Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary …

Background

These guidelines have been developed to support appropriate care and timely
referral for people with diabetes in the Nottingham area They are a
consensus view and incorporate, where available, national and international
recommendations on standards of care In the event of significant new
research findings or national recommendation, specific areas may be updated
ad hoc Full revision will be undertaken every two to three years

By 2010, it is estimated that there will be 30,000 people with diabetes in
Nottingham

Guideline Development

The following people have contributed:

Return to Index page

If you have comments on the content of the guidelines, please contact:

Dr Tasso Gazis Tel:
0115 924 9924 ext 41100
Diabetes and Endocrinology Department Fax: 0115 970 1080
C Floor, South Block E-mail: tassogazis@qmcnhsuk
University Hospital
Nottingham
NG7 2UH

Referral Guidance

Diagnosing Diabetes / Glucose Intolerance

Also see other diagnostic categories below

Oral Glucose Tolerance Test OGTT

Detection of People at High Risk of Diabetes3

Routine / population screening of non-pregnant, asymptomatic adults is not
recommended

The following groups are at higher risk of diabetes
- In these groups, opportunistic testing for
diabetes may be appropriate
over age 45 years
- Only laboratory samples can be used to diagnose diabetes, not
fingerprick samples
- If glucose tolerance is abnormal, but not in the range for diabetes,
follow up testing may be appropriate

Known impaired fasting glycaemia / impaired glucose tolerance
History of vascular disease
Race / ethnicity - South Asian, African / Caribbean
Parent or sibling with diabetes
Polycystic ovarian syndrome
Prior gestational diabetes
Obesity BMI 30kg/m2

Does the Newly Presenting Patient Need Insulin?

Guidance below not appropriate for paediatric patients

Monitoring and Complications

The Annual Review

Structured care with annual review is essential
Prevention and identification of complications is otherwise frequently
inadequate
Underlined text is hyperlinked to explanatory flowsheet / text - point and
click

General

- Weight / body mass index
- Lifestyle advice
- Dietary Advice or Referral to Dietitian
- Smoking cessation advice
- Sick day rules
- Medication problems -
polypharmacy / dosette box refer to pharmacist
- Clinical waste / sharps

Macrovascular Disease
- Coronary Heart Disease Risk
- Blood Pressure
- Aspirin and Lipid Lowering Treatments
- The Diabetic Foot

Glucose Control
- Review Glucose Monitoring records
- HbA1c
- Oral Hypoglycaemic Agents Tablets
- Symptoms of hyperglycaemia / episodes of hypoglycaemia
- Injection sites for lipohypertrophy

Microvascular Disease
- Microalbuminuria and Proteinuria
- Retinopathy
- The Diabetic Foot
- Erectile dysfunction

Blood Glucose Monitoring
See notes below
Blood glucose testing is useful if it makes a difference to treatment
Education in use of information from blood glucose testing is key to
appropriate use
Every patients needs should be individually assessed by an appropriately
experienced healthcare provider Changes in testing regimen should be
agreed with the patient
The guidance below is neither rigid nor exhaustive

Notes for Blood Glucose Monitoring

Blood glucose tests are usually done before meals and bed

Lower frequency testing may be:
the occasional test before meals or bed
testing before each meal and bed
2-3 times per week

this will be patient dependent

Glycosylated Haemoglobin - HbA1c

HbA1c is generally measured every 2 - 6 months
Measures average blood glucose over previous 4 - 6 weeks
Measures how much glucose is stuck to red blood cells life span about 6
weeks
The HbA1c target should be individualised - if 1 above target, consider
adjusting treatment
Conditions which affect red cells affect HbA1c - including haemolysis,
bleeding, haemoglobinopathies and others

Retinopathy Screening

Diabetes remains the leading cause of preventable blindness in the working
age population

The retinopathy screening service now complies with Quality Assurance
Standards developed by the National Screening Committee and the National
Service Framework for Diabetes

This service replaces optometry-based retinopathy screening - but not
refraction / glaucoma assessment

The Nottingham Diabetic Retinopathy Service DRS uses digital photography
It provides centralised annual call-recall and notifies patients and
Practices of screening results Patients with sight threatening retinopathy
are referred directly for treatment, reducing the risk of visual
loss

Contact details are:

Web: wwwnottinghamretinopathycouk

Phone: 0115 919 4411

Post: The Nottingham Diabetic Retinopathy Service DRS
Department of Diabetes and Ophthalmolgy
Nottingham University Hospitals
QMC Campus
C Floor, South Block
Derby Road
Nottingham NG7 2UH

Currently, there are 4 screening sites The number will increase over 2007
Hospital transport is available by the usual route:

Carlton Park House Health Social Care Centre
Stapleford Care Centre
Queens Medical Centre Campus - Clinic 2
City Hospital Campus - Dundee House

Microalbuminuria, Proteinuria and Renal Disease

Measure serum creatinine / GFR and see notes and renal referral guidance
below
See Aspirin and Lipid section calculate CHD / CVD risk
See Blood Pressure section

Notes for GFR, Microalbuminuria and Proteinuria

Glomerular filtration rate GFR
Preferred measure of renal function as it accounts for age, sex,
ethnicity and weight
Already or shortly to become routinely reported in local hospitals
If abnormal, annual repeat testing
unlikely to be sufficient See renal
referral guidance

Microalbuminuria

Excess albumin in the urine but not detectable using protein dipstick
Earliest indicator of chronic kidney disease nephropathy
Predictive of cardiovascular morbidity and mortality

Proteinuria

Excess albumin in the urine but detectable using protein dipstick
An important finding in patients with type 1 and type 2 diabetes
Represents progression of urine albumin excretion from microalbuminuria
Associated with progressive chronic kidney disease due to diabetic
nephropathy
Predictive of cardiovascular morbidity and mortality

Urine sample for laboratory screening
10 ml early morning first pass urine sample in a Universal specimen
container
Early morning sample excludes postural proteinuria
Clinical chemistry form for albumin/creatinine ratio ACR or
protein/creatinine ratio PCR

PCR is the best test to confirm clinical proteinuria - at higher levels
above 30 mg/mmol ACR may be inaccurate There is no need for 24 hour
urine collections

Renal Unit Referral Guidance

Also see Microalbuminuria and Proteinuria section above
General renal referral advice / guidance is available from CHN Renal Unit
969 1169

If non-diabetic renal disease suspected
If patient under care of Diabetes Service, referral may already be in hand

Malignant hypertension visual disturbance, retinal haemorrhages
exudates
Immediate referral by phone or fax on 0115 962 7678

Proteinuria with oedema and low serum albumin nephrotic syndrome
Dipstick proteinuria with urine protein : creatinine ratio 100 mg/mmol
and patient not known to UHN / CHN diabetes service
Dipstick proteinuria and microscopic haematuria present
Macroscopic haematuria but urological tests negative

For management of advancing chronic kidney disease
If patient under care of Diabetes Service, referral may already be in hand

GFR 15 ml/min
Roughly equivalent to serum creatinine 400 umol/L in men

300 umol/L in women

Immediate referral to renal service by phone 969 1169or fax 962
7678
Ensure general renal referral guidance followed
GFR 15-29 ml/min
Roughly equivalent to serum creatinine 200-400 ?mol/L in men

150-
300 ?mol/L in women
Repeat within 5 days
If repeat GFR 15 ml/min: urgent renal referral as above
Otherwise routine renal referral - ensure general renal referral
guidance followed
GFR 30-59 ml/min
progressive fall in GFR / increase in serum creatinine OR
microscopic
haematuria present OR
dipstick proteinuria present OR
unexplained anaemia, abnormal potassium, calcium or phosphate OR
symptoms suggest systemic illness eg SLE OR
uncontrolled BP 150/90 on 4 agents
Routine referral - ensure general renal referral guidance followed
GFR 60-89 ml/min
not chronic kidney disease unless other problems persistent
proteinuria or haematuria
GFR 90 ml/min
normal

Blood Pressure

See Notes on next page
See Aspirin and Lipid section calculate CHD / CVD risk
See Microalbuminuria and Proteinuria section
The aim is to lower systolic and diastolic pressure below target
Check blood pressure and adjust treatment every 4 weeks until target
attained

Notes for Blood Pressure

Initial assessment

Measuring blood pressure - British Hypertension Society recommendations:

Patient seated and relaxed for 5 minutes with arm supported

No tight clothing to constrict the arm
Bladder should encircle between three-quarters and whole upper arm
Cuff level with heart
Alternative adult cuff 125 - 130 x 35 recommended
for use in all
adults
For arm circumference over 42 cm large bladders may be required

Cuff Sizes Width cm Length cm
Normal 120 - 130 23 - 33
Alternative adult 125 - 130 35 - 42

Electronic monitors
- in general wrist monitors are inaccurate, upper arm machines are
suitable
More information available at http://wwwbhsocorg
Ambulatory / Home Blood Pressure readings
- Subtract 10/5 mmHg to correlate with clinic pressure
- 130/75 ambulatory / home 140/80 in clinic

Non-pharmacological measures prior to pharmacological treatment

Stop smoking
Weight Loss
Increase physical activity
No added salt diet
Reduce alcohol to 2 units /day

ACE Inhibitors / AII Receptor Blockers
Make sure patient not taking potassium-retaining diuretic or Lo-Salt

Check potassium and creatinine before and within 2 weeks of
- starting ACE inhibitor or AII-receptor blocker OR
- increasing dose

Stop ACEI / ARB and refer for investigation for renal artery stenosis
if:
- K 60mmol/L OR
-
Creatinine rise 20 OR
- GFR fall of 15

If ACE inhibitor not tolerated or cough, switch to Angiotensin II
receptor blocker

Ethnicity

People of African-Caribbean ethnicity may respond poorly to ACEI, AII
receptor blockers and -blockers
Addition of a diuretic partially overcomes this
Consider calcium channel blocker as alternative

Aspirin and Lipid Lowering Treatments4

See Notes on next page
See Microalbuminuria and Proteinuria section
See Blood Pressure section

Notes for Aspirin and Lipids

Initial assessment

Pre-existing cardiovascular disease means prior myocardial infarction,
angina, CABG, angioplasty or heart transplant, peripheral vascular
disease, transient ischaemic attack TIA or ischaemic stroke
10-year coronary heart disease CHD risk should be assessed annually if
there is no pre-existing cardiovascular disease primary prevention:
- UKPDS risk engine type 2 diabetes
http://wwwdtuoxacuk/indexhtml?maindoc/ukpds/publicationshtml
- Framingham equation - underestimates risk where there is a family history
of premature CHD, microvascular end-organ damage
and in some ethnic
groups eg south Asians
10-year CHD risk of 15 is equivalent to a cardiovascular disease CVD
risk of 20
Identify people with adverse lipid profile secondary to conditions other
than diabetes mellitus - excess alcohol consumption, hypothyroidism

Aspirin
Usual dose is 75 mg daily
In primary prevention, reduce systolic blood pressure 145mmHg
Consider proton pump inhibitor if GI side effects
Use clopidogrel 75mg daily only in those truly allergic not just
intolerant of aspirin

Statin
Ideally,
- LDL target 20 mmol/l
- Total cholesterol target 40 mmol/l
Otherwise, reduce total cholesterol by 25 or LDL cholesterol by 30

Fibrate
Use of a statin and fibrate together increases the likelihood of adverse
effects see British National Formulary

Fasting lipid profiles
Both insulin and sulphonylureas may cause fasting hypoglycaemia
If you wish to check a fasting lipid profile, ensure that you have given
clear instructions to the patient about avoiding hypoglycaemia
Treatment decisions can often be taken using results from random samples

The Diabetic Foot

Community Podiatry

Referral to Community Podiatry
Service
POD 1 referral form available from health centres to nearest health
centre irrespective of GP practice

A podiatrist will carry out an assessment using the evidence based Trent
Diabetic Assessment Tool This includes vascular and neurological
examination together with podiatric and biomechanical examinations and will
result in a risk classification

Podiatrists employed by Gedling Primary Care Trust PCT spend between
three and six months working in UHN or CHN foot clinics to support the
practitioner and standardise practice

Musculoskeletal Podiatry / Biomechanics

Examination of lower limb function bone structure, muscles and joint
function This enables diagnosis of functional problems
Problems treated with orthoses and strengthening / stretching exercises to
improve foot function Referral should be made via general referral to the
Podiatry service

Minor Surgery
Podiatrists carry out nail surgery at a number of community clinics
Performed using local anaesthetic and may involve phenolisation of the nail
bed
Effective for chronic and acute nail problems where conservative measures
have been ineffective

Podiatry Service Lead for Diabetes

UHN
Alison Shone 0115 9249924 Ext 44122
CHN Alison Shone 0115 9691169 Ext 37946

Good Foot Care
TAKE CARE OF YOUR FEET AND PROBLEMS CAN BE PREVENTED
Diabetes can cause nerve damage and poor circulation in your feet
Nerve damage means you are less likely to feel an injury to your feet
Poor circulation means the injury or ulcer may be slow to heal

Check your feet carefully every day

Between the toes
The soles and tops of your feet
Your heels
If you cannot do this ask someone else to help if possible

Look for

red areas
cracks on the heels or between the toes
any hard skin
any new sores or ulcers

If you spot any of these contact your local GP surgery, Health Centre or
Podiatrist for advice

Community Podiatry / Chiropody Clinics

Arnold Health Centre

High Street,
Arnold
NG5 7BQ
Tel 0115 967 0888
Fax 0115 967 1909

Beeston Health Centre

38, Wollaton Road,
Beeston,
NG9 2NR
Tel 0115 925 4281
Fax 0115 925 3361

Bestwood Park Health Centre

Pedmore Valley
Bestwood Park
NG5 5NN
Tel 0115 920 8799
Fax 967 1910

Bulwell Health Centre

Main street
Bulwell
NG6 8QJ
Tel 0115 977 0022
Fax 0115 977 1236

Calverton Health Centre

4 St Wilfreds Square
Calverton
NG14 6FP
Tel 0115 965 2610
Fax 0115 965 5456

Carlton Health Centre

61 Burton Road
Carlton
NG4 3DQ
Tel 0115 961 7616
Fax 0115 961 3268

John Ryle Health Centre

Southchurch Drive
Clifton
NG11 8EW
Tel 0115 940 5298
Fax 0115 945 6455

Cotgrave Health Centre

Candleby Lane
Cotgrave
NG12 3JG
Tel 0115 989 2627
Fax 0115 989 9359

Daybrook Health Centre

Salop Street
Daybrook
NG5 6HP
Tel 0115 919 3230
Fax 0115 967 4803

Eastwood Health Centre

Nottingham Road
Eastwood
NG16 3GL
Tel 01773 712218
Fax 01773 530655

Hucknall Health Centre

Curtis Street
Hucknall
NG15 7JE
Tel 0115 968 0011
Fax 0115 968 0497

Kimberley Health
Centre

Newdigate Street
Kimberley
NG12 2NJ
Tel 0115 916 3301

Mary Potter Health Centre

Gregory Boulevard
Hyson Green
NG7 5HY
Tel 0115 942 0330
Fax 0115 979 2765

Meadows Health Centre

1 Bridgeway Centre
The Meadows
NG2 2JG
Tel 0115 986 1831
Fax 0115 986 1397

Old Basford Health Centre

1 Bailey Street
Old Basford
NG6 0HB
Tel 0115 942 0323
Fax 0115 942 3053

Radford Health Centre

Ilkeston Road
Nottingham
NG7 3GW
Tel 0115 942 0360
Fax 0115 942 2672

Radcliffe on Trent Health Centre

Main Road
Radcliffe on Trent
NG12 2GD
Tel 0115 933 2948
Fax 0115 933892

St Anns Health Centre

St Anns Well Road
Nottingham
NG3 3PX
Tel 0115 948 0560
Fax 0115 958 8493

Sherwood Health Centre

Elmswood Gardens
Sherwood
NG5 4ND
Tel 0115 969 1777
Fax 0115 969 3167

Sneinton Health Centre

Beaumont Street
Sneinton
NG2 4PJ
Tel 0115 948 0488
Fax 0115 958 8382

Stapleford Health Centre

97 Derby Road
Stapleford
NH9 7AT
Tel 0115 939 6111
Fax 0115 970 9241

Strelley Health Centre

116 Strelley Road
Strelley
NG8 6LN
Tel 0115 929 6911
Fax 0115 929 0295

West Bridgford Health Centre

97 Musters Road
West Bridgeford
NG2 7PX
Tel 0115 945 5066
Fax 0115 945 5731

Wollaton Vale Health Centre

Wollaton
Vale
Nottingham
NG8 2GR
Tel 0115 928 7793
Fax 0115 928 0590

East Leake Health Centre

Gotham Lane
East Leake
Loughborough
Leicestershire
LE12 6JG
Tel 01509 852181
Fax 01509 852099

Type 2 Diabetes

Patient Education

People learn partly by what they are told or read, but mainly from their
own experiences of living with diabetes For example, hypoglycaemia can be
explained but is often meaningless until the individual has experienced the
symptoms

Education needs to be specific to individual needs This is best achieved
by structured, one to one or group education It is important that the
information given is accurate, clear, concise and not conflicting or
ambiguous It is essential that educators are appropriately trained

When providing education to the patient with diabetes:
Allow sufficient time and avoid information overload:
- proceed at an appropriate pace for each patient
- be aware of the patients saturation point
Ensure that everyone is saying the same things
Written material should enhance teaching, not replace it
- make sure you know what is in the booklets / leaflets you use
- messages often need to be re-iterated several
times Much of what is
said is forgotten, not heard or not understood
Include a relative or friend where appropriate
Be aware of language and cultural implications
Education may have legal implications, for example driving and
hypoglycaemia, DVLA, insurance and employment - so use a checklist to
record what has been said and done

New Patient Education

At first appointment, a comprehensive history and examination must be
performed

Print the checklist and use the annual review guidance to ensure all
aspects of care are covered
Lipid profile
Blood pressure
HbA1c
Retinopathy screening
Dip urine and perform urinary albumin : creatinine ratio if appropriate
UE, creatinine
Foot examination
Body mass index
Full blood count
Thyroid function tests
Liver function tests

Book Second appointment

if SYMPTOMATIC in 2 weeks

if ASYMPTOMATIC in 4 weeks
Use the checklist below and the annual review guidance to ensure all
aspects of care covered

Book Third appointment

if SYMPTOMATIC in 2 weeks

if ASYMPTOMATIC in 4 weeks
Use the checklist below and the annual review guidance to ensure
all
aspects of care covered

Book Next appointments

Use the checklist below and the annual review guidance to ensure all
aspects of care covered
Follow Practice protocols

Education checklist for diet/tablet treated diabetes

See second part on next page also

Education checklist for diet/tablet treated diabetes

Activity and Lifestyle Advice

General advice
Increase activity levels within patient capability
Initially may be by reducing sedentary behaviour at home and increasing
walking

Benefits
Weight loss and improved insulin sensitivity
Lower
blood glucose
Increase HDL and lower LDL cholesterol
Lower blood pressure

Aims
Current activity recommendations are:
30 minutes of moderate activity on at least 5 days of the week OR
10,000 steps a day

Schemes
There are a number of activity schemes throughout Nottinghamshire:
Ashfield Go for Fit
Get Moving Nottingham - LEAP
Exercise Referral Schemes including:
Positive Moves, Exercise for Health in Rushcliffe, Broxtowe Borough
Exercise for
Health
Walking the Way to Health Schemes including:
Arnold Golden Amblers, Walk off Weight, Broxtowe Borough Walk and Talk,
Hucknall Taking Steps, Best Foot Forward, Trent Tickers

Further information on these schemes and other ways of increasing activity:
wwwnottinghamhearthealthnhsuk

Basic Dietary Guidance / Advice

Literature and training is available for non-dietetic staff

Aims:
Minimise symptoms of hyperglycaemia and fluctuations in blood glucose
Minimise the risk of hypoglycaemia
Minimise the long term macro- and microvascular complication of diabetes
Promote weight loss in people who are overweight
Reduce the risk of coronary artery disease

Advise on diet following assessment of:

Readiness to make changes to diet and lifestyle
Lifestyle
Social circumstances
Current intake

The recommended diet follows the UK healthy eating guidelines
Dietary changes should be negotiated with each patient using the following
general principles:
Modify existing eating habits rather than attempt major changes to the
patients pattern of eating
When weight loss is advised reduce total calorie intake by 500 kcal to
- promote a weight loss of 1 to 2 kg/month
- aim for an agreed target weight
At least half of the energy intake should comprise carbohydrate with the
majority in the form of complex carbohydrate, with a high fibre content,
especially soluble fibre
Increase:
- fruit and vegetables to at least 5 portions/day to achieve recommended
antioxidant intakes
Encourage:
- low glycaemic index foods at each meal as part of a balanced diet
- 1-2 portions of oily fish a week
Reduce:
- intake of refined carbohydrate, especially sugary foods and drinks
- total fat and replace saturated fat with monounsaturated and
polyunsaturated fats
- dietary salt to less than 6g/day Avoid salt substitutes
- alcohol Maximum
of 14 units for women and 21 units for men per week,
including 1 to 2 alcohol free days each week
Special diabetic products are high in calories, cause gastrointestinal
upset and are not recommended

Community Dietetic Services for Patients with Diabetes

Diabetes Education Groups
- Held at various health centres around Nottingham Health District
- Patients will be offered a place if one is held in their area
- Contact the Community Nutrition and Dietetic Service for further
information
Clinics in health centres and clinics throughout Nottingham Health
District
Dietary management of some patients can be dealt with in general
practice
Referral may be appropriate when more specific advice is needed - if
unsure seek advice from a dietitian prior to written referral
One 30-minute appointment is offered:
- detailed patient assessment
- care plan or dietary targets agreed
- referrer and GP informed
- follow up in primary care recommended
Support available includes:
- telephone advice
- dietetic information for non-dietetic staff
- training for non-dietetic staff

Whom to refer to
Community Dietitian

Dietetic Information for Non-dietetic Staff

Patient Literature - available from Community Dietetic Service
The following information should be given to all patients with diabetes:
Healthy Eating for Diabetes - Advice for Lowering Blood Sugar Levels
This is an A4 sheet giving basic guidance on dietary management of
diabetes
AND/OR
Eating, Drinking and Diabetes - a Guide for You This is a booklet
giving comprehensive dietary advice on the dietary management of
diabetes 2nd edition 2003

Further dietary information is available from the:
wwwbdaukcom
wwwbdaweightwisecom
wwwdiabetesorguk

Staff Training Courses

Suitable for anyone whose role includes discussion on food and nutritional
related issues:
Practice Nurses, School Nurses, District Nurses, Health Visitors
Community Health Doctors, General Practitioners

The Balance of Good Health - Half day, bi-monthly
Learning Outcomes
- Current evidence based healthy eating messages
- The use of the National Food Guide The Balance of Good Health as a
teaching tool for different
client groups

Dietary Management of Diabetes and Hyperlipidaemia - Half day, twice yearly
Learning Outcomes
- Current evidence based dietary advice for diabetes and hyperlipidaemia
- Reinforce the use of the Balance of Good Health model as a tool for
education
- Eliminate misconceptions concerning dietary advice for these conditions

An Holistic Approach to Obesity Management - Half day, twice yearly
Learning Outcomes
- Current evidence based dietary advice for the management of obesity
- Reinforce the use of the Balance of Good Health model as a tool for
education
- Eliminate misconceptions concerning dietary advice for these conditions

Contact: Community Dietetic Service

Cost: 30 for each course, to those not exempt from charges

Courses advertised in:
Learning Development Opportunities Brochure
Nottingham PCTs Learning Development Shared Services
Standard Court
1 Park Row
Nottingham
NG1 6GN
Tel 9123344

Smoking Cessation

New Leaf is a free NHS service for any one that wants to stop smoking
It offers support from trained advisors at over 40 clinics across the
Greater Nottingham District

Further
information on Nottingham Heart Health website:
wwwnottinghamhearthealthnhsuk
or by contacting the service:

Asian Diabetes Liaison Worker

Preventative programmes of care:
Developing / facilitating exercise in the community
- safe levels of exercise
- cultural / religious appropriateness
Health Promotion
- raise awareness of diabetes - incidence, recognition of symptoms and
referral routes
Development of community initiatives to:
- Promote healthy eating messages and increase intake of fresh fruit and
vegetables
- Improve links between voluntary and statutory organisations

Diabetes Education Role

Group sessions amongst the Asian population
- at GP practices and other venues
- allow patients to share experiences and practical ways of managing
diabetes
Participation in local events to raise awareness of diabetes

Oral Hypoglycaemic Agents Tablets

See Notes on next page

Notes for Oral Hypoglycaemic Agents Tablets

Only prescribe one agent from each class - there is no point prescribing
two sulphonylureas together
Substituting agents is unlikely to
significantly improve glucose control -
swapping metformin plus sulphonylurea for metformin plus glitazone is
unlikely to significantly improve glucose control
The addition of a third agent to a combination of two oral hypoglycaemic
drugs taken at maximally tolerated doses is unlikely to significantly
improve glucose control If a glitazone is used as a third agent, do not
stop either of the first two agent as this may precipitate significant
deterioration in control

Glycaemic Target
A target should be discussed with each patient
Tight control HbA1c 65 - 75 / fasting glucose 6 mmol/l is an
appropriate aim for most patients providing they are not having frequent
hypoglycaemia
In the very elderly or frail, symptom control alone may be the priority

Metformin - see BNF for prescribing guidance
Take tablets with or immediately after a meal to increase insulin
sensitivity
Consider in all patients with diabetes with residual functioning islet
cells
Increase dose every 2-4 weeks to achieve glycaemic target up to 1 gram
three times daily
Diarrhoea occurs in up to 20, is dose dependent and may resolve with
dose
reduction
Alternatively, try modified release preparation
AVOID in patients with
- creatinine 150 mol/l / eGFR60ml/min, severe heart failure / severe
liver disease lactic acidosis risk
Stop metformin 48 hours before
- radiological procedure needing intravenous contrast
- surgery requiring general anaesthesia
- re-start if renal function stable after the intervention completed
May reduce cardiovascular events in obese patients

Sulphonylureas - gliclazide, glimepiride, glibenclamide - see BNF for
prescribing guidance
Take tablets before meals to stimulate insulin release from the pancreas
Increase dose every 4-6 weeks to achieve glycaemic target or maximal dose
is reached
Average weight gain is 2-4 kg and in some patients this may exceed 10kg
However, there is little evidence to support routine use of a glitazone
as a second agent in overweight patients
Educate patients in recognising and treating hypoglycaemia
AVOID long acting sulphonylureas - Glibenclamide and Chlorpropamide
- in patients over 70 years old
- in those with poor renal function
Glimepiride has a lower risk of hypoglycaemia / weight gain than

glibenclamide

Thiazolidinediones Glitazones - see BNF for NICE and prescribing guidance
Reduce insulin resistance and increase glucose uptake into muscle
Licensed as monotherapy and as add on therapy
- patient already taking one oral hypoglycaemic and
- glycaemic targets not achieved and
- metformin / sulphonylurea not tolerated as 2nd agent
Little evidence to support routine use as second agent in overweight
patients or in triple therapy - though probably effective in some
patients
- if glitazone used as third agent, do not stop either of the first two
agents immediately as this may precipitate abrupt deterioration in
control
- if unsure, discuss with Diabetes Consultant / Registrar at UHN / CHN
Associated with modest weight gain few kg
Maximal therapeutic effect in 3-6 months
Not licensed for combination with insulin
- if unsure, discuss with Diabetes Consultant / Registrar at UHN / CHN
AVOID in patients with heart failure fluid retention recognised side
effect, acute liver disease or ALT 25 x upper limit of normal

Insulin Therapy in Type 2 Diabetes

There is no best insulin
regimen for patients with type 2 diabetes
Consider a trial of insulin in all patients who remain symptomatic or do
not achieve their glycaemic target despite maximal doses of two oral
agents

Local audit data suggest that patients with HBA1c 87 despite optimal
diet and tablet therapy are most likely to benefit from a trial of insulin
therapy

Tablets and insulin

Combining insulin with metformin may help to limit weight gain -
particularly useful in overweight patients
Commonly used regimens include:
twice daily pre-mixed insulin with twice or three times daily metformin
bedtime intermediate / long-acting acting insulin and twice or three
times daily metformin and other oral hypoglycaemics
Combination with thiazolidinediones glitazones is not currently licensed
but probably safe

Insulin alone

Where continuing metformin therapy is unacceptable
Twice daily pre-mixed insulin is generally used first but four times
daily insulin may be necessary

How to start insulin treatment

UHN and CHN offer audited insulin start services - refer by letter / fax
/ electronic
- generally using twice daily mixed insulin with metformin if appropriate
- patient reviewed by
Consultant
- insulin initiation led by Specialist Nurse and Specialist Dietitian
- appropriate use of home blood glucose monitoring
- autonomy in insulin adjustment
- what to do during illness
- UHN offers small group and one-to-one teaching to start insulin
- CHN offers one-to-one teaching to start insulin

Insulin starts in Primary Care depend on local expertise

Clinical Waste / Sharps

Sharps boxes for syringes, needles and fingerprick testing equipment should
be provided on FP10
Collection of full sharps boxes from people with diabetes is from the
Health Centres below
Health centres do not issue new sharps boxes They need to be provided on
FP10

All GP surgeries in EREWASH will accept full sharps boxes from patients who
are registered at that surgery

Type 1 Diabetes

Structured Diabetes Education for Type 1 Diabetes

- Intensive education programmes to promote empowerment for people with
Type 1 diabetes
- Supported by NICE guidance
- Suitable for people with type 1 diabetes who are prepared to manage
diabetes intensively
- blood testing four or more times daily
- insulin four or more times daily
- carbohydrate counting
- Referral is via the respective diabetes service

University Hospital

DAFNE - Dose Adjustment For Normal Eating
Part of the national DAFNE collaborative
Associated with long term reduction in HbA1c, weight stability and improved
quality of life
- One week, non-residential course for up to 8 participants at Queens
Medical Centre
- People attend introduction evening prior to enrolment on DAFNE course
- Diabetes
specialist nurse and diabetes specialist dietitian jointly
facilitate each course with input from a diabetologist
- Long term follow up in a DAFNE clinic is offered

Nottingham City Hospital

EDWARD - Education for Diabetes Without A Restricted Diet
Based on the existing BERTIE Model of Patient Education
- A series of workshops held one day a week for four consecutive weeks
at Dundee House
- People attending EDWARD have a pre-assessment appointment with a
Diabetes Specialist Nurse and then join an EDWARD programme with up to
8 participants
- Diabetes specialist nurse and diabetes specialist dietitian jointly
facilitate each workshop with input from a diabetologist
- A further 3 month post Edward follow up is offered
- Long term follow up is offered

Insulin Pump Service for Adults

- Supported by NICE guidance
- Suitable for people with type 1 diabetes
- Referral to pump team via secondary care diabetes services at UHN and CHN

Suitable for people with type 1 diabetes who:
- Have attended an intensive Type 1 diabetes education programme with
carbohydrate counting
- Use a basal bolus multiple injection
insulin regimen
- Find it impossible to maintain HbA1C 75 without disabling
hypoglycaemia despite a high level of self care of diabetes and
adequate trials of analogue short and/or long acting insulins
- Have no medical, communication, psychological or personal problem
which would prevent insulin pump use

Requires: assessment for individual NHS funding arrangements - NICE
approval
use of pager-sized insulin infusion pump 24 hours a day
replacement of infusion set and subcutaneous cannula every 3
days
ongoing support from trained insulin pump team

Paediatric Services

General Information
UHN and NCH services are closely integrated, sharing Diabetes Specialist
Nurses DSN and a common approach to management Children and
adolescents are managed on insulin regimens comprising 2,3 or 4
injections daily and using pen injection devices
There are a small number of patients on insulin pumps
The DSNs facilitate close liaison with families, General Practitioners,
nurseries and schools and work to promote education and self-care
Transition arrangements are made to the geographically
appropriate adult
team
Emergencies
Families are encouraged to seek prompt medical or specialist nurse advice
in order to anticipate and prevent problems of hypoglycaemia, illness
induced ketoacidosis and persistent poor control
Contact numbers

Outpatient Clinics
Dr T Randell and Dr L Denvir
UHN Friday am 1st and 3rd occasional 5th age banded 6-
18 yr
UHN Thursday am 1st pre-school
Newark Monday pm 2nd Newark Grantham area
UHN Friday pm Nurse led/pump patients
Dr J Drew
NCH Wednesday pm 1st, 3rd occasional 5th age banded 8-
16 yr
NCHDundee Hs Wednesday pm 2nd Transition clinic
16-18yr
NCH Monday am 2nd of month age banded 0-7 yrs
NCH Thursday 4th Nurse led/Drop in
Patients have 3 or 4 clinic reviews per year An annual review incorporates
retinal examination, blood pressure measurement and screening for
microalbuminuria, coexistent autoimmune thyroid disease or coeliac disease
The erratic nature of diabetes in the young is such that there
is
considerable additional home visiting and telephone contact

Pregnancy, Fertility and Contraception

Gestational Diabetes
See Notes and post-natal advice on next page

Notes for Gestational Diabetes

Glucose Tolerance Testing in Pregnancy
Risk of GDM increases with duration of pregnancy: normal OGTT in early
pregnancy does not exclude possibility of GDM later on in pregnancy
There is no universal agreement about the interpretation of the OGTT in
pregnancy Patients with fasting glucose ?6 or 2 hrs ?78 mmol/l will
generally require specialist supervision but this will depend on the
individual patient

Diabetes Ante-Natal Clinics
Pregnancy Assessment Centre PAC at UHN ext 44873 or via Diabetes
Service
Ante-natal clinic at CHN ext 45244 or via Diabetes Service

Post- Natal Glucose Testing
75g OGTT at 6-8 weeks usually arranged by hospital
Women with GDM have a 50 risk of developing Type 2 diabetes over the
following 15 years
Recommend:
- lifestyle advice
- annual fasting blood glucose
- counselling and assessment prior to future planned
pregnancy

Diabetes and Contraception

As with all patients seeking contraception, discussion should be in the
context of what will best suit the need of the patient Condom use is
encouraged to help prevent sexually transmitted infection

Combined oral contraceptives

Generally safe in younger patients with type 1 diabetes
Patients with two or more risk factors ie diabetes plus any one of the
following: age 35yrs, hypertension, vascular disease, obesity BMI 30
kg/m2, smoking should not use the combined contraceptive pill
Low dose combined pills with gestodene or desogestrel 3rd generation
have a minimal effect on carbohydrate and lipid metabolism but a higher
thromboembolic risk
Low dose combined pills containing levonorgestrel 2nd generation have a
greater effect on carbohydrate and lipid metabolism but a lower
thromboembolic risk
Low dose combined pills are especially suited to the young patient

Progestogen only pill

Metabolically neutral but less reliable than low dose combined
contraceptive pill
Safe in patients with diabetes

Depo Provera
Injectable contraception may alter the dosage requirements for
diabetic
control, but these are suitable for use in patients with diabetes

Implanon
Suitable for patients with diabetes

IUCD/US
Safe in women with diabetes Avoid in women with multiple sexual partners

Barrier methods

Safe but less reliable than hormonal contraceptives Encourage use to
help prevent sexually transmitted infection

Hormone Replacement Therapy

Evidence from randomised trials suggests that HRT increases the risk of
cardiovascular disease during the first few years of use
Not recommended for routine use
Use should be restricted to women:
- with severe, intractable symptoms of oestrogen insufficiency
- in the lowest dose and for the shortest duration possible
- following clear counselling about cardiovascular risk

Summary

Diabetes and Erectile Dysfunction

Inability to obtain and sustain an erection suitable for intercourse

References and Other Guidance Used

1 Tuomilehto J, Lindstrom J, Eriksson JG, et al Prevention of Type 2
Diabetes Mellitus by Changes in Lifestyle among Subjects with Impaired
Glucose Tolerance N Engl J Med 2001;
344:1343-1350
2 The Diabetes Prevention Program Research Group Costs Associated With
the Primary Prevention of Type 2 Diabetes Mellitus in the Diabetes
Prevention Program Diabetes Care 2003; 26:36-47
3 Screening for Type 2 Diabetes Diabetes Care 2004; 27:11S-14
4 Brandle M, Davidson MB, Schriger DL, Lorber B, Herman WH Cost
Effectiveness of Statin Therapy for the Primary Prevention of Major
Coronary Events in Individuals With Type 2 Diabetes Diabetes Care
2003; 26:1796-1801
5 Jeffcoate WJ, Harding KG Diabetic foot ulcers Lancet 2003; 361:
1545-1551
American Diabetes Association Preventive Foot care in Diabetes Diabetes
Care 2004; 27 suppl 1: S63-S64

National Institute for Health and Clinical Excellence guidance:
wwwniceorguk
Technology appraisals:
smoking cessation 39
long acting insulin analogues 53
insulin pump therapy 57
patient education models 60
glitazones 63
Guidelines
Type 1 diabetes CG15
Type 2 diabetes - blood glucose
Sep 2002

Type 2 diabetes - footcare
CG10
Type 2 diabetes - management of blood pressure and blood lipids
Oct 2002
Type 2 diabetes - renal disease
Feb 2002
Type 2 diabetes - retinopathy
Feb 2002

The Renal Association: wwwrenalorg
The National Kidney Foundation wwwkidneyorg
The British Hypertension Society: wwwbhsocorg
Diabetes UK: wwwdiabetesorguk
The American Diabetes Association: wwwdiabetesorg

Diabetes and Kidney Disease International Diabetes Federation, 2003
Diabetes and Foot Care: Time to Act International Diabetes Federation,
2003
Diabetes Education International Diabetes Federation, 2004
The Diabetic Foot: Amputations are preventable International Diabetes
Federation 2005

Nottingham Preferred Prescribing List: http://onlinenottingham-
pctnhsuk/docs/guidelines/{96D1DEFD-6379-4794-B7EF-
7AC430793C3A}_Preferred20Prescribing20Listpdf

———————–
Refer next diabetes antenatal clinic

Present

Blood glucose testing generally routine

4 or more times daily in some circumstances
Strips usually on repeat prescription

Absent

9mmol/l

HbA1c
Creatinine
LH / FSH / testosterone
TSH

Prolactin

Less than 6 mmol/l fasted OR
Less
than 7 mmol/l with 2 hr of meal

Psychosexual therapy?

Endocrine opinion if testosterone / prolactin abnormal

Possible type 1 diabetes
Refer same day to Diabetes Service
1
Nottingham Diabetes Management Guidelines 2006

Education, lifestyle, diet

Yes

Nutrition and Dietetic Service
Linden House
261 Beechdale Road
Aspley
Nottingham NG8 3EY
Tel: 0115 942 8744

Yes

See Aspirin and Lipid section See Blood Pressure section

Repeat in 12 months

Start ACE inhibitor - see UE monitoring guidance

Yes

2 / 3 Positive

Repeat x 2 in 3 months

Normal

Abnormal

Send for albumin : creatinine ratio

IF or greater
Send for protein : creatinine ratio
See Renal Unit referral guidance

Negative

Positive

Obtain morning urine sample - but any sample is better than none
Dip with standard dipstick

Over 6 mmol/l fasted OR
7 - 9 mmol within 2 hr of meal

Fibrate
Consider referral to lipid or diabetes clinic

Fasting triglycerides 10 mmol/L

Fibrate
Monitor annually

Fasting triglycerides 23 but 10 mmol/l

Reduce alcohol consumption, obesity and improve diabetes control if
possible

Yes

Lifestyle measures
Repeat assessment annually

Random triglycerides 23 mmol/l

Aspirin and Statin

Diabetes unlikely Present

Yes

Estimate 10 year CHD risk

Yes

Pre-existing cardiovascular disease OR
Hypertension OR
Microalbuminuria OR
Proteinuria OR
Abnormal renal function

Under 35 years choose from
Combined oral contraceptives
IUCD/IUS POP
Depo Provera Implanon
Barrier

Consider switch from combined pill to progestogen only pill if other
cardiovascular risk factors present

If above target 130/75mmHg start

If above target 140/80mmHg start

Yes

ACE inhibitor - click for UE monitoring guidance

If above target 130/75mmHg add

Bendroflumethiazide
If normal renal function
Furosemide
If impaired renal function

If above target 130/75mmHg add

Yes

Long acting calcium channel blocker
eg Diltiazem

If above target 130/75mmHg add

Alpha blocker

If above target 130/75mmHg

Bendroflumethiazide

Paediatric DSN
Vreni Verhoeven 0115 9346411 Full time MAILBOX
Karen Cuttell 0115 9346412 Full time MAILBOX
Glyn Feerick 0115 9345951 Full time MAILBOX

Emergency Pager FOR URGENT
MEDICAL ADVICE ONLY
800am - 600pm Tel 0765 913 2445 -Leave a short message including name
and number If no answer after 15 mins please try again Monday - Friday
only
600pm - 800am Contact on-call Paediatric Medical Registrar at relevant
hospital
and at WEEKENDS AND BANK HOLIDAYS

City Hospital
Dr J Drew secretary
Tel 0115 9691169 Ext 49792
Fax 0115 9620564

If above target 140/80mmHg add

Glucose tolerance test at 14 weeks gestation
Ethnicity

If above target 140/80mmHg add

Newly diagnosed or suspected patients
Urgent same day telephone referral to Paediatric Medical on-call team at
UHN or CHN

If above target 140/80mmHg

Consider 5th agent / referral

Microvascular complications OR
Pre-existing cardiovascular disease OR
Microalbuminuria OR
Proteinuria OR
Abnormal renal function

Present

University Hospital
Dr T Randell and Dr L Denvir secretary
Tel 0115 9249924 Ext 43343
Fax 0115 9709763

Typical symptoms AND
Diagnostic blood glucose

Patient ill: vomiting or semiconscious

TWO or more of the following
Severe symptoms
nocturia x 3-4
Short
history days / weeks
Marked weight loss disregard absolute weight
A first degree relative with type 1 diabetes
A personal history of autoimmune disease

Moderate / heavy ketones in urine

Normal weight
BMI 20- 25 kgm-2

Gliclazide 40-80mg od

CONTACT NUMBERS FOR REFERRAL

UHN 0115 924 9924 Dr Simon Page Secretary 64464
Fax 970 1080 Dr Peter Mansell Secretary 63834
Dr Tasso Gazis Secretary 61100
Dr Garry Tan Secretary 63862
Diabetes Unit Secretary 61215
Diabetes Unit Direct line 9709215
Diabetes Registrar via switchboard

NCH 0115 969 1169 Dr Alan Archer Secretary 39357
Fax 962 7959 Dr Renee Page Secretary 37929
Dr Nigel Sturrock Secretary 46200
Dr William Jeffcoate Secretary 46201
Dr Fran Game Secretary 34161
Dundee House Manager 46812
Diabetes Registrar via switchboard

Or discuss
with Diabetes Registrar in hours / On-call Medical Registrar out
of hours

Yes

Patient label

Yes

Guidelines provide guidance
These recommendations should not be rigorously applied in all clinical
circumstances Good clinical practice always involves weighing the
advantages and disadvantages of a clinical intervention depending on
individual circumstances

Yes

Admit to hospital

No immediate need for insulin
Dietary advice

Patient under 30 years of age

No immediate need for insulin
If first degree relative on diet or tablets consider Maturity Onset
Diabetes of the Young MODY

Consider non-urgent referral

Strong indication for insulin
Same Day referral

Other Diagnostic Categories

Impaired glucose tolerance IGT Impaired fasting glycaemia
IFG
Fasting glucose 7 mmol/l Fasting glucose ? 61 but 70
mmol/l
2 hour glucose ?78 but 111 mmol/l

IFG and IGT are risk factors for future diabetes
Exercise and weight loss reduces the risk of developing diabetes1 There is
no consensus on the cost effectiveness of the use of metformin to prevent
diabetes in these patients2
Annual OGTT is recommended
for those with IGT; 3 yearly for IFG

Symptoms of Diabetes
Polyuria passing a lot of urine
Polydipsia drinking excessively
Weight loss
Lassitude
Blurred vision
Urinary or genital infection
Skin infection including pruritis

There may be few if any symptoms

12 hour fast prior to test water only for comfort
Refrain from smoking / eating / drinking / exercise during the test

Take baseline venous sample for glucose
Give 75g oral anhydrous glucose - equivalent to Lucozade Original Energy
- 394ml
Take further venous glucose sample 2 hours later
The patient should remain rested, fasted and in the surgery
Send samples to laboratory
Fingerprick glucose values should not be used to diagnose diabetes

Most cases are diagnosed in this way
75g OGTT is not usually necessary

DIABETES

Fasting plasma glucose 70 mmol/l
OR
Random venous plasma glucose 111 mmol/l
OR
2 hour venous plasma glucose 111 mmol/l on OGTT

PLUS, on a separate day

PLUS

Symptoms of diabetes

Fasting plasma glucose 70 mmol/l
OR
Random venous plasma glucose 111 mmol/l
OR
2 hour venous plasma glucose 111 mmol/l on OGTT

Check urine ketones Present

Symptoms of diabetes?

Yes

Check random glucose and note last time of
meal

TWO DIAGNOSTIC ELEMENTS NEEDED

Test for glycosuria at each antenatal visit

Shayasta Taj
Asian Diabetes Liaison Worker
Radford Health Centre
Ilkeston Road, Radford
Nottingham
Tel: 0115 942 0360
Fax: 0115 942 2672

Adjust dose every 1-3 months to optimise glycaemic control or until maximal
tolerated dose reached

Absent

Glycaemic target achieved?

Overweight OR Obese
BMI 25-30 kgm-2 BMI 30 kgm-2

Metformin 500mg od

Yes

Trial of insulin ?

Adjust dose every 1-3 months to optimise glycaemic control or until maximal
tolerated dose reached

Add gliclazide 40-80mg od

Add metformin 500 mg od

Yes

Review every 2 - 6 months

Glycaemic target achieved?

Obesity - BMI 35 kg/m2
Large for dates baby - FAC 97 th centile
Polyhydramnios
1st degree relative with Type 2 or gestational diabetes
Polycystic ovarian syndrome

Polycystic ovarian syndrome

Review every 2 - 6 months

glitazones - see notes

Glucose tolerance test at 28 weeks gestation

Check for alternative causes:
Infection - Send to microbiology for microscopy, culture and sensitivity
Thrush
Menstruation

Interpretation of HbA1c

HbA1c Interpretation

Less than 6
Hypoglycaemia?
Less than 7 Excellent
7 - 8 Acceptable
8 - 9 Poor
Over 9 Very poor

Glycaemic target achieved?

The Nottingham Diabetes Service Advisory Group NDSAG does NOT recommend
referral for uncomplicated, newly diagnosed Type 2 diabetes
Initial management diagnosis, education, treatment and monitoring is the
responsibility of Primary Care Teams, supported by the PCTs and Nottingham
Diabetes Management Guidelines

ACE inhibitor - see UE monitoring guidance

Organic cause suggested by:
Normal libido
Gradual onset of erectile dysfunction
Partial erection achieved
Normal ejaculation

Risk factors:
Smoking
Alcohol
Current medication
Operation / radiotherapy or trauma to pelvis / scrotum

Over 35 years consider
switch from combined pill to progestogen only pill if other cardiovascular
risk factors present

IUCD/IUS or sterilisation if family complete

Review every 2 - 6 months

Yes

Type 1 diabetes
Insulin or insulin and tablet treated type 2 diabetes

Planning pregnancy
Pregnant
Preparation for insulin therapy in type 2 diabetes

Diet treated Type 2 diabetes
Metformin monotherapy
Glitazone monotherapy

Blood glucose testing not
needed routinely
Testing may be needed in some circumstances
Urine testing useful if:
Acceptable to patient
Renal threshold for glucose normal
Appropriate action taken following test

Sulphonylurea mono / combination therapy
Illness / unstable control / change in treatment
Suspected hypoglycaemia
Driving
Renal failure
Unpredictable lifestyle
Significant exercise

Blood glucose testing may be needed
Lower frequency testing: see notes below
Education in appropriate use
Strips usually provided via specific request

Check HbA1c 2 - 6 monthly

Yes

High Risk Pregnancy

Usual antenatal care

Book with Consultant Obstetrician

Yes

New Leaf
The Voluntary Action Centre
7 Mansfield Road
Nottingham
NG1 3FB
0115 934 9526

Annual assessment from GP Practice team

OGTT via antenatal clinic

HbA1c Equivalent mean plasma glucose mmol/l
6 75
7 95
8 115
9 135
10 155
11 175
12 195

Abnormal sensation
OR
Impalpable / reduced foot pulses

Infection, ulceration, necrosis, suspected Charcot foot

Community podiatry

Hospital diabetic foot clinic

Yes

Obesity - BMI 40 kg/m2
Prior macrosomia
97th centile
for gestational age or 45 kg at term
Prior unexplained intra-uterine death
Prior gestational diabetes

Increased Risk of Gestational Diabetes

Yes

History and examination

Poor response / not tolerated ?

If physical treatment appropriate / desired

Psychogenic cause suggested by:
Sudden onset of erectile dysfunction
Early collapse of erection
Good quality spontaneous /self stimulation / waking erections
Premature ejaculation or inability to ejaculate
Relationship / psychological problems or major life events

PDE5 inhibitor
Sublingual apomorphine
Vacuum device
Urethral alprostadil
Intracavernosal alprostadil

In surgery or via referral to diabetes erectile dysfunction service at UHN
/ CHN

Print and hand out
Good Foot Care
page of Guidelines

For Practices in City PCT, support is available from:
Gill Peck
Lead Specialist Nurse Diabetes
Base: Sneinton Health Centre
Beaumont Street
Sneinton Nottingham
Tel: 0115 948 0488

Consider referral for review / advice

Yes

First-line advice when newly diagnosed with
Type 2 Diabetes OR
Impaired fasting glycaemia OR
Impaired glucose tolerance
Follow up support for those initially advised by a
dietitian

Referral letter to include:
Body mass index BMI
Relevant blood results
Current medication
Whether interpreter required and language spoken

In the first instance, advice from
General Practitioner OR
Practice Nurse OR
Community Nurse
Following appropriate training
and using appropriate literature

Specialist advice from a Registered Dietitian:
CHD risk factors and diabetes OR
Poor control - HbA1c consistently 8 OR
Poor understanding of dietary management following first line advice

Source:nottinghamdiabetes.nhs.uk

del.icio.us:Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary ...

digg:Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary ...

spurl:Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary ...

newsvine:Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary ...

blinklist:Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary ...

furl:Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary ...

reddit:Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary ...

fark:Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary ...

Y!:Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary ...

Diabetes Treatments

Detection of People at High Risk of Diabetes. Other diagnostic categories Diagnosed Patient with Type 2 Diabetes. Activity and Lifestyle Advice. Dietary …

Recent Diabetes Treatments Articles

Categories