Managing ClinicalProblems in Diabetes

Edited by

Trisha DunningAM, RN, MEd, PhD, CDE, FRCNA

Glenn WardMBBS, BSc, DPhil (Oxon), FRACP, FRCPath

Managing Clinical Problems in Diabetes

Managing ClinicalProblems in Diabetes

Edited by

Trisha DunningAM, RN, MEd, PhD, CDE, FRCNA

Glenn WardMBBS, BSc, DPhil (Oxon), FRACP, FRCPath

© 2008 by Blackwell Publishing Ltd

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First published 2008 by Blackwell Publishing Ltd

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Library of Congress Cataloging-in-Publication DataManaging clinical problems in diabetes / edited by Trisha Dunning, Glenn Ward.

p. ; cm.Includes bibliographical references and index.ISBN-13: 978-1-4051-5571-7 (pbk. : alk. paper)ISBN-10: 1-4051-5571-X (pbk. : alk. paper)

1. Diabetes–Treatment. 2. Diabetes–Complications–Treatment. I. Dunning, Trisha.II. Ward, Glenn, MBBS.[DNLM: 1. Diabetes Mellitus–therapy–Case Reports. WK 815 M2654 2008]RC660.M338 2008616.4′6206–dc22

2007029631

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Contents

Author profiles........................................................................... ix

Foreword ................................................................................... xv

Preface....................................................................................... xvii

Dedication and acknowledgements ............................................ xix

Diabetes management – a matter of balance ............................... xxi

1 Introduction and overview of the book ............................... 1Introduction ....................................................................... 1Aims of the book ................................................................ 2References .......................................................................... 4

2 Presentation, diagnosis and classification of diabetes........... 5Introduction ....................................................................... 5Diabetes mellitus ................................................................ 6The main types of diabetes .................................................. 6Prevalence of diabetes ......................................................... 8Type 1 diabetes in children and young people ...................... 9Case discussions ................................................................. 14References .......................................................................... 32Recommended reading ....................................................... 35

3 Health assessment, management targets, and deciding on a management plan ........................................................ 37Introduction ....................................................................... 37The aims of diabetes management....................................... 38Monitoring the effectiveness of the management plan ......... 43Holistic health assessment................................................... 45Laboratory assessments ...................................................... 46Multidisciplinary team care and shared care........................ 48Case discussions ................................................................. 49References .......................................................................... 54Recommended reading ....................................................... 56

vi Contents

4 Nutritional management and physical activity .................... 57Introduction ....................................................................... 57Obesity............................................................................... 60Low-calorie diets and weight loss medicines........................ 61Incidence and consequences of malnutrition........................ 62Measuring the carbohydrate content of food....................... 63Increasing mobility and exercise.......................................... 63Case discussions ................................................................. 64References .......................................................................... 67Recommended reading ....................................................... 68

5 Pharmacotherapeutic management ..................................... 69Introduction ....................................................................... 69Quality use of medicines ..................................................... 70Oral hypoglycaemic agents ................................................. 71Combining OHAs and insulin............................................. 73Insulin ................................................................................ 73Sliding scales and top-up regimens ...................................... 77Lipid-lowering agents ......................................................... 77Antihypertensive agents ...................................................... 78Salicylates........................................................................... 80Case discussions ................................................................. 82References .......................................................................... 95Recommended reading ....................................................... 97Independent medicine information...................................... 97

6 Short-term complications.................................................... 99Introduction ....................................................................... 99Hypoglycaemia................................................................... 100Hyperglycaemia.................................................................. 103Case discussions ................................................................. 107References .......................................................................... 117Recommended reading ....................................................... 119

7 Long-term complications .................................................... 121Introduction ....................................................................... 121Cardiovascular disease........................................................ 123Cerebrovascular disease...................................................... 127Nephropathy ...................................................................... 127Retinopathy........................................................................ 129Neuropathy ........................................................................ 129

Contents vii

Dental infection .................................................................. 132Musculoskeletal effects ....................................................... 132Case discussions ................................................................. 133References .......................................................................... 141Recommended reading ....................................................... 143

8 Psychological issues and quality of life ................................ 145Introduction ....................................................................... 145Depression.......................................................................... 146Signs and symptoms of depression ...................................... 146Tools used to measure depression........................................ 148Quality of life ..................................................................... 149Case discussions ................................................................. 150References .......................................................................... 162Recommended reading ....................................................... 164

9 Diabetes education ............................................................. 165Introduction ....................................................................... 165Education processes............................................................ 166Aims of diabetes education ................................................. 166Survival skills education...................................................... 167Empowerment .................................................................... 168Case discussions ................................................................. 169References .......................................................................... 176Recommended reading ....................................................... 176

10 Gestational diabetes............................................................ 177Introduction ....................................................................... 177Managing gestational diabetes ............................................ 177Commencing insulin ........................................................... 179Case discussion................................................................... 179Education ........................................................................... 181Case discussions ................................................................. 183References .......................................................................... 184

11 Complementary and alternative therapies ........................... 185Introduction ....................................................................... 185Profile of CAM users........................................................... 186Reasons for using CAM ...................................................... 187Herbal and nutritional therapies ......................................... 188Complementary and conventional medicine interactions..... 191

viii Contents

Case discussions ................................................................. 194References .......................................................................... 201Recommended reading ....................................................... 203

Index ........................................................................................ 205

Author profiles

Editors

Trisha DunningAM, RN, MEd, PhD, CDE, FRCNA

Professor Dunning is the Inaugural Chair in Nursing at DeakinUniversity and Barwon Health in Victoria, Australia. She has been adiabetes educator for 20 years and is passionate about holistic nurs-ing care. Trisha is the Inaugural Chair of the International DiabetesFederation (IDF) Consultative Section on Diabetes Education. She isthe author of several books for people with diabetes and many booksand papers for health professionals. She is an active researcher with a focus on people’s beliefs and attitudes and how they affect profes-sional care and self-care. Trisha is a very active worker on a greatmany Australian and international diabetes-related committees.

Glenn WardMBBS, BSc, DPhil (Oxon), FRACP, FRCPath

Glenn Ward is Head of Diabetes Services and Deputy Director,Department of Endocrinology and Diabetes, Clinical Consultant inthe Department of Clinical Biochemistry at St. Vincent’s Hospital,Melbourne, Australia. He is an Associate Professor in the Universityof Melbourne Department of Pathology, and a Senior Fellow, ClinicalSchool University of Melbourne, St Vincent’s Hospital. He wasPresident of the Australian Diabetes Society from 2002–2004; VicePresident of the Australian Diabetes Society 2000–2002; Chair of theMedical, Educational and Scientific Council of Diabetes AustraliaNational 1998–2000; Honorary Secretary of the Australian DiabetesSociety 1998–2000; a Councilor of the Australian Diabetes Society1994–2004; Member of Board of Directors of Diabetes Australia

x Author profiles

1994–2004; a Member of the National Executive Committee ofDiabetes Australia 2002–2004; and is the current Chair of the CrossCultural Committee of Diabetes Australia. Glenn has over 70 pub-lished articles focusing on in vivo research on insulin action and secre-tion in human subjects.

Contributors

Ralph AudehmMBBS, DipRACOG, Graduate Certificate in Clinical Research

Ralph is a general practitioner in Melbourne with a special interest in diabetes education and care. He is the GP Liaison Officer with the Royal Melbourne Hospital and Medical Advisor to DiabetesAustralia, Victoria. He is active on several local and state committeesconcerning diabetes and collaborates in research projects through theDepartment of General Practice, the University of Melbourne.

Thyra BoltonEN

Thyra Bolton has coordinated the High-risk Foot Clinic at RoyalPrince Alfred Hospital in Sydney since its inception in 1988. She hasbeen extensively involved in health professional training, especially inrural areas and for visiting health professionals from overseas. Thyrahas assisted in the establishment of high-risk foot clinics in Fiji andThursday Island, which included training health professionals.Together with the staff of Royal Prince Alfred Diabetes Service sheestablished the first High-risk Foot Telemedicine Service and conti-nues to participate in online consultations. She was an invited speakerat the IDF Congress in Mexico in 2000 and Paris in 2003, the VascularConference in China in 2004 and contributed to the NSW BetterPractice Guidelines on the Management of Lower Limb Ulceration.

Lesley BraunB Pharm, Dip Appl Sci (Naturopathy), Grad Dip Phytotherapy

Lesley is a qualified pharmacist, naturopath, and herbalist. She acts asa consultant to industry and is a senior lecturer in The AustralianCollege of Natural Medicine. Lesley is frequently invited to speak on

Author profiles xi

complementary medicines. She is the author of many articles aboutnatural medicines, and writes a regular column for the Journal ofComplementary Medicine. She is the author of Herbs and NaturalSupplements, which is now in its second edition.

Trudi DeakinBSc (Hons), Ad Dip, PGCE, PhD, RD

Dr Trudi Deakin is Clinical Champion for the East LancashireDiabetes Network and Chief Research Dietitian. Trudi qualified as a dietitian in 1993, specialised in paediatric diabetes in 1994 andbecame a diabetes specialist dietitian (adults/children) in 1996.Enrolment in a postgraduate certificate in education (PGCE) courseenabled her to develop adult education principles. Concentrating onstructured patient education, she undertook further research and wasawarded a doctorate in diabetes in 2004. Trudi is passionate aboutresearching, modernising and improving diabetes care and treatmentand has assisted in developing and implementing many national initi-atives. She is also an active member of the Diabetes UK ProfessionalAdvisory Council.

Sandra HoodBSc (Hons), RD, DipADP

Sandra Hood is a specialist diabetes dietitian. She is the Lead for theDiabetes Service, working for the Nutrition and Dietetic Department,Dorset County Hospital, Dorchester, UK. She has a specialist interestin vegan diets and is an accomplished author and authority in thisfield. Since the recent changes in the management of diabetes careSandra has developed a well-respected structured patient educationprogramme.

Pamela JonesRN, CDE

Pamela Jones is manager of the Diabetes Referral Centre at BarwonHealth, the Geelong Hospital, Geelong, Victoria, Australia. Pamela isa Credentialed Diabetes Educator and has been working in diabetessince 1989. She has extensive experience working with children andadults with diabetes, both in the acute and community care setting.

xii Author profiles

Pamela was responsible for the establishment of the Barwon RegionDiabetes Educator’s working group in 1990. This group consists ofmultidisciplinary health professionals, who focus on sharing infor-mation and expertise that is aimed at improving client education.Pamela has a special interest in diabetes and pregnancy. This led to thedevelopment of a gestational diabetes ambulatory care programmethat promotes women’s potential for self-care with little disruption totheir lives during this very special time. Pamela regularly conducts dia-betes courses for nurses and other health professional and communitygroups.

Marg McGillRN, MSc (Med)

Marg McGill has been a Vice President of the International DiabetesFederation (IDF) since 2003 and was appointed the Senior VicePresident in 2006. Since 2000 she has been Chair of the IDFConsultative Section on Diabetes Education. In this role she hasactively promoted the importance of role of the health professional.She has conducted leadership needs assessment workshops and pro-fessional education programmes in most regions of the IDF. She hasled teams to develop (1) an International Curriculum for DiabetesHealth Professional Education; (2) Content for the Curriculum; (3) anIDF-recognised Multidisciplinary Education Program for DiabetesHealth Professionals; and (4) International Standards for DiabetesEducation. She was Australia’s first paediatric diabetes educator in1978. For the last 18 years she has managed the Royal Prince AlfredHospital Diabetes Ambulatory Care Centre, which is a large adult ser-vice focusing on clinical care and research. Her clinical and researchinterest is in the assessment and management of diabetic complica-tions. She has published consistently on this topic in peer-reviewedjournals. She is a regular invited speaker at many international dia-betes scientific meetings.

Vanessa NubéDip App Sci (Podiatry), MSc (Med)

Vanessa is senior podiatrist at the Royal Prince Alfred HospitalDiabetes Centre. In 2000 she was appointed co-ordinator of theDiabetes Amputation Prevention Programme for the Central SydneyArea Health Service, which introduces strategies for improving the

Author profiles xiii

management of diabetic foot disease. An invited speaker on the topicof diabetic foot disease both locally and internationally, Vanessa’spublications include two original research papers published in TheFoot and The Journal of the American Podiatric Medical Associationand she has contributed to other publications on the diabetic footincluding the NSW Health publication Lower Limb Ulcers in Peoplewith Diabetes. She is on the advisory committee for the AustralasianJournal of Podiatric Medicine.

Michelle RobinsRN, MRCNA, Graduate Certificate in Diabetes Education, CDE

Michelle Robins is an endorsed nurse practitioner with 14 years’experience as a diabetes educator in a variety of settings. Her interestsin diabetes management include improving the care of older peoplewith diabetes, type 1 diabetes in young adults and better managementstrategies for people with type 2 diabetes who have complex needs.She is passionate about educating health professionals and buildingstrong networks between the tertiary and primary care sectors.

Chas SkinnerPsychologist

Dr Chas Skinner was Senior Lecturer in Health Psychology, Universityof Southampton, UK, before taking up his current position at theUniversity of Wollongong, NSW, Australia.

Victoria StevensonRN, FRCNA, CDE

Victoria is the Diabetes Clinical Nurse Coordinator at Austin Health,Victoria, Australia. In her many years in diabetes education, Victoriahas established diabetes education services in several hospitals and aprivate diabetes education practice. She developed teaching resourcesthat help people come to terms with the practicalities of having dia-betes, and co produced several videos, the most recent being Join withUs, which promotes the Australian Diabetes Educators Association.Victoria is actively involved in state and national diabetes health pro-fessional groups that aim to better inform people with diabetes andthose associated with them.

xiv Author profiles

Sheridan WaldronRD, BA, PhD

Sheridan is a specialist diabetes dietitian working for Dorset CountyHospital, Dietetic Department. She has spent over 20 years work-ing with children and adults with diabetes. Her research interests concern the dietary management of children’s diabetes. Her currentresearch is examining the barriers and facilitators of dietary change in children with type 1 diabetes. She has held national positions thathave contributed to setting national recommendations and policy inthe UK. She also holds official positions in the International Societyfor Pediatric and Adolescent Diabetes and the International DiabetesFederation.

Foreword

It is a great pleasure to pen the foreword to this significant book.Never was the presence of the contributing authors so strongly pre-sent, deeply courageous in the exposure of their personal and profes-sional responses that in turn makes this book so highly engaging. Itembodies a candour and integrity that goes beyond the contemporaryconstraining philosophy of political correctness and has at its heartthe centrality of the patient and moves it into the principles and philo-sophy of what I call the humanity of care.

The structure, while logical, has the merit that the introduction ofeach of the eleven chapters is reflected in the reality of the referrals andthe signature of key points. Each chapter is appropriately referencedand the principle of evidence base is critically followed and resonatesin the response to the individual referrals. The authors have movedbeyond the paradigm of acute management and are firmly embeddedin the paradigm of chronic disease management.

Using the professional narrative approach from the perspective of different disciplines exemplifies the core constituents of a multi-disciplinary professional team. While the approach may differ in somerespects, the key elements of dialogue between the individual authorshave resonance with the model of patient narrative as exemplified byDr Natalia Piana et al. in the use of patient narrative in therapeuticpatient education.

The examples and availability of actual referrals, professional orself referrals, give an authenticity and resonance for diabetes teams in daily practice. This is what makes this book so vibrant. It has the merit of promoting private reflection as well as team reflection.Furthermore, as an educational learning tool it has much to recom-mend by way of use for group discussion and it has additional merit in master class format for both specialists and non-specialists alike.

While the book can be read in one sitting it is also eminently suitable for use as a selective reference source for dipping into asneeded and incorporated into structured professional education in thespecialty of diabetes. It is of particular note that although the majorityof the authors work in the Australian health care system there is a universality of message that diffuses into all health care systems.

xvi Foreword

The enduring imprint that this book leaves on me is the primacy of the patient and the imperative of multi-disciplinary and inter-disciplinary co-operation in managing clinical problems in diabetesand enabling individual patients to continue their journey of life-longself management.

Anne-Marie FeltonPresident, Federation of

European Nurses in Diabetes

Preface

The idea for this book grew out of a constant flow of telephone andemail requests for advice, particularly from rural health professionals,and responding to letters from people with diabetes in a regular col-umn in Diabetes Conquest, a magazine for people with diabetes.Many of our colleagues will recognise their patients in the case histor-ies presented in the book. Obviously names have been withheld, iden-tifying information removed, and the initials changed to protect theprivacy of both the people with diabetes and their health professionalcarers.

Rationale for the book

The incidence and prevalence of diabetes is increasing globally.Therefore, most health professionals are likely to care for people withdiabetes and often find they have to make clinical decisions withoutexpert support, which can be difficult.

The proposed book aims to support theory with practical sugges-tions for addressing common clinical problems based on evidence andthe clinical experience of diabetes educators, endocrinologists, generalpractitioners, and other health professionals who encounter suchproblems on a daily basis. The book was designed to be used as a clin-ical resource and illustrate how the health professionals concernedapproach common clinical problems. It was also designed to comple-ment other diabetes texts.

Aims of the book

The aims are to:

(1) address commonly encountered diabetes management problems;(2) develop comprehensive responses from a range of relevant health

professionals who suggest management approaches relevant to their area of practice. The specific health professionals who

xviii Preface

provide comments about each case depend on the specific clinicalissue; and

(3) stimulate thought and discussion.

Target readership

The target readership is health professionals from a range of profes-sional backgrounds and general as well as specialist professionals suchas general practitioners, nurses, dietitians, and podiatrists. The bookwill be particularly useful for beginner practitioners specialising in dia-betes. In addition, it will provide suggestions or food for thought formore experienced practitioners.

The cases discussed in the book are all real and are presentedexactly as the information was received from the person making thereferral. General practitioners, diabetes educators and people withdiabetes referred most of the cases; some were self-referrals by peoplewith diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues. Alist of key chapter points and recommended reading accompanies eachchapter.

Trisha Dunning and Glenn Ward

Dedication andacknowledgements

This book is dedicated to all people with diabetes and the health pro-fessionals who care for them.

Glenn and I sincerely acknowledge the contributions of all theauthors whose voices can be heard in this book for facing the chal-lenge of suggesting management options for the cases presented andmaking their critical thinking, reflective practice, and problem-solvingprocesses visible through those suggestions.

Diabetes management – a matter of balance

The essence of diabetes care is achieving balance in all aspects of the life of a person with diabetes. Achieving balance requires lifelong collaborative, multidisciplinary care where the person with diabetesplays a central role in determining his or her life priorities, health goalsand planning his/her care. There is a ‘doctor within’ each person,which if motivated and supported, can lead to improved health out-comes and better quality of life. The challenge for health professionalsis to recognise this concept and learn how to identify and support the‘doctor within’ each person with diabetes they have the privilege ofcaring for.