult Australians are thought to have pre-diabetes and all these people have an increased risk of sufferig both fatal and non-fatal cardiovascular disease (heart attacks and strokes). For this reason people with pre-diabetes need to be treated aggressively with lifestyle interventions including weight loss, appropriate diets (diets with a low fat, a low glycaemic load and a high fibre content) and management of their blood pressure and blood fats (cholesterol and triglycerides) with the same targets as people with diabetes. (See section on Reducing the risk of developing and / or exaccerbating diabetic complications.) People with pre-diabetes do not need regular home blood sugar testing but do need to be tested regularly by their dioctor to see whether they have gone on to develop diabetes. Each year roughly 3% to 10% of people with pre-diabetes go on to develop proper diabetes.

Diabetes: As time progresses, this situation worsens resulting in blood sugar levels that are high most of the time, not just after a meal. The person now has diabetes; a condition that occurs in about 9% of the adult population.

There are two factors that make diabetes more likely to occur.

(i) Members of some ethnic groups are genetically predisposed to developing type 2 diabetes

Both the ability to produce insulin and the body’s insulin requirement vary considerably between ethnic groups and certain ethnic groups who tend to produce lower insulin amounts of insulin and / or have greater insulin requirements have a significantly increased risk of developing either impaired glucose tolerance or diabetes. These include indigenous Australians, Torres Strait Islanders and those from high incidence countries, such as the Pacific islands, China, the Indian sub-continent, northern Africans and southern Europeans.

(ii) Obesity increases insulin resistance and the risk of developing type 2 diabetes

An increase in the level of abdominal obesity can significantly reduce the effectiveness of insulin in removing glucose from the blood (i.e. increase insulin resistance). Thus, overweight people need more insulin to keep blood sugars at normal levels and tend to develop diabetes earlier in life than they would if their weigt was normal. (Their disease also progresses more quickly). Unfortunately the incidence of adult obesity in increasing in Australia at present and this trend has led to an increase in the incidence of diabetes and to diabetes being diagnosed in increasingly younger people.

 

Reducing insulin resistance (and thus insulin requirements) by losing weight can reverse this process to some extent. It certainly delays the progression of the disease and in some people weight loss can prevent diabetes occurring completely. It is worthwhile mentioning at this time that very few people with a Body Mass Index of 22 (the middle of the healthy weight range) develop diabetes. On the other hand, a BMI of between 25 and 30 causes a three-fold increase in risk of developing the disease and a BMI of over 35 increases the risk by 20 fold.

Type 2 diabetes is also termed non-insulin dependant diabetes. However, as many people with type 2 diabetes need to be treated with insulin, this name is a bit misleading and is no longer being used.

Type 2 diabetes is part of the ‘Metabolic syndrome’

Type 2 diabetes occurs as part of the ‘metabolic syndrome’ in most cases and thus usually occurs in conjunction with at least one and often several of the following;

  • abdominal obesity
  • abnormal blood fats (lipids), most commonly a low HDL cholesterol and high triglycerides. About half of the people with type 2 diabetes have a total cholesterol over 5.5mmol/L..
  • high blood pressure and a clotting tendency. About two thirds of people with diabetes are on medication for high blood pressure.

The metabolic syndrome is associated with a significant increase in illess and an increased mortality rate. (See section on Obesity - Definition and causes for more information.)

 (Back to top)

(C) Gestational Diabetes.

Gestational diabetes is defined as any degree of glucose intolerance the develops or is first diagnosed during pregnancy and it occurs because insulin resistnce increases in pregnancy. About 4% to 10% of women develop diabetes during their pregnancy (usually in the last trimester) and the indicence is gradually inceasing, with women from certain ethic backgrounds having a significantly higher incidence; Aboriginal and Torres Strait Inslanders, Pacific Islanders and women from the Indian subcontinent, east Asia and the Middle East.

It is very important that women are screened for diabetes during their pregnancy as untreated (or poorly treated) diabetes can cause harm to both the mother and the baby. Problems that can occur include:

In the baby: A larger than normal baby, which can cause harm to both mother and child during delivery, an increased incidence of respiratory distress syndrome, polycythaemia, cardiomegaly (an enlarged heart), hypoglycaemia (low blood sugars) after birth and hypocalcaemia (low blood calcium level). If untreated, gestational diabetes also inceaases the risk of foetal death. (In the long term there is a higher incidence of obesity and diabetes.)

In the mother: High blood pressure / pre-eclampsia, increased need for delivery by caesarian section use of forceps during delivery. (In the long term there is a higher incidence of chronic diabetes and cardiovascular disease.)

Screening is normally done at 24 to 28 weeks (by doing a glcose tolerance test) and at any time earlier if the woman is at increased risk of developing gestational diabetes. (See below) It is diagnosed if any of the following blood glucise levels occur in the test: a fasting BGL >5.5mmol/L, a one hour BGL >10mmol/L or a two hour BGL >8.0mmol/L. (There is discussion at present regarding whether the fasting level BGL should be lowered to to >5.3mmol/L and the two hour level should be raised to >8.5mmol/L.)

The blood glucose levels of women who develop diabetes during pregnancy usually return to normal after the pregnancy but these women do have an increased risk of developing type 2 diabetes later in life, with over 40% developing the disease within ten years of their pregnancy. This risk can be reduced by long-term weight loss after the pregnancy. Women who do develop gestational diabetes need to be regularly screened for diabetes subsequently. Unfortunately this is not happening as often as it should, partly because young mothers are busy people and their health concerns often take second place after caring for children. Also, as most feel well, they think that the test is likely to be normal anyway.

Women at increased risk of diabetes in pregnancy include those:

(It is worthwhile mentioning here that low birth-weight can also increase insulin resistance and increase the baby’s risk of developing diabetes later in life.)

(Back to top)

(D) Diabetes caused by other diseases (secondary diabetes)

A small proportion of diabetes is caused by:

 

 (Back to top)

Diabetic Complications – the dangers of diabetes

There are numerous serious complications caused by diabetes and about 66% of people with diabetes suffer from the complications of their disease. While these complications generally develop slowly over years, the rate of progression depends on how well the person controls their blood glucose levels. Complications usually occur about ten years after the onset of the disease. However, as diagnosis is often delayed, complications need to be looked for at diagnosis.

The complications are caused by several mechanisms, the main two being:

Diabetic complications also occur in people with impaired glucose tolerance

It is important to understand that diabetes is diagnosed according to whether a person has certain blood sugar levels, not whether they suffer from insulin resistance; and it is insulin resistance that causes the complications of diabetes. Many people have mild insulin resistance that either:

The complications of diabetes (especially vascular complications) commence with any increase in insulin resistance and people with impaired glucose tolerance who do not go on to develop diabetes still have an increase in mortality of about 50 per cent over the next five years. (Understandably, the situation is even worse in those with diabetes.)

A. Complications due to an increase in vascular disease

 

Most diabetic complications are due to damage to blood vessels from vascular disease caused by:

  • Harmful changes to blood lipids including:
    • Increased insulin increases LDL (bad) cholesterol by the liver
    • Higher blood glucose levels causing a higher level LDL cholesterol that is bound to glucose. This glucose-bound LDL is though to cause more vascular disease than non glucose-bound LDL.
    • Lowered HDL (good) cholesterol levels
    • Increased triglyceride levels
  • Elevated blood glucose levels damage the cells lining the inside walls of the arteries (blood vessels)

Insulin resistance, the fundamental cause of type 2 diabetes, is also associated with other diseases that increase vascular disease, including high blood pressure and kidney damage.

Vascular complications can be divided into two main groups according to the type of vessels that are affected.

(i) Large vessel complications (macrovascular complications)

Complications caused by damage to large blood vessels (macrovascular complications) include coronary artery disease (heart attacks), strokes and peripheral vascular disease. (Peripheral vascular disease mainly affects the lower legs and can cause gangrene and loss of part of the limb.)  These ‘large vessel’ complications are more common in type 2 diabetes and over 50% of people with type 2 diabetes have at least one macrovascular complication. Macrovascular complications occur in all people with insulin resistance and about 66% of all deaths due to cardiovascular disease occur in people with either diabetes (33%) or pre-diabetes (i.e. impaired glucose tolerance or impaired fasting glucose) (also 33%).

(ii) Small vessel complications (microvascular complications)  

Complications caused by damage to small blood vessels (microvascular complications) include blindness, kidney disease and nerve damage. (Impotence is another small vessel complication.) Small blood vessel complications are equally common in type 1 and type 2 diabetes. Over 66 per cent of people with type 2 diabetes have at least one microvascular complication. (Most people with diabetes develop eye disease and about 30% suffer from significant kidney disease.)

Good diabetic control does reduce macrovascular complications, although the effect on reducing microvascular complications is significantly greater. (Each drop 1% in HbA1c level translates into a 14% drop in the risk of coronary artery disease. See below.)

Good blood presure control also reduces both microvascular and macrovascular complictions.)

B. Osteoporosis and diabetes

Postmenopausal women with diabetes also have a significantly higher rate of fractures associated with osteoporosis than other postmenopausal women and they need to be assessed and treated for osteoporosis early in menopause.

(Back to top)

Prevention strategies for type 2 diabetes

WARNING: A word of warning before this topic is discussed. Any person who is taking oral medication or insulin to treat existing diabetes needs to consult their doctor before altering their diet or exercise program. Such changes may cause blood sugars to go too low (a ‘hypo’) if medication levels are not adjusted beforehand. All people with diabetes should carry a source of sugar with them at all times to consume if they feel their blood sugar is dropping too low.

a. Prevention through weight loss, restriction of carbohydates in the diet and exercise

As stated previously, type 2 diabetes is by far the most common type of diabetes and excess weight is a very important causal factor. (As mentioned above, a BMI of between 25 and 30 causes a three-fold increase in risk of developing the disease and a BMI of over 35 increases risk by 20 fold.)

 

Luckily, there is good evidence to show that the onset of type 2 diabetes can be delayed in the majority of people with glucose intolerance (in some people permanently) by lifestyle modification programs that include exercise and maintaining a healthy weight; that is, a BMI between 20 and 25. Abdominally obese people, particularly men, are particularly at risk and, with respect to reducing diabetes risk, the best way to assess weight loss is by measuring the reduction in waist circumference. For Europeans, the optimum waist circumference for men is less than 94cm and for females is less than 80cm and all people at increased risk of developing diabetes or who have diabetes should aim for these figures.

 

 Restricting carbohydrate intake in the diet can also have a major effect on reducing blood sugars.

 

While attaining an optimal weight is best, any weight loss above 5% that is maintained in the long term . has been shown to be of benefit in helping to prevent diabetes occurring. (

 

For weight loss interventions to be successful, people need all of the following.

Lifestyle modification without such help is much less likely to be successful. General advice regarding suitable diet and physical activity programs appear in section on nutrition and physical activity.

 

Weight loss does work even for people with type 2 diabetes

A study in 2017 looked at people who had type 2 diabetes for less than six years to see whether a closely monitored intensive weight loss program could 'cure' their diabetes. Impressively, the program achieved a 46% remission rate (off medication), with the highest success rates being attained by people who lost 15kg of weight or more.

 

 

b. Reducing carbohydrate intake and eating carbohydrate containg foods that have a low glycaemic index

Dietary carbohydrates are the source of glucose that enters the blood via the intestines and a person’s blood glucose level rises after consuming foods containing carbohydrates. Reducing their intake under the supervision of a dietician can reduce blood sugars.

 

Recent research has also shown that categorizing carbohydrates according to how quickly they release glucose into the blood following digestion is very helpful in determining how much insulin is required to move this glucose from the blood into body cells.

 

The ‘glycaemic index’ (GI) of a carbohydrate containing food is a measure of the extent and the duration of the rise in blood glucose (sugar) that occurs following the consumption of that food. A low GI food causes a lower and slower increase in blood sugar and such foods require relatively less insulin to be released to 'handle' their ‘glucose load’. A food with a high GI needs does the opposite and thus requires relatively more insulin to be released to 'handle' the same amount of glucode. This means that the 'glucose loads' associated with high GI foods are much harder for people with glucose intolerance to deal with as they already have insufficient insulin.

 

This topic was dealt with in detail in the section on Nutrition and carbohydrates and should be revised as the inclusion of low GI foods should be an integral part of everyone’s diet. The health advantages of a diet containing mostly low GI carbohydrate foods include the following.

Remember that, because of the interactions of different foods in a meal, these GI levels can only act as an approximate indication of glucose response. Thus, foods with a small GI difference of say 10 are not likely to have significantly different effects. It is more important to make changes in food choices where the difference in GI levels is large, say 30. It is also important to worry mostly about the GI levels of foods containing large amounts of carbohydrate, as these have the greatest effect on the overall GI load of a meal.

 

c. Avoid prescription medications that can exacerbate diabetes (and insulin resistance)

Several commonly used drugs can increase insulin resistance. These include:

 

(Back to top) 

Prevention - Who is most at risk?

People at increased risk of developing diabetes include:

Obesity is very important because it is a risk factor that can be modified; as can physical inactivity and smoking. People with abdominal obesity are especially at risk.

 

All people at increased risk of developing diabetes should be actively encouraged to maintain a healthy weight (a BMI of between 20 and 25), maximize their physical activity, and have a diet with a low glycaemic load. They also need to be regularly screened for diabetes (see the boxed section below for Australian diabetes screening guidelines).

(Back to top)

Screening for diabetes

As stated previously, half the diabetics in Australia remain undiagnosed. This is despite that fact that 90% of this group visited a doctor within the last year. A comprehensive screening program targeting at risk groups has been introduced to overcome this problem and is outlined in the box below. It is estimated that 80% of undiagnosed people with diabetes are in these groups.

 

Screening blood tests are ordered by medical practitioners when a person presents for routine check ups and at check ups associated with pregnancy. Testing also occurs when a person presents with symptoms that may be caused by diabetes, including blurred vision, skin/other infections, slow wound healing, numbness in the feet, foot ulcers, passing excess urine, passing urine at night and loss of weight. (Weight loss only occurs very occasionally in diabetes and is due to fluid loss associated with excess urine output. Most people with diabetes are overweight.)

 

Type 2 Diabetes Screening Guidelines: Using the AusDrisk - The Free Online Diabetes Risk Calculator

The incidence of diabetes does not warrant the screening of all Australian adults. However, with the increase in diabetes incidence, the the National Health and Medical Research Council (NHMRC) has developed a test (The AUSDRisk calculator) to identify those who are at a significantly increased risk of developing the disease and require to to screened. All adults should do this 'risk calculator questionnaire' test initially no later than 45 years of age and ethnic groups at increased risk should do the test from 35 years. These include:

Other important risk factors include age (over 60 years), a personal history of pre-diabetes, a family history of type 2 diabetes, and abdominal obesity.

 

The AusDrisk - The Free Online Diabetes Risk Calculator can be accessed by typing the following web site address into your search engine (google etc). (Clicking on the link does unfortunately not provide access.)

 

http://www.health.gov.au/internet/main/publishing.nsf/Content/diabetesRiskAssessmentTool

 

Answering the 10 questions in the risk calculator gives the person a score that indicates their risk of developing diabetes. (The higher the score, the higher the risk. The overall score may overestimate the risk of diabetes in those aged less than 25 years and underestimate the risk of diabetes in people of Aboriginal and Torres Strait Islander descent.)

Screening should be done using a fasting blood sugar and a glucose tolerance test. Actions that should be taken as a result of screening results are as follows:

Screening should be done by a blood test, either measuring the HbA1c level or by measuring the blood sugar in blood taken by a syringe. (Blood glucose testing using a home glucose monitor is not accurate enough for the diagnosis of diabetes.) Abnormal (see "Diagnosis of diabetes' box below) requires further investigation.

 

(Back to top)

Diagnosing Type 2 Diabetes

 

Diagnosis of diabetes

Test using HbA1c measurement

Tests using blood glucose measurement

 

HbA1c

blood test

mmol/mol (%)

 

Fasting blood glucose level

(mmol/L)

Blood glucose level 2 hours after a ‘glucose load’

(mmol/L)

Normal

48

mmol/mol (6.5%)

or less

Normal

 

Less than 6.0

Less than 7.8

Impaired fasting glucose

6.1 – 6.9

Less than 7.8

Impaired glucose tolerance

Less than 7.0

7.8 – 11.0
Prediabetes

48 to 52 mmol/mol (6.5% to 6.9%)

Diabetes

Over 48

mmol/mol (7.0%)

Diabetes

Greater than 7.0

Greater than 11.0

Screening can be done by measuring an HbA1c test or a fasting blood glucose test. A fasting blood glucose level greater than 6.0mmol/L requires further investigation, usually by doing an HbA1c test or less commonly by doing an oral glucose tolerance test. (This test measuesthe blood glucose level two hours after after a specific oral dose of glucose is consumed.)

A positive test indicating diabetes needs to be confirmed by a repeated test before a diagnosis is made.

 

The method for diagnosing diabetes in Australia has changed. Until recently it was done using fasting blood glugose levels (or via a glucose tolerance test, which measures the fasting blood glucose level and a glucose level two hours after the fasting person has consumed a standard amount of glucose (i.e. a glucose load)). These tests are somewhat time consuming and require multiple trips to the doctor.

The HbA1c test on the other hand allows diabetes to be diagnosed via a single blood test. This test provides an indication of what the person's blood glucose level has been like over the past three months, with a level over 48 to 52mmol/mol (6.5% to 6.9% in the old terminology) indicating prediabetes diabetes and levels over 52mmol/mol (6.9%) indicating diabetes. A positive test does need to be confirmed by a second test before diabetes is dignosed. This test is generally regarded as the best indicator of the amount of illness that diabetes is causing.

(Back to top)

Reducing the risk of developing and / or exaccerbating diabetic complications

a. Regular assessment

Assessment for diabetic complications needs to be done regularly by both GPs and specialist medical practitioners. This includes assessment and treatment by several health professionals:

  • General practitioners / specialist doctors to:
    • overview diabetes control. This includes review of patient's blood sugar levels and performing HbA1c measurements at least twice a year. Patients should be reviewed at least twice a year but often require more frequent review.
    • monitor kidney function: Yearly checks of kidney function (by measuring the glomerular filtration rate) and albumin (protein) in the urine (done by a dipstick that measures the albumin to creatinine ratio). If protein has previously been found in the urine, three to six monthly testing is required. For more on kidney testing see section on Kidney disease. Initial testing should occur when diabetes is diagnosed.
    • monitor blood pressure
    • perform yearly eye checks done by an opthalmologist (eye specialist): At present, about 50% of Australians with diabetes have not seen an ophthalmologist in the past two years, significantly increasing their risk of retinopathy and resultant impaired vision. (Early detection and prompt treatment can revent most loss of vision due to damage to the retina from diabetes (i.e. diabetic retinpoathy). People diagnosed with type 2 diabetes should see an opthalmologist at the time of diagnosis and then at least second yearly (or more frequently if significant eye disease is present). People diagnosed with type 1 diabetes should see an opthalmologist three years after diagnosis and then at least second yearly.
    • look for evidence of other complications; This includes testing feet every year for sensory loss and blood supply (by checking pulses).
    • immunise patients for influenza and pneumococcal pneumonia
  • Diabetes health educators: Patients need to have a sound knowledge about all aspects of the disease that is kept up to date.
  • Dietitian: Proper diet is a cornerstone of diabetes treatment and requires expert assessment, advice and ongoing supervision by a dietitian.
  • Exercise physiologists: To advise regarding appropriate physical activity.
  • Podiatrists: Overview foot care to prevent ulcer formation
  • Psychologists: Diabetes care is a ifelong condition and is often associated with mental health problems, especially depression and eating disorders . Patients often also need therapy to keep them motivated to optimise their adoption of advice regarding lifestyle modification and treatment.

Who needs referral to a diabetic specialist / diabetic centre?

All people newly diagnosed with diabetes so that they receive a thorough initial assessment and optimum initial diabetic education.
  • All children with Type 1 or Type 2 diabetes need ongoing care at a dibetes centre.
  • Women with pre-existing diabetes who wish to become pregnant or are pregnant.
  • People with diabetic foot disease
  • People with Type 2 diabetes who need to go onto insulin or require specialised therapy such as the use of insulin pumps.
  • People with significant kidney failure.
  • People with additional significant cardiovascular disease risk factors, such as high blood pressure and high cholesterol.

 (Back to top)

b. Good control of blood glucose levels in people with diabetes

Good control of blood sugars in people with diabetes, mediated through regular blood sugar monitoring, benefits all diabetic complications but especially microvascular complications, such as those affecting the eyes and kidneys. Methods of monitoring include home blood glucose monitoring and regularly checking HbA1c levels to assess longer term blood glucose control.

 

Target levels for blood glucose levels and HbA1c levels appear in the following table.

 

Target blood sugar levels for controlling diabetes

Level of control

BSL*

before

meal

(mmol/L)

BSL*

after

meal

(mmol/L)

Average BSL*

 

(mmol/L)

HbA1c

(%)

(mmol/mol)**

 

Comment

Ideal***

4.0  to 5.4

4.0 to 7.7

6.0

Less than 7%

or

53mmol/mol

Normal levels.

 

Moderate

4.0  to 7.7

4.0 to 11.0

8.0

7% to 8%

 

53 to 65mmol/mol

Associated with macrovascular complications (minimises microvascular complications)

Action is required.

Poor

Greater than 7.7

Greater

than 11.0

Greater than 10.0

Greater than 8% or 65mmol/mol

Associated with microvascular and macrovascular complications.

Very strong action required.

* BGL – Blood sugar (glucose) level

**HbA1c evels have in the past been measured as a percentage (%). In the future HbA1c will be measured in a new unit; mmol/mol. Both units are given in this table.

***Ideal levels may need to be slightly higher in people whose diabetic trweatment causes recurrent severe hypoglycaemia or who are unaware when hypoglycaemia occurs, in children and adolescents with diabetes and in older people with a reduced life expectancy.

Regular check ups with a GP are important to adjust treatment. As can be seen from the table below, unfortunately about half of Australians with type 2 diabetes are not adequately controlled!! (i.e. 47 per cent have a HbA1c of 7.0% or greater.) For every 1% drop in HbA1c there is a 37% reduction in microvascular complications, a 25% reduction in diabetes related deaths and an 18% reduction in heart attacks.

(Back to top)

c. Good control of other factors that increase the risk of diabetic complication developing / worsening (mostly other risk factors for vascular disease)

An integral part of reducing diabetic complications is treating other risk factors that worsen these complications and this is also very important in people with glucose intolerance (‘pre-diabetes'). These risk factors are outlined in the table below. As can be seen from the table, the majority of people with diabetes do not achieve target levels for these risk factors. Those with diabetes who are at most risk include people of Aboriginal and Torres Strait Islander decent, those aged over 60, those with albumin in their urine and those who have had the disease for more than 10 years.

 

People with diabetes should aim to reduce alcohol intake to 20g (two standard drinks) per day or less.

 

 

Risk factors that worsen diabetic complications – Target HbA1c levels

Risk factor

Target level for people with diabetes

% of people with diabetes who do NOT achieve target

HbA1c level

Less than 7.0% (or < 53mmol/mol)

47%

Blood pressure

Less than 130/80mmHg*

74%

Smoking and

alcohol use

Cease cigarette use

No more than two standard drinks per day

 

Weight

(Best assessed by waist measurement)

Waist measurement of less than 94cm in men and less than 80cm in women

Body mass index of 20 to 25

81%

Physical activity

At least 30 minutes per day of moderate activity

 

Total cholesterol

Less than 4.0mmol/L

82%

LDL cholesterol

Less than 2.5mmol/L**

 

Triglycerides

Less than 1.5mmol/L

 

Urine albumin ***

(Albumin makes up about 60% of all protein excreted in urine )

Less than 20mg/L (timed overnight collection)

 

Urinary albumin - creatinine ratio***

Less than 3.5mg/mmol in women and less than 2.5mg/mmol in men

 

*Blood pressure should be less than 125/75mmHg in people with diabetes who have significant protein in their urine (over 1g/day).

**LDL cholesterol should be less than 1.8mmol/L for those at very high risk of cardiovascular disease or who already suffer from cardiovascular disease. This includes many people with diabetes.

***Urine albumin and urinary albumin-creatinine ratio are good indicators of kidney damage due to diabetes. People with persistent protein in their urine due to diabetic kidney damage have a high incidence of heart attacks and strokes; and a poor 10-year survival rate. Regular assessment of kidney function is important in all patients with diabetes and protein in their urine, as is regular review by a diabetic or kidney specialist. (See separate section on kidney disease.)

Notes:

The three most important risk factors for microvascular complications (in order) are poor diabetic control, high blood pressure and smoking.

(Back to top)

Therapy for diabetes

Good weight control and exercise will not prevent all diabetes occurring and many people will require medication to treat diabetes. It is beyond the scope of this web site to discuss in detail the treatment options for diabetes. However, a short summary appears in the table below.

Good diabetic control usually means a small gain in weight: Most people who improve their diabetic control will unfortunately put on a little weight. The main reason for this is that people with poorly controlled diabetes continuously lose a small amount of glucose (sugar) in their urine. Better blood sugar control reduces or eliminates this loss and, assuming the extra sugar is not burned off through additional exercise, it ends up being converted to fat and stored in the body. Unfortunately, some medications used for treating diabetes also tend to cause slight weight gain.

 

Therapy for diabetes*

Medications that reduce insulin resistance

Medication

Mode of action / comments

Metformin

Metformin acts by reducing excessive liver production of glucose and increases uptake of glucose by the tissues. In doing so, it improves sensitivity to insulin i.e. reduces insulin resistance. This is the major problem in most people with type 2 diabetes and thus metformin is the usual first line medication in these people.

When used in conjunction with insulin injections, metformin can reduce the insulin dosage by up to 20 to 30 per cent.

Metformin should be avoided in people with significant kidney impairment, liver impairment or severe heart failure.

Glitazones

 

Glitazones act by improving the sensitivity of the peripheral tissues (mostly fat, muscle and the liver) to the action of insulin i.e. they reduce insulin resistance. They are less likely to be useful in patients who are lean. They do tend to increase total body fat but may improve fat distribution i.e. decrease the proportion of abdominal fat.

Glitazones can cause coronary heart disease and heart failure and should not be used if these conditions are present. They can also cause ankle swelling.

Medications that increase insulin levels

(Important: Medications that increase insulin levels have the problem of causing occasional hypoglycaemia.)

Medication

Mode of action

Sulfonylureas

These drugs act by stimulating insulin secretion from the pancreas. People with type 2 diabetes have resistance to the action of insulin and try to overcome this by producing more insulin. Thus they already have high blood insulin levels. These drugs act to make these high insulin levels even higher and this acts to increase body fat. If the body is already producing insulin at close to its maximum capability, they will not have a great effect.

Medications that enhance the effect of incretin hormones.

Incretin hormones are released from the gut in response to glucose consumption and act to increase insulin secretion from the pancreas. They are quickly broken down by the gut enzyme DPP4. The drug sitagliptin acts to inhibit this enzyme and thus increases the effect of incretin hormones, which in turn increases insulin and decreases blood sugar. It has few side effects and has two advantages over sulphonyl ureas; it does not cause weight gain and it does not cause hypoglycaemia.

Insulin

Insulin performs the functions of normal insulin. As stated above, insulin resistance is a major cause of type 2 diabetes and these people produce extra insulin to try and overcome this resistance i.e. they have high insulin levels. Giving insulin (like giving sulfonylureas), while helping to keep blood glucose at normal levels, increases these already high insulin levels. As with sulfonylureas, this acts to increase body fat.

In type 1 diabetes the underlying problem is that the pancreas is able to produce little or no insulin and thus insulin is the only effective treatment.

In type 2 diabetes it is often recommended to start insulin if HbA1c is greater than 7.5% (59mmol/mol) despite optimum oral medication and lifestyle intervention.

* This summary only provides an idea of how these medications affect blood sugar. It does not examine side effects etc and patients need to discuss with their doctor which medication best suits their situation.

 

 

Further information

Diabetes Australia www.diabetesaustralia.com.au

 

 

(Back to top)