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Diabetes mellitus (DM) is a common long-term health condition characterised by excess levels of glucose in the blood. In the UK, diabetes affects approximately 4.7 million people with an estimated one million unaware that they have diabetes. This means that one person in every fifteen of the population has diabetes and one in six hospital beds are occupied by a person living with diabetes.

Type 2 diabetes is the most common type of diabetes: about 90% of people with diabetes have type 2 diabetes (T2DM) about 8% have type 1 diabetes (T1DM) and about 2% have rarer types ().

Diabetes is a condition where the amount of glucose is a person’s blood is too high because their body is unable to process this glucose properly. This could be for two reasons:

1. Their pancreas does not produce any insulin or does not produce enough insulin to allow glucose to enter the cells of their body. This is called insulin deficiency.
2. The insulin they are producing does not work properly. This is called insulin resistance.

For the majority of people diagnosed with diabetes, it is a life-long condition which requires long-term motivation and competence to keep their blood sugar levels as close to normal as they are able. The role of self-management of diabetes cannot be over-emphasised. The World Health Organization estimates that 99% of diabetes-related healthcare decisions are made independently by the person with diabetes. This burden is a large part of the reason why diabetes is associated with increased rates of depression  (, 2023, ). 

Blood glucose control

Insulin is essential for life. It is a hormone produced in the pancreas. An important job that insulin does is to move glucose into cells around the body to produce the energy needed for everyday life. 

Glucose comes mainly from digesting carbohydrates. Many foods contain carbohydrates. These include starchy foods such as bread, rice, potatoes and chapattis, fruit, some dairy products, sugary food and drinks. For this reason, diet is an important part of diabetes management.

Glucose can be stored in the liver and muscles. When the blood glucose levels fall this is released again in a process known as gluconeogenesis. Glucose is also stored in body fat. This ability to store glucose to use later is what allows us to undergo periods of hunger and fasting.

Normal glucose metabolism is illustrated below.

Abnormal glucose metabolism in diabetes 

You can think of insulin as the key that opens the glucose channel into the cells of the body. If there are not enough keys (insulin deficiency) or if the locks have become stiff so insulin cannot open them (insulin resistance) then the cells cannot use the glucose effectively and glucose levels in the blood rise above normal. 

This is called hyperglycaemia and it is important because we know that over time hyperglycaemia causes damage to the body, in particular the blood vessels.

For example, this means that over the years. if poorly controlled, diabetes can damage the eyes, kidneys and nerves, as well as increasing the risk of heart disease. These are called the long-term complications of diabetes. 

References

• The Diabetes Control and Complications Trial Research Group. (1993) , New England Journal of Medicine, 329(14), pp. 977-986

In type 1 diabetes the person is no longer able to produce any insulin at all. This is because all the cells in the pancreas that produce insulin have been destroyed. These cells are called pancreatic beta-cells and are destroyed by an autoimmune process. This means that the body’s immune system attacks and destroys parts of its own tissues. In the case of type 1 diabetes, the body’s immune system destroys all the pancreatic beta-cells resulting in the complete loss of ability to produce insulin. 

A person with type 1 diabetes does not produce any insulin. This means they must inject insulin for the rest of their lives. 

Insulin is essential to life. This means their insulin injections should NEVER be discontinued. 

Stopping insulin injections in type 1 diabetes leads to a condition called diabetic ketoacidosis which is a life-threatening emergency. 

What causes type 1 diabetes?

It is likely that the cause of type 1 diabetes is a combination of two factors. Firstly, some genetic variations which make the person susceptible to type 1 diabetes then something in their environment which triggers the autoimmune response. This is called an environmental trigger and an example might be catching a virus. 

The most common age for this to happen is between 10 and 14 years old. It is usually diagnosed after a short period of passing lots of urine, thirst, tiredness and weight loss. 

It is estimated that 400,000 people in the UK have type 1 diabetes (Diabetes UK, 2019).

This diagram is explained in this video produced by the charity Diabetes UK. See: 

How is type 1 diabetes managed?

Good glycaemic control in type 1 diabetes can reduce long-term complications by up to 76% as shown in the seminal Diabetes Control and Complications Trial.

People with type 1 diabetes usually take four or five insulin injections per day. Some people with type 1 diabetes use an insulin pump. Their insulin doses must be adjusted around variables such as diet and exercise. People living with type 1 diabetes are taught to adjust their insulin on a structured education program. They are also taught carbohydrate counting.

Testing blood glucose is essential for adjusting insulin doses and avoiding hyperglycaemia and hypoglycaemia. NICE recommends testing between four and ten times per day for most people with type 1 diabetes. Some people with type 1 diabetes will wear a glucose monitoring sensor. 

People living with type 1 diabetes also need to check their ketone levels sometimes. This is because ketones can be a sign of serious illness.

People with type 1 diabetes should be cared for by a specialist multidisciplinary team usually in secondary care. Self-management of type 1 diabetes is complex and demanding, and the person living with type 1 diabetes usually knows more about this than the non-specialist health care professional. For this reason, if they are able to, people with type 1 diabetes should manage their own insulin doses during a hospital admission.

Further resources

• NICE guideline (updated 2021) . This guideline covers care and treatment for adults (aged 18 and over) with type 1 diabetes. It includes advice on diagnosis, education and support, blood glucose management, cardiovascular risk, and identifying and managing long-term complications. In July 2021, NICE reviewed the evidence and updated the recommendations on long-acting insulin therapy.

What causes type 2 diabetes?

Type 2 diabetes develops when the body can still produce some insulin but not enough for energy from glucose to be utilised properly, or when the cells in the body do not react properly to insulin. This is called insulin resistance.

How is type 2 diabetes managed?

The treatment of type 2 diabetes centres on lifestyle management including a healthy diet, regular exercise and the person monitoring their blood glucose level. The condition may progress over time and a number of oral glucose therapies are also used, with or without additional insulin injections and Incretin mimetics / GLP-1 analogues. Some medications help the body to use insulin more effectively whilst others increase the amount of insulin that the body produces.

Type 2 diabetes is often associated with obesity, and is also increasingly becoming more common in children, adolescents and young people of all ethnicities. Type 2 diabetes is far more common than type 1 diabetes - around 90% of all adults in the UK with diabetes have type 2 diabetes.

Type 2 diabetes risk factors include:

• carrying too much excess body fat – especially central body fat
• having high blood pressure or cholesterol
• genetics: having a close family member with type 2 diabetes (mother, father, brother or sister)
• having previously had gestational diabetes
• drugs such as steroids and anti-depressants
• ethnicity: common in Asian and Afro-Caribbean.

Further resources

This section of the resource aims to give a summary of the issues caused by diabetes in pregnancy. It is written for non-specialist registered and unregistered ÌÀÍ·ÌõÎÛÁÏ and midwifery practitioners. It is designed to promote the health of women with diabetes and their babies.

This section does not replace the need for registered practitioners to be familiar with their local protocols and pathways.

All registered practitioners should be aware of the national guidelines which underpin local protocols. Some of these are signposted below in the resources section. 

Pregnancy and diabetes

Women with diabetes make up 5% of pregnancies in England and Wales. This is around 35,000 pregnancies per year ).

Diabetes has a profound effect on the risks of pregnancy to the foetus and the mother. This in turn affects the care women with diabetes or a history of gestational diabetes need.

The challenge for health care professionals is to provide safe, competent care to a relatively rare but very high risk pregnancy group. Any woman with diabetes who is already pregnant should be referred to the specialist diabetes team immediately.

There are various types of diabetes affecting pregnancy:

*figures for England and Wales ()

What are the risks of pregnancy in diabetes?

The complications of diabetes in pregnancy can be truly devastating. By planning pregnancy in diabetes and following effective care pathways from conception to delivery and beyond we have the opportunity to help women and babies avoid them.

It is helpful to understand the reasons why pregnancies in diabetes are high risk. Understanding this gives insight into the challenges women with diabetes experience during pregnancy. It also shows how important it is that the specialist diabetes team is involved in individual care planning as early as possible. Understanding the risks of pregnancy in diabetes also helps understand why planning the pregnancy is so important.

These risks are explained in more detail below:

Hypoglycaemia becomes more likely as blood sugar management is tightened using insulin. To bring their HbA1c down to a target of 48mmol/mol, women aim for a blood glucose below 7mmol/l before meals when planning for, and during pregnancy. Many areas now have funding for continuous glucose monitoring during pregnancy for women with type 1 diabetes to help avoid low blood glucose. This funding does not cover preconception or other types of diabetes. This means it is important that health care professionals are able to recognise the signs of hypoglycaemia and to help the woman recognise and treat these. Women using insulin must also be aware of DVLA rules for diabetes and driving.

Congenital abnormalities are more common if blood glucose is raised at conception and during the first trimester.

Birth injuries to mother and baby and macrosomia. Birth injuries are more likely in diabetes due to macrosomia. Macrosomia refers to abnormally large babies. This is due to the baby having excess nutrition during later gestation and is associated with raised blood glucose in the second and third trimesters. Large babies are more likely to suffer injuries and other complications during delivery.

Worsening diabetic retinopathy occurs in pregnancy due to the effects of tightening blood glucose control and the stresses of pregnancy on the blood vessels of the back of the eye. Retinal screening and stabilisation of retinopathy before trying to conceive are important. (Lo Wang and Shah 2016)

Pre-eclampsia occurs between 20 weeks of pregnancy and 6 weeks post-delivery. It is likely to be caused by inadequate blood supply to the placenta. The placenta keeps the foetus healthy by supplying nutrients and oxygen and removing waste products. Symptoms include high blood pressure, protein in the mother’s urine, headaches, visual disturbances and oedema to the face, hands and feet. Early detection and monitoring are important to prevent more serious complications including reduced foetal growth and maternal fitting, CVA and clotting disorders.

Miscarriage, still birth, neonatal death and birth before 37 weeks are all more common if diabetes is poorly controlled during the second and third trimesters. A miscarriage is when a baby dies before 24 weeks gestation and after this it is called a still birth. A neonatal death is when a baby dies within four weeks of being born. A baby born before 37 weeks gestation is considered to be premature and the earlier the birth the higher the risk to the baby of health problems (Tommys.org).

Neonatal hypoglycaemia is more common in poorly controlled diabetes during later pregnancy. If the blood supplied to the foetus through the placenta contains raised glucose then the foetus will produce more insulin. The baby will continue to produce more insulin after delivery and this can cause neonatal hypoglycaemia. This can potentially cause neonatal death and damage a baby’s neurological development (Lo Wang and Shah 2016).

How can ÌÀÍ·ÌõÎÛÁÏ professionals support women with diabetes to plan pregnancies?

Pregnancy in diabetes should always be planned. This allows the multidisciplinary team to protect the mother and her baby from complications during pregnancy, delivery and beyond. Whilst all risk cannot be removed, planning a pregnancy allows the mother and baby’s health to be protected before trying to conceive and so reduces these risks.

Pre-conception counselling should be a routine part of diabetes care for all women of childbearing age. They should all be advised to use contraception according to their preference and to approach their health care team before stopping contraception.

Preconception care for diabetes includes:

• reducing the risk of congenital abnormalities and miscarriage
• screening the mother for complications of diabetes to manage them during the pregnancy
• managing blood glucose to a target HbA1c of 48 mmol/mol. One barrier to this is that hypoglycaemia becomes harder to avoid as blood glucose levels are reduced
• finding alternatives to medications known to be, or suspected of being harmful to the foetus
• and preparing the mother for the time, effort and lifestyle adjustments required for pregnancy and diabetes.

The risks of pregnancy in diabetes to the woman and her baby need to be discussed sensitively without scaring the woman. It should emphasise that her care before, during and after pregnancy is designed to reduce these risks and is based on the latest research. It is important that the woman with diabetes and her partner understand this so that they are motivated to manage the demands of diabetes treatment during pregnancy. Most antenatal clinics will see women with diabetes at least every fortnight. The time, effort and lifestyle adjustments required for pregnancy with diabetes are significant.

The woman should be referred to the specialist diabetes team for care planning and education according to the local pathway. Women often need specialist diabetes support to achieve their glucose targets before conception. They should be referred for structured education if they have not already had this opportunity.

It is important that the woman understands she should not stop using contraception until this is agreed with her health care team. She also should not tighten her glucose control rapidly until significant retinopathy has been excluded.

Blood and urine tests should be organised. These will include:

• HbA1c (to assess current glycaemic control)
• U+Es and urinary ACR (to assess for diabetic nephropathy)

It is also important to find out if the woman has had retinal screening in the last six months. If not, this should be booked. This allows significant retinopathy to be stabilised with laser therapy to reduce the risk of damage during pregnancy. She should not tighten her glucose control rapidly until this is done.

The woman will need a medication review before conception. This will include:

• review of her medications for diabetes, hypertension, dyslipidaemia and other comorbidities. Alternatives must be prescribed for medications known to be, or suspected of being, harmful to the foetus. For diabetes this effectively means optimising blood glucose on diet, metformin and insulin.
• as in all pregnancies, Folic Acid 5mg OD should be started prior to trying to conceive. This is to reduce the risk of neural tube defects which can affect a baby’s brain and spinal cord or spine. This is a higher dose of Folic Acid than is used in pregnancies without diabetes.

Women with diabetes will also benefit from dietary education before conception and support to lose weight if their BMI is >27. In women who do not have diabetes, the risk of gestational diabetes increases if her BMI is above 30kg/m2. Thus losing weight before conceiving can reduce her risk of gestational diabetes.

To bring their HbA1c down to 48mmol/mol women aim for a target blood glucose of below seven before meals. This tight control increases the likelihood of episodes of hypoglycaemia. Many areas now have funding for continuous glucose monitoring during pregnancy for women with type 1 diabetes to help avoid low blood glucose. This funding does not cover the period before conception. Thus, it is important that health care professionals are able to recognise the signs of low blood glucose and to help the woman recognise and treat these. Women must also be aware of DVLA rules for diabetes and driving.

Further resources

•  (PDF)
•  (PDF)

References

• Low Wang, C., and Shah, A. (2016) Medical management of type 1 diabetes. Virginia: American Diabetes Association.

This section provides a brief overview of diabetes in childhood.

The ÌÀÍ·ÌõÎÛÁÏ care of people under the age of 18 is beyond the scope of this resource which is for the care of diabetes in adults. Resources which may be useful to those working with diabetes in children are provided at the end of this section.

Over 3000 children in the UK are diagnosed with diabetes each year meaning that two in every 1000 children aged 18 and younger have diabetes. 

• 95% of children have type 1
• 5% of children with diabetes have type 2 diabetes, cystic fibrosis related diabetes or monogenic diabetes (see table below) ().

The management of diabetes in children usually takes place in hospitals and is led by the paediatric diabetes multidisciplinary team.

Diagnosis of any type of diabetes in childhood is traumatic and living with diabetes in childhood is challenging. It affects the whole family as well as the child’s schooling and leisure activities. Adolescence can be a particularly challenging time when the young person struggles to come to terms with their diabetes. They begin to manage their own diabetes as they begin to take over from their parents. Regular contact with the diabetes team is important, as is maintaining a good, non-judgemental relationship with the young person.

Most services run a joint paediatric and adult clinic between the ages of 16 and 19. They support the young person as they begin to manage their diabetes independently whilst often sitting exams and looking for employment or further education places. Many services provide a Young Adult Diabetes Service to provide extra support up to the age of 25.

Further resources

If you or your patient suspects that these symptoms may indicate diabetes then it needs to be correctly diagnosed before treatment can be given. It is important to be vigilant for the signs and symptoms of diabetes and non-diabetic hyperglycaemia when treating patients, and to diagnose as early as possible so that treatment can be started. In the case of NDH, early diagnosis could mean that type 2 diabetes can be prevented. Once somebody is diagnosed with diabetes, they should be entered onto their GPs diabetes register to ensure they begin the diabetes care pathway.

Diabetes is often missed in the elderly. A range of diagnostic approaches are outlined below:

HbA1c

Glycated haemoglobin is the chemical that carries oxygen in red blood cells, which also has glucose attached to it. It differs from a blood glucose level as it provides a longer-term average reading (approximately three months – the lifespan of a red blood cell). The HbA1c test is usually done in hospital or a GP clinic and then sent to a laboratory and is usually checked at six monthly intervals. Increasingly, instant readings may be obtained at new ‘point of care’ testing stations.

HbA1c has become the most common method of diagnosing diabetes, as recommended by the World Health Organization (WHO). It primarily measures the levels of HbA1c in the blood to identify the average plasma glucose concentration over the previous six to twelve weeks. The test measures a part of the amount of blood glucose attached to haemoglobin. The test gives a good indication of an average blood glucose control as it reflects periods of higher blood glucose, for example, following meals and periods of lower blood glucose, for example, following exercise.

A blood sample is required. An HbA1c of 48mmol/l (6.5%) or more is a diagnosis of diabetes in most situations. HbA1c is also used to monitor diabetes in a patient and will normally be done every two to six months. Patients with diabetes aim to lower the HbA1c level to below a target level, normally around 48-53 mmol/mol (6.5% - 7.0%, NICE guidelines 2018). However, individualisation of the target goal level will be negotiated between the patient and their diabetes team as the levels may vary for each patient, e.g. in the elderly and frail. Attempting to maintain a low HbA1c may place an elderly or frail patient at risk of hypoglycaemia and falls.

When it cannot be used:

• children and young people
• if patient is suspected of having type 1 diabetes
• patients has symptoms of diabetes for less than two months
• patients who are acutely ill
• if patient is taking medication that may cause rapid glucose rise, for example steroids
• patient has acute pancreatic damage, including pancreatic surgery
• pregnancy
• patients with abnormal red blood cells such as Thalassaemia.

Random blood glucose test

In a medical emergency, when a patient (most often a child) has such high glucose levels that they are drifting in and out of a coma, a blood glucose reading can be found by taking a blood sample to measure the glucose with no consideration to when the last meal was eaten. A level of 11.1 mmol/L or more in the blood sample indicates diabetes. A further blood glucose test will need to be done to confirm the diagnosis.

Fasting blood glucose test (FBG)

The FBG test is taken using a blood sample obtained following a period of fasting (so no food or drink, except water) of at least eight hours. The fast normally starts from midnight. A sample of blood is taken early the next day, before food or drink. A level of 7.0 mmol/L or more after an overnight fast indicates diabetes. To confirm the diagnosis, it is usually necessary to repeat the test a second time on a different day.

Oral glucose tolerance test (OGTT)

For this test the patient fasts from midnight and then a baseline fasting blood glucose test is taken. The patient then consumes a drink that contains 75g of glucose (Lucozade is normally used)– recent reductions in the sugar content of certain drinks should be checked to ensure the correct dose is administered. Two hours later the blood glucose level is measured again. This test is different from the others as the patient drinks a sugary drink as a way of measuring how effectively the pancreas secretes insulin to manage the glucose load. In a person without diabetes glucose levels rise and fall quickly, as the body naturally produces insulin to lower the blood glucose. A person with diabetes will see a sharp rise and a sustained high level of glucose during this test. This is because the pancreas is unable to deliver the insulin needed to lower the glucose in the blood. A blood glucose level of 11.1 mmol/L or more in the blood sample taken after two hours indicates diabetes.

Urine test for glucose

A simple dipstick test can detect glucose in a sample of urine. In a dipstick test, a doctor or nurse uses a special chemical strip that is dipped into a sample of the patient's urine. Colour changes on the strip show whether there is glucose in the urine sample. Some people have kidneys that are more 'leaky' and glucose may leak into urine with a normal blood level. If a patient's urine contains any glucose a blood test should be carried out to measure the blood level of glucose to confirm, or rule out, diabetes.

Whether a fasting glucose, random glucose or HbA1c is used to test for diabetes it will generally need to be repeated as there should be evidence of two results using the same testing method to confirm diagnostic testing.

Diagnostic values

According to the World Health Organization, someone may have diabetes if they have:

• In patients without symptoms of diabetes the laboratory venous HbA1c should be repeated. If the second sample is <48mmol/mol (6.5%) the person should be treated as at high risk of diabetes and the test should be repeated in 6 months or sooner if symptoms develop (, Diabetes UK)
• a fasting blood glucose of 7 mmol/L or more, OR
• a blood glucose 11.1 mmol/L or more after a two-hour oral glucose tolerance test. (GTT).

Someone has impaired glucose tolerance if they have:

• a fasting blood glucose of less than 7 mmol/L, AND
• a blood glucose of 7.8 mmol/L or more but less than 11.1mmol/L after a 2-hour oral GTT (where a person is fasted and then given a quantity of glucose to observe the pancreatic response to raised blood glucose).

Someone has impaired fasting glycaemia if they have:

• a fasting blood glucose between 6.1 to 6.9 mmol/L, AND
• a blood glucose of less than 7.8 mmol/L after a two-hour oral GTT.

NHS Diabetes Prevention Programme

There are currently 5 million people in England at high risk of developing type 2 diabetes – if trends continue then by 2034, one in ten will develop type 2 diabetes (). 

There is strong international evidence that behavioural interventions can significantly reduce the risk of developing the condition, through reducing weight, increasing physical activity and improving the diet of those at high risk (NEJM, 2001).

The (NHS DPP) aims to target those identified at high risk and refers them to a behaviour change programme – those at risk are also able to self-refer. Eligibility criteria to join the programme are people aged over 18 with non-diabetic hyperglycaemia (NDH).

NDH is defined as having an HbA1c 42 – 47 mmol/mol (6.0 – 6.4%) or a fasting plasma glucose (FPG) of 5.5 – 6.9 mmol/l. The blood result indicating NDH must be within the last 12 months to be eligible for referral and only the most recent blood reading can be used.

Referral routes into the programme vary according to local pathways. Primary mechanisms for referral are:

• Those who have already been identified as having NDH and have been included on a register of patients with high HbA1c or FPG.
• The NHS Health Check programme, which is currently available for individuals between 40 and 74. NHS Health Checks includes a diabetes filter, those identified to be at high risk through stage 1 of the filter are offered a blood test to confirm risk.
• Those who are identified with non-diabetic hyperglycaemia through opportunistic assessment as part of routine clinical care.

Individuals can also complete a and self-refer for further evaluation to commence the programme.

The programme runs for nine months and provides support to achieve a healthier weight, improve nutrition and increase physical activity. Delivery of the programme varies by geographical area.

Typically, the programme offers support to participants via:

• initial one-to-one assessment with a health and well-being coach
• attendance at a local group programme, which consists of nutritional guidance and support, strategies to enable long term progress and physical activity sessions and advice
• an end of programme one-to-one review with a health and well-being coach to celebrate success and consolidate learning.

Remission of type 2 diabetes 

The  (Diabetes Remission Clinical Trial) aimed to determine whether a structured weight management programme delivered in a realistic primary care setting was a viable treatment for producing remission of type 2 diabetes. Results showed that some people with type 2 diabetes can become non-diabetic again, at least for a period. A remission of diabetes will allow the patient to stop taking anti-diabetic drugs. This is important as the drugs are inconvenient and can cause side effects. The impact of remission on future health could be highly significant.

Further resources

• NHS England.
• Tuomilehto,J. et al. (2001) , N Engl J Med, 3 May, 2001; 344:1343-1350

Interventions which improve diet and lifestyle have been shown to delay the onset of type 2 diabetes and to improve risk factors related to long term complications ().

NHS Diabetes Prevention Programme

There are currently five million people in England at high risk of developing type 2 diabetes – if trends continue by 2034, one in ten will develop type 2 diabetes (). The NHS Diabetes Prevention Programme (NHS DPP) aims to target those identified at high risk and refers them to a behaviour change programme – those at risk are also able to self-refer. Eligibility criteria to join the programme are as follows: Individuals eligible for inclusion have ‘non-diabetic hyperglycaemia’ (NDH), defined as having an HbA1c 42 – 47 mmol/mol (6.0 – 6.4%) or a fasting plasma glucose (FPG) of 5.5 – 6.9 mmol/l. The blood result indicating NDH must be within the last 12 months to be eligible for referral and only the most recent blood reading can be used. Only individuals aged 18 years or over are eligible for the intervention. Referral routes into the programme vary according to local case finding pathways. Primary mechanisms for referral are:

• Those who have already been identified as having an appropriately elevated risk level (HbA1c or FPG) in the past and who have been included on a register of patients with high HbA1c or FPG.
• The NHS Health Check programme, which is currently available for individuals between 40 and 74. NHS Health Checks includes a diabetes filter, those identified to be at high risk through stage 1 of the filter are offered a blood test to confirm risk.
• Those who are identified with non-diabetic hyperglycaemia through opportunistic assessment as part of routine clinical care.
• Individuals can also complete a and self-refer for further evaluation to commence the programme.

runs for nine months and provides support to achieve a healthier weight, improve nutrition and increase physical activity. Delivery of the programme varies by geographical area.

Typically, the programme offers support to participants via:

• initial one-to-one assessment with a health and well-being coach
• attendance at a local group programme, which consists of nutritional guidance and support, strategies to enable long term progress and physical activity sessions and advice
• an end of programme one-to-one review with a health and well-being coach to celebrate success and consolidate learning.

Nutritional management

Effective management of nutrition is recommended as an integral component of education and clinical care for those at risk of developing or living with any type of diabetes. Input from a registered dietitian should be offered to all people living with diabetes and those deemed to be at high risk of developing type 2 diabetes. The following recommendations are adapted from . These recommendations can be used to develop individualised nutrition and activity plans.

Nutritional recommendations for the prevention of type 2 diabetes

• target weight loss of 5%
• restrict energy intake
• reduce total and saturated fat intake
• increase fibre
• increase physical activity
• include wholegrains, some fruit, green leafy vegetables
• reduction in red and processed meat, potatoes, sugar sweetened beverages and refined carbohydrates (CHO)
• multi component lifestyle interventions which are culturally sensitive to reduce risk in ethnic minority groups.

Recommendations for glycaemic control and type 2 diabetes

• aim for 5% weight loss in those who are overweight by reducing calories consumed and increasing energy expenditure
• aim for a Mediterranean style diet or equivalent
• offer individualised support to identify and quantify CHO intake, encourage low glycaemic index (GI) foods and consider reducing amount of total CHO. Low GI food take longer to breakdown raising blood glucose levels steadily and may be associated with improved HbA1c.

Recommendations for glycaemic control and type 1 diabetes

• education to support people with type 1 diabetes should be offered to identify and quantify dietary and CHO intake for glycaemic control specifically
• adjust insulin to CHO intake in people using multiple daily injections or insulin pumps (carbohydrate counting)
• aim for consistent quantities of CHO on a day-to-day basis in people on fixed insulin regimes.

Further resources

Diabetic foods

People living with diabetes should avoid foods labelled as ‘diabetic’ / ‘suitable for diabetics’ as there is no role or benefit from the use of diabetic foods. ‘Diabetic’ foods have been a feature in many chocolate, sweets, biscuits, and bakery ranges available in a variety of high street outlets such as supermarkets, pharmacies and “health food shops” as well as being widely available on the internet. As ‘diabetic’ foods can be just as high in calories and fat, continued consumption of these foods can contribute to weight gain and increase an individual’s susceptibility to other health conditions, for example, heart disease and stroke ().

Carbohydrate counting

While people with type 2 diabetes are taught to be aware of the size of their carbohydrate intake, people with T1DM need a more exact measure called carbohydrate counting. Carbohydrate counting helps them to optimise their blood glucose control by adjusting their insulin doses. CHO can be counted in two ways, in grams or as CHO portions (CP). One CP is usually equal to 10g of carbohydrate.

Insulin-to-carbohydrate ratios (Insulin-CHO ratio) are different from person to person, depending on age, weight, activity levels and how sensitive the person is to insulin.

The diabetes health care team will help the person with T1DM diabetes to work out their insulin-CHO ratio and, eventually, a different ratio may be set for each meal. They will usually estimate the starting insulin-to-carb ratio and then fine-tune this based on blood glucose control.

Once the quantity of CHO of a meal and the insulin-carb ratio are known, then the insulin bolus dose for that meal can be calculated.

If the meal had 70g of carbohydrate and the Insulin -CHO ratio was 1 unit of bolus insulin for every 10g carbohydrate, then seven units would be given for that meal.

The amount taken will also depend on other factors such as current blood glucose level, illness or planned physical activity.

See: . BERTIE is a diabetes education course that teaches people with type 1 diabetes how to manage insulin doses, matching them to carbohydrate intake, and live life on a day-to-day basis.

Alcohol

Alcohol in moderate amounts can be enjoyed safely by most people with T1DM and general advice about safe alcohol intake (14 units or less per week) should be applied. However, alcohol intake is associated with an increased risk of hypoglycaemia for those taking insulin. Pragmatic advice for those who wish to continue to consume alcohol would be insulin dose adjustment, additional carbohydrate or a combination of both. Alcohol is contraindicated for those with hypertension, hypertriglyceridemia, some neuropathies, retinopathy and during pregnancy.

For more information, see: Alcohol

Smoking

There is a long established, clear link between smoking and the risk of developing type 2 diabetes due to increasing insulin resistance, caused by cellular damage. Increased insulin resistance caused by smoking, means those with already established type 2 diabetes may require intensification of diabetes medications (including insulin). Persistently elevated blood glucose levels caused by increased insulin resistance, leads to significant long-term complications affecting major organ systems within the body ().

People living with diabetes should be encouraged to stop smoking and educated as to the multiple health benefits. People living with diabetes can be referred to the local .

For more information, see: Smoking cessation

Older people with diabetes

Some older persons with diabetes may experience poor nutritional status with physical, social and psychological factors affecting intake. Education should continue to be offered to older persons, including dietary intervention – age should not restrict access. Dietetic input is key to assess nutritional status and formulate individualised care plans which take into account the changes in nutrients that are required as the body ages. Guidelines and care planning should be further adapted for those living with dementia with a focus on maintaining nutritional intake and preventing malnutrition.

Ramadan

Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith. Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The European Association for the Study of Diabetes consensus recommendations emphasise the importance of patient factors and comorbidities when choosing diabetes medications including the presence of comorbidities, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, hypoglycaemia risk, weight issues and costs. Structured education and pre-Ramadan counselling are key components to successful management of patients with diabetes. These should cover important aspects like glycaemic targets, self-monitoring of blood glucose, diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast.

Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycaemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and foetal outcomes. Hypoglycaemia is a common concern during Ramadan fasting. To prevent hypoglycaemic and hyperglycaemic events, the adoption of diabetes self-management education and support principles are recommended. The use of the emerging technology and continuous glucose monitoring during Ramadan could help to recognize hypoglycaemic and hyperglycaemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier ().

Summary guidance for fasting during Ramadan

• NHS England.
• The Muslim Council of Britain. 
• The Muslim Council of Britain & Diabetes UK.

Structured education programmes

A number of structured education programmes are available for those living with diabetes.

DESMOND

DESMOND - Diabetes education and self-management for ongoing and newly diagnosed - is group-based education which aims to support people with a diagnosis of type 2 diabetes and work with them to self-manage their condition, through a structured education programme to target lifestyle modification and behaviour change which can be culturally adapted. These programmes are delivered virtually or in-person over one whole or two half days.

Content includes:

• thoughts and feelings of the participants around type 2 diabetes
• understanding diabetes and glucose: what happens in the body
• understanding the risk factors and complications associated with diabetes
• understanding more about monitoring and medication
• how to take control – Food Choices – Physical Activity

DAFNE

– Dose adjustment for normal eating, aims to help adults with type 1 diabetes lead as normal a life as possible, whilst also maintaining blood glucose levels within healthy targets, to reduce the risk of long-term diabetes complications. DAFNE educates people with type 1 diabetes about their condition, insulin use and CHO counting.

Education programmes will vary depending on geographical location.

Reversal of type 2 diabetes

Inspired by the results from the ground-breaking , the year-long programme aims to help people recently diagnosed with diabetes lose weight and put their condition into remission.

For three months, people with type 2 diabetes provided with low-calorie total diet replacement products, such as shakes and soups. After this, they’ll be supported to reintroduce solid foods and maintain their weight loss.

Alongside making changes to their diet, people taking part in the programme will also be provided with support to increase their exercise levels. And they’ll be able to take part in virtual one-to-ones and group sessions throughout the year too.

Recommendations for weight management and remission for people living with type 2 diabetes:

• for overweight or obese people with Type 2 diabetes
• for remission, aim for weight loss of 15kg as soon as possible after diagnosis – this may be achieved by total diet replacement or meal replacement plans providing 800-1200 Kcal per day for 12 weeks
• to improve glycaemic control and CVD risk, aim for at least 5% weight loss achieved by reducing calorie intake and increasing energy expenditure.

Physical activity

Increased physical activity is associated with a 25-40% reduction in the relative risk of developing type 2 diabetes ().

Weight management, physical activity and exercise have numerous benefits for people with type 2 diabetes – improving blood glucose control, cardiovascular risk factors and well-being. Target activity should be at least 150 minutes per week of moderate to vigorous physical activity over at least 3 days.

In type 1 diabetes, physical activity can improve cardiovascular fitness leading to a reduction in CVD and mortality. However, there is limited evidence of improved glycaemic outcomes, and whilst exercise will reduce blood glucose levels, it is also associated with increased hypo and hyper glycaemia. For planned exercise, reduction in insulin is the preferred method to prevent a hypo. For unplanned exercise, additional CHO may be required.

which assist the health care professional to educated the person living with, or at risk of developing diabetes. 

For more information, see: Physical activity

Treatment for diabetes aims to help people with the condition to control their blood glucose levels and minimise the risk of developing complications over time.

Treatment for type 1 diabetes

Lack of insulin production by the pancreas makes type 1 diabetes particularly difficult to control. A management plan defined by the diabetes team that centres around the needs and goals of a person typically includes dietary advice and maintaining a constant health weight, home blood glucose monitoring and exercising regularly. Unfortunately, the treatment cannot eliminate the need for insulin or reverse the disease.

Insulin

All patients with type 1 diabetes will need to have daily insulin injections as their body is unable to produce any insulin. The injections come in the form of a syringe, insulin pen or insulin pump.

Syringe

Insulin pens

Insulin pump

The reason that insulin is injected is because if it were taken as a tablet, it would be broken down in the stomach and would not enter the blood stream. When a person is first diagnosed, the diabetes team will teach them the correct procedure for their injections. This involves showing them when, where and how to inject themselves and how to adjust insulin doses. They will explain how to store the insulin and safely dispose of the needles.

The team will also discuss the management of diabetic emergencies, such as hypoglycaemia and information relating to sick day rules, and driving a vehicle or operating machinery. The person will be educated about insulin dosing and safety. Each person who is taking insulin may carry an 'Insulin Passport' or 'Insulin Safety Card'.

Insulin passport

Treatment for type 2 diabetes

It is possible for a person to initially control the symptoms of type 2 diabetes by following a healthy diet, taking regular exercise and keeping their blood glucose levels within an agreed target range. Type 2 diabetes can  be a progressive condition for some people, so they may eventually need to take diabetes medication which will usually be in tablet form. A treatment programme will be tailored to suit the person's needs by the diabetes team and will typically include one or a combination of the following:

• changing to a healthier diet
• medication such as metformin
• injectable GLP-1
• insulin therapies.

Keeping blood glucose levels under control is vital in reducing the risk of diabetes complications. If a person is overweight, weight loss can often help to reduce the extent of diabetes symptoms. Type 2 diabetes is effectively controlled when a person is involved in the management of their own programme of treatment. Effective 'self-management' is essential to successfully achieving their healthy targets for HbA1c, blood pressure and cholesterol levels. A person with type 2 diabetes may need (or eventually need) medication that reduces high levels of blood glucose. In the first instance this will usually be glucose-lowering tablets (sometimes a combination of more than one type of tablet) and it may also include injectable insulin. Some oral medications for lowering blood glucose levels can cause hypoglycaemia for example, Gliclazide, Glipizide and Glimpiride.

As research in diabetes continues, new and more effective medication are becoming available that assist with weight reduction and improve blood glucose level control in some people with type 2 diabetes without causing hypoglycaemia. Oral medication include: Sitagliptin, Linagliptin and Saxagliptin (Alogliptin and Vildagliptin). Injectable therapies (GLP-1) include: Exenatide, Liraglutide Semaglutide, Dulaglutide exenatide (bydureon), a once weekly preparation.

Further resources

• Diabetes UK (2019) . Guidance on diabetes meters, Flash, CGMs, medications, insulins, pens and pumps that are available in the UK
• NICE.  (PDF)
• RCN (2022) Starting Injectable Treatments in Adults with Type 2 Diabetes

Self-management

Diabetes is one of the few serious medical conditions for which the outcome relies almost entirely on the person’s ability to self-manage. This is why structured group education and individualised care plans are so important to improve peoples ability and confidence to manage their own diabetes.

People living with diabetes need on-going advice and support about maintaining a healthy diet, keeping active and monitoring their health. People living with diabetes spend around three hours per year with a health care professional; for the remaining 8,757 hours they must manage their diabetes themselves’. Diabetes can be a burden, but most people can live relatively normal active and healthy lives and even small adjustments to their lifestyle can make significant improvements. Most diabetes management relies on a person 'self-managing' the condition, so their motivation is a major consideration regarding effective treatment. The health care professional can support the person to identify and set realistic goals and planning smaller steps to achieve and maintain these goals. The health care professional also has an important role in assessing self-care abilities and referring the person for further support where a gap is identified.

All patients should have their blood glucose levels checked by a health care professional every two to six months. The diabetes health care team should discuss the patient’s blood glucose levels with them and agree a target range with them. Many people with diabetes monitor their blood glucose levels at home using a simple finger prick blood test. They may need to do this several times a day, depending on the type of treatment that they are receiving.

Patients who use insulin – that is all with type 1 diabetes and some with type 2 – should usually test their blood glucose three to ten times per day depending on how difficult their blood glucose levels are to control. This allows them to judge the effectiveness of their previous dose of insulin and helps them to determine the amount of insulin needed for their next dose. Patients with type 2 diabetes should test their blood glucose levels at least once a day, although not all type 2 patients, like those treating their condition through diet or using metformin, need to monitor and it will be down to their own self-management programme which is has been agreed with their diabetes team.

Careful monitoring of blood glucose levels will reveal individual patterns of blood glucose changes. This can help the person with diabetes to see if the treatment programme is working, help plan their meals and activities and to make the necessary amendments if required. Regular testing allows for a quick response to high blood glucose (hyperglycaemia) or low blood glucose (hypoglycaemia). This response could include insulin and adjustments to diet and exercise regimes. It is vital that the patient understands the importance of regular testing. Many patients claim to know when their blood glucose levels are too high but unfortunately this is often not the case. The way that they feel is generally not an accurate guide to what is happening unless their blood glucose levels are very high.

Emotional well-being and mental health

The impact of diabetes on the person, and the level of self-management required can significantly affect emotional well-being and mental health. As mentioned above people with diabetes spend on average, three hours a year with a health care professional and the remaining 8,757 hours managing diabetes themselves. People with diabetes are twice as likely to suffer from depression and are more likely to be depressed for longer and more frequently. Around 40% of people with diabetes struggle with their psychological well-being often because of the demands of the disease. It is important to recognise how cultural and socio-economic factors can increase the burden of diabetes. The NHS spends an extra 50% treating the physical health of someone who has type 2 diabetes and poor mental health compared to someone with type 2 and no mental health problems. For people without diabetes, having depression increases someone’s risk of type 2 diabetes by 60%.

Diabetes specific psychological disorders

• diabetes distress occurs in 42% in people with T1D, 36% in T2D. Assessment of emotional distress should not be addressed as a separate co-morbid ‘condition’ that is diagnosed and treated only when detected
• needle phobias, injecting fear
• eating disorders – affect >30% of women in their early 20’s with T1D
• 64% of people with diabetes feel down and 1/3rd are interested in counselling from a trained professional.

Factors which impact on emotional wellbeing across type 1 and 2 diabetes

Diabetes distress

Diabetes distress is a natural and rational emotional response to living with a demanding, long-term condition. People feel frustrated, defeated and/or overwhelmed by diabetes. All feelings are focused on diabetes so outwardly an individual may not seem unhappy. It’s not the same as depression - where people feel negative about themselves, others and the future - and it’s not a ‘disorder’. Multi-national studies estimate that at highest levels, diabetes burnout affects 44% of people diagnosed with type 1 or type 2 diabetes. And it’s been consistently linked with higher HbA1c levels. Diabetes ‘burnout’ is a state of physical and emotional exhaustion caused by the continuous stress and efforts to self-manage diabetes. Distress may be a natural reaction to having managed their diabetes over a long period of time - without a single day off.

Distress / burnout may coincide with a particularly demanding time for example relationship difficulties, family stress or bereavement. When these events happen, diabetes may naturally be seen as a low priority. Developing diabetes-related complications can be the motivation some people need, but others find themselves asking ‘What’s the point?’ and wondering why it’s even worth trying.

Diabetes distress / burnout can be indicated by the following symptoms:

• feeling overwhelmed and defeated by diabetes
• feeling angry about diabetes and frustrated about the demands of managing it
• feeling as though diabetes is controlling the person’s life
• worrying about not taking enough care of diabetes but unmotivated or unwilling to change
• avoiding parts of the diabetes routine e.g. attending appointments, testing
• not caring about blood sugar levels
• reverting to unhealthy behaviours e.g. poor diet
• feeling alone and isolated with diabetes.

As clinical psychologist, Dr William Polonsky, describes, ‘they are at war with their diabetes – and they are losing it’.

Management of diabetes distress may include:

• explaining what diabetes distress is and that many people with diabetes experience it
• explaining the signs and consequences of diabetes distress (e.g. the impact on their daily self-management and well-being)
• acknowledgement of the significant daily efforts required to manage diabetes – this by itself may reduce the distress
• 'normalise’ negative emotions about diabetes
• use a validated tool in line with local policies and procedures
• explore the most appropriate support for the individual, for example, diabetes education or revising their management plan, advice on lifestyle changes, emotional or social support, or a combination of these
• if a decision is made to refer, consider a diabetes specialist health professional for difficulties with diabetes management and support or a mental health professional, a psychologist or psychiatrist (preferably with an understanding of diabetes) for stress management or if other emotional problems such as depression or anxiety or more complex psychopathology are underlying the diabetes distress.

Psychological Disorders and Diabetes

People with underlying mental health issues or psychological disorders are at higher risk of diabetes. Medications such as antipsychotics can increase the risk of type 2 diabetes by as much as 60% and many of the atypical antipsychotics have impaired glucose tolerance as a side effect, this is often due to weight gain caused by medications.

As patients get older the risk of diabetes also increases, meaning patients with dementia or Alzheimer's are also often at risk. These conditions can be challenging as patients may lack insight into understanding their diagnosis of diabetes, meaning it is harder to get them to consent to any treatment or to accept treatment on a regular basis leading to increased risk of complications.

Eating disorders and Intentional Insulin Restriction (‘Diabulimia’)

Among people with diabetes, the full syndrome eating disorders are rare. The most common disordered eating behaviours are binge eating and insulin restriction/omission but prevalence is not well established. Eating problems in people with diabetes are associated with sub-optimal diabetes self-management and outcomes, overweight and obesity, and impaired psychological well-being.

Intentional insulin restriction (IIR) or omission for the purposes of weight loss is sometimes referred to a ‘Diabulimia’ – IIR is the preferred clinical term. Estimates of insulin omission have been reported in up to 40% of people with type 1 diabetes. People may also omit or restrict insulin for other reasons than weight loss (e.g. fear of hypoglycaemia). Eating disorders are associated with early onset of diabetes complications and higher morbidity and mortality.

Evidence for the management of eating disorders in combination with diabetes is very limited. Thus, in practise, generally eating disorder treatments are applied to address the needs of people who are living with both conditions.

Healthcare professionals in both primary and secondary care should:

• consider emotional and psychological support as part of the remit of the whole multidisciplinary team
• ensure they have adequate training and supervision to identify psychological problems in people with diabetes and deliver an appropriate level of proactive support as part of ongoing diabetes care, including through the care planning process
• be familiar with the emotional and psychological support services available to their patients both locally and through national organisations such as Diabetes UK.
• deliver a diagnosis of diabetes without blame or stigma, and give sources of support and information at diagnosis. Time should be allowed to agree a care plan.
  ()

Having a quality conversation about emotional health and diabetes 

It’s important to ask people about their emotional health at every appointment. Just because everything may seem okay the first time you ask, this can change over time. Don’t think of this as an added extra. If someone is struggling emotionally, they’re going to find looking after their diabetes much more difficult ()

Top tips

Step 1 – Opening up the conversation

Ask “How are you feeling?”

Step 2 – Making the most of the conversation

Gain insight before the appt, open questions, active listening, reflection, info prescriptions, positive language, use of time, validated scales / tools

Step 3 – Safely closing the conversation

Agreeing actions at the patients pace, ask them to summarise, ‘what questions do you have?’, End on a positive, emphasis on importance of well-being, refer as necessary.

Language matters

The language used by healthcare professionals can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it day-to-day. At its best, good use of language; verbal, written and non-verbal (body language) which is more inclusive, and values based, can lower anxiety, build confidence, educate and help to improve self-care. Conversely, poor communication can be stigmatising, hurtful and undermining of self-care and have a detrimental effect on clinical outcomes. The language used in the care of those with diabetes has the power to reinforce negative stereotypes, but it also has the power to promote positive stereotypes ().

Top tips

1. Recognise that some words, phrases and descriptions are potentially problematic, whatever the intention of the user.
2. Use language (including tone and non-verbal gestures) that is:
   -  free from judgment or negative connotations, particularly trying to avoid the threat of long-term consequences or scolding (‘telling off’); is inclusive and values based          language.
   -  person-centred, (also known as ‘person first’)to avoid labelling a person as their condition.
   -  collaborative and engaging, rather than authoritarian or controlling.
3. Review the use of common expressions and what underlying attitude they may convey,
   regardless of intention.
4. Avoid language which attributes responsibility (or blame) to a person for the development of their diabetes or its consequences.
5. Avoid language that infers generalisations, stereotypes or prejudice, or links one individual with previous experience of others of a similar background or in a similar
   situation.
6. Use or develop an empathic language style which seeks to ascertain a person’s point of
   view of their condition, rather than assume.
7. Listen out for a person’s own words or phrases about their diabetes and explore or acknowledge the meanings behind them.
8. Become alert to the use of language, and non-verbal communication i.e. body language and recognise if it may be creating a negative effect.
9. Consider how to limit any negative effects from language used, both for yourself and
   with others around you.

Further resources

• NHS England. Language Matters: Language and diabetes. This guide provides practical examples of language that will encourage positive interactions with people living with diabetes and subsequently positive outcomes.
  

There are over currently over 30 different insulin preparations available which fall in to the following main types: 

Insulin is used to manage blood glucose levels in various regimes which can include single insulin types or insulins used in combinations. Typical insulin regimes fall into the following:

Basal

• Basal insulins are often given once a day, often at night to control pre breakfast blood glucose levels.
• Insulin Glargine (Lantus) (Abasaglar), Insulin Detemir (Levemir), Insulin Degludec (Tresiba), and U300 Toujeo 300 Units/mL have the advantage of greater predictability, potentially less weight gain, and lower risk of hypoglycaemia, particularly at night compared to intermediate acting insulin.
• They can be given as a basal insulin or in a Basal Bolus regimen.
• Basal insulin alone is suitable for type 2 diabetes. 

Basal plus

• These regime’s often progress from basal insulin regimes’ and introduce 1 or 2 injections of rapid acting insulin with meals to prevent blood glucose levels rising after food. 

Basal bolus or multiple daily injections (MDI) 

• MDI is a combination of basal insulin once daily and rapid acting insulin with each meal. 
• This regime is suitable for people with type 1 and type 2 diabetes. 

Mixed

• Mixed insulins contain a proportion of rapid or short acting and a proportion of intermediate acting insulin. 
• The number following the name of the insulin identified the proportion or rapid or short acting insulin (E.g. NovoMix 30 indicates that the proportion of rapid acting insulin with in the mixture is 30%) 
• This regime is suitable for people with Type 1 and Type 2 diabetes but is more restrictive than MDI. 

Appropriate insulin regimes should be decided in partnership with the person with diabetes, focusing on their lifestyle, considering when they eat, activity levels, occupation and if they are able to self manage or will require support with administration. 

Appropriate training should be provided and should include but is not exclusive to: 

• insulin type and how it works in relation to meals
• administration 
• device
• storage
• sharps disposal 
• driving 
• management of hypoglycaemia 
• blood glucose monitoring 
• self-titration (if appropriate).

High strength insulins

All insulin is available in a concentration / strength of 100 units/ml. This should be the most commonly prescribed insulin strength and always used for new insulin starts.

Some manufacturers have developed insulin with a higher strength formulation e.g. 200 units/ ml & 300 units/ml. These offer the same insulin action but in less volume and can be very useful for patients on doses greater than 40 units to help with insulin absorption and lower the risk of lipohypertrophy (lumpy injection sites).

These insulins only are available in pre-filled pens to ensure that the correct dose: volume concentration is given. The patient still dials to the same dose but a different volume is given.

Biosimilar insulins

Biosimilar insulins are a biological copy that is not identical but demonstrates similarities to the original product in terms of quality, efficacy, cost and safety.

Some of the currently available biosimilar insulins are Abasaglar and Semglee. These are not interchangeable and therefore it is important that insulin is prescribed by brand name.

More biosimilar insulin products are soon to be available in the UK.

• For information about initiating insulin for people with type 2 diabetes, see: RCN (2022) Starting Injectable Treatments in Adults with Type 2 Diabetes.
• For information about insulin types and insulin delivery including insulin pump therapy, see: Diabetes UK (2020) .

Insulin should be initiated and managed by people with suitable knowledge and qualifications. If required you may need to refer people who require insulin to your local Diabetes Specialist Team. 

Further resources

• Diabetes on the Net. . An essential module for all those prescribing, managing or administering insulin, with the overall aim of reducing insulin errors in clinical practice. Its focus is on insulin use within the primary-care setting.

NICE guidelines for the UK currently recommend the following targets (the target blood glucose ranges below are indicated as a guide).

See: 

•  (Last updated 2023)

Children with Type 1 diabetes 

• fasting plasma glucose level of 4–7 mmol/l on waking
• plasma glucose level of 4–7 mmol/l before meals at other times of the day
• plasma glucose level of 5–9 mmol/litre after meals ().

Adults with Type 1 diabetes 

• fasting plasma glucose level of 5–7 mmol/L on waking and
• plasma glucose level of 4–7 mmol/L before meals at other times of the day
• for adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating ().

Type 2 diabetes (Diabetes UK Council of Healthcare Professionals 2015)**

• before meals: 4–7mmol/l
• two hours after meals: less than 8.5mmol/l.

Pregnant women with diabetes 

• fasting plasma glucose below 5.3 mmol/l
• plasma glucose level below 7.8 mmol/l 1 hour after meals
• plasma glucose level below 6.4 mmol/ l of 2 hours after a meal 

Pregnant women on insulin, should also be advised to keep their blood glucose above 4 mmol/litre, because of the risk of hypoglycaemia ().

Source:

When should blood glucose levels be measured?

The number of times per day the individual with diabetes should measure their blood glucose levels will vary from patient to patient depending entirely on their condition. The following is a useful general guideline however it doesn't apply to everyone and each case should be given individual advice.

Individuals with type 1 diabetes using insulin should check their blood glucose levels before every meal, sometimes as often as ten times per day.

Individuals with type 2 diabetes may measure their glucose levels if they are taking medications that can lead to hypoglycaemia (such as insulin and sulfonylurea). The frequency varies depending on the medication they are taking.

Individuals on Metformin and diet only, still may need to test their blood glucose periodically to observe trends in rising blood glucose.

Wearable glucose monitoring sensors

There are two types of continuous glucose monitoring (CGM) technologies; intermittently scanned flash glucose monitoring (isCGM) and real-time continuous glucose monitoring (rtCGM) which are described in this section. isCGM – Abbott Freestyle Libre and rtCGM Dexcom ONE are more commonly available in primary care.

CGM is available to any person living with type 1 diabetes based on their individual preferences, needs, characteristics and the functionality of the device. Shared decision making should be used to identify the most suitable device; if multiple devices meet their needs, the device with the lowest acquisition cost should be offered.

See this 

Factors to consider when choosing a CGM device (NICE, 2022a):

• accuracy of the device
• whether the device provides predictive alerts or alarms and if these need to be shared with anyone else (for example, a carer)
• whether using the device requires access to particular technologies (such as a smartphone and up-to-date phone software)
• how easy the device is to use and take readings from, including for people with limited dexterity
• fear, frequency, awareness and severity of hypoglycaemia
• psychosocial factors
• the person's insulin regimen or type of insulin pump, if relevant (taking into account whether a particular device integrates with their pump as part of a hybrid closed loop or insulin suspend function)
• whether, how often, and how the device needs to be calibrated, and how easy it is for the person to do this themselves
• how data can be collected, compatibility of the device with other technology, and whether data can be shared with the person's healthcare provider to help inform treatment
• whether the device will affect the person's ability to do their job
• how unpredictable the person's activity and blood glucose levels are and whether erratic blood glucose is affecting their quality of life
• whether the person has situations when symptoms of hypoglycaemia cannot be communicated or can be confused (for example, during exercise)
• clinical factors that may make devices easier or harder to use
• frequency of sensor replacement
• sensitivities to the device, for example local skin reactions
• body image concerns.

In addition, people living with type 2 diabetes are eligible to receive CGM if they are on multiple daily insulin injections (2 or more per day) or:

• they have recurrent hypoglycaemia or severe hypoglycaemia
• hey have impaired hypoglycaemia awareness
• hey have a condition or disability (including a learning disability or cognitive impairment) that means they cannot self-monitor their blood glucose by capillary blood glucose monitoring but could use an isCGM device (or have it scanned for them)
• they would otherwise be advised to self-measure at least 8 times a day.

For guidance on continuous glucose monitoring (CGM) for pregnant women, see the

• 1.6.18 - Offer isCGM to adults with insulin-treated type 2 diabetes who would otherwise need help from a care worker or healthcare professional to monitor their blood glucose.
• 1.6.19 - Consider real-time continuous glucose monitoring (rtCGM) as an alternative to isCGM for adults with insulin-treated type 2 diabetes if it is available for the same or lower cost.

Healthcare professionals who will be working with flash and continuous glucose monitoring are directed to . It is important you are able to help your patients access wearable glucose monitoring devices appropriately, interpret their data and improve their glycaemic outcomes.

Continuous Glucose Monitoring

Unlike finger-prick blood glucose testing, flash-is-CGM and rt-CGM measures a person’s interstitial glucose level. This means the glucose levels in the body tissues below the skin. Interstitial glucose levels lag behind capillary blood glucose by approximately 4.5-4.8 minutes (‘lag time’). This means that when blood glucose is changing rapidly the measurements will differ. For this reason during times of rapidly changing blood glucose levels such as hypoglycaemia patients and clinicians must revert to finger-prick testing.

How does it work

A sensor sits on the back of the arm with a probe just under the skin.

An overview of flash-isCGM

• Flash-isCGM requires an interstitial sensor and a receiver. The sensor is self-inserted into the upper arm and lasts up to 14 days. It is attached to the body with clinical adhesives. It transmits glucose data to a receiver when it is scanned. The receiver may be a handset or the user’s mobile phone and it stores and displays their data.

• By scanning or 'flashing' the sensor with a scanning device or mobile phone the person can observe:
  a) glucose level
  b) a graph of glucose level for the last 8 hours
  c) a direction or ‘trend’ arrow showing if levels are going up or down. The device also stores your data and makes it easy to view patterns over time.

• Various apps and software are available to present this data to the user and clinician using the cloud. They can then review and respond to glucose patterns.

• Interstitial glucose lags behind capillary blood glucose by 2.4 minutes (known as lag time). This means that when blood glucose is changing rapidly the measurements will differ. For this reason during episodes of hypoglycaemia patients and clinicians must revert to finger-prick testing.

• isGM (Libre2)  has an optional alarm connected via Bluetooth to warn the wearer if their blood glucose is going too low. Scanning is still required to see the actual blood glucose level and trend arrow.

Advantages of isCGM

• relatively painless insertion
• reduction in frequency of finger pricking
• easier to identify trends and improve control
• ability to test more regularly
• easier than finger-pricking in lots of situations (on transport, in rain, in cold, during sport)
• less social stigma than finger pricks
• modest impact on glucose monitoring costs for people with type 1 using intensive insulin regimes. Flash may even confer savings regarding potential reductions in severe hypogylcaemia
• some people preferred the arm as a location rather than stomach
• data can be downloaded for the user and clinician to view values and trends and uploaded for clinician review of ambulatory glucose profiles
• has been proven to improve HbA1c
• in 2019 the DVLA allowed the use of CGM as an alternative to finger prick testing to check blood glucose levels while driving provided glucose levels are >4.0mmol/l (if 4.0mmol/l or below a confirmatory finger prick is required.

Disadvantages of isCGM

• it can give inaccurate readings if blood glucose levels are changing rapidly
• must be scanned at least every 8 hours to provide an ambulatory blood glucose profile
• some users have reported reactions to the adhesive
• a finger prick blood glucose must still be used to check erroneous readings and also to manage control if symptoms do not match readings. 

An overview of rt-Continuous Glucose Monitoring

Real time continuous glucose monitoring (rtCGM) works in a similar way to intermittently scanned flash-isCGM with a sensor, transmitter and receiver as described above and can be worn on the arm / abdomen, or with some sensor buttocks in those under 17 years old. rt-CGM provides a constant stream of real time glucose data throughout the, day and night without the need for scanning. Lag time of rtCGM is approximately 4 -5 minutes depending on the device.

There are a number of rt-CGM systems licenced in the UK for example Dexcom ONE, G6 & G7, Medtronic G4, GlucoRx AiDEX and Glucomen Day.  (PDF).

Additional advantages of real-time CGM:

• rtCGM systems do not need to be scanned by the wearer. The glucose data is automatically transmitted to the handset/smart device and to the cloud in ‘real-time
• rtCGM systems have additional alarms which can be individualised to alert the person that they need to take action to adjust their blood glucose – the blood glucose level is displayed in real time alongside the alarm. 
• some rtCGM systems are licensed to link to an insulin pump and use the data to adjust some the persons insulin doses for them using an algorithm to enable a ‘closed loop’ system
• multiple sensor sites.

Disadvantages of rtCGM:

• phone compatibility can vary
• some users report alarm fatigue
• some users do not like being continually attached to technology
• some users do not trust the technology, and this can lead to overriding advise which can cause erratic glucose levels. 

Further resources

• . Further information on wearable technologies
• . Further information on the law around using flash-GM and CGM for driving. See here:
•  - this has both Libre and Dexcom
• Trend Diabetes.
• Trend Diabetes. 
• Dexcom.

What is Diabetic ketoacidosis (DKA)

Diabetic ketoacidosis (DKA) is an acute medical emergency. It is mainly seen in people with T1DM however does occur in type 2 diabetes particularly when SGLT2 inhibitors are being taken. If an individual with diabetes has sustained high blood glucose readings, it is an indication that there is not have enough insulin in their system, or that the insulin that they have is not working properly.

When this happens, it is possible that their body will start breaking down fat and proteins in order to get energy for metabolic processes. As ketones build up in the body, a state of ketoacidosis occurs, or in diabetes, Diabetic Ketoacidosis (DKA). The body cannot function properly in a state of acidosis. The person may initially experience nausea, vomiting and fatigue. As symptoms progress the person may begin to exhibit deep and fast breathing, confusion and the breath may smell of pear drops or nail varnish. Normal levels of ketones are usually considered to be <0.6 and these levels may be seen in people without diabetes eg when fasting for long periods.

If the acidosis is not corrected, this may lead to coma and in rare cases, death. () See Diabetes and acute illness, sick day rules section.

Access to ketone testing is recommended for all individuals with type 1 diabetes. NICE (2020) recommends testing for ketones if fasting or premeal blood glucose levels become  unusually high - usually above 11 mmol/l for an unknown reason (such as illness, dehydration or abdominal pain). Ketone testing is also recommended for lower blood glucose if the person feels unwell.

• they forget or decide not to take their insulin
• they are unwell of injured
• they are using ‘flozin’ (SGLT2) tablets to manage their diabetes

Testing for ketones in this way can help detect the problem at an early stage. This allows for advice and treatment to be given before the level of ketones in the blood becomes dangerous.

The table below gives advice on when you should check for ketones however local policies will vary and should be followed.

Ketones can be measured in two ways:

Urine - This involves dipping a urinalysis test strip in urine and the strip changes colour depending on the amount of ketones detected. It is usually recorded as +, ++, +++ or ++++.

A result of 2+ or more mans there is a high chance of DKA.

Blood – This involves a finger prick and using a blood ketone meter (similar to a blood glucose meter).

Blood Ketone Levels:

< 0.6mmol/l = normal

0.6-1.5 mmol/l - slightly increased risk of DKA – test again in 2 hours

1.6-2.9 mmol/l - increased risk of DKA – contact GP / Diabetes team ASAP

3 mmol/l or more - very high risk of DKA – immediate medical help required.

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Blood ketone testing is considered more accurate because the level of ketones in urine reflects the length of time the urine has been in the bladder.

Urine ketone testing is cheaper. Urine ketone testing might be preferred when a person does not want to have to do another finger prick, for example if they are testing for ketones very frequently.

How to perform a ketone test

1. Assemble the required equipment to perform the urinalysis

3. Check the urine sample is fresh - observe the colour and odour. Cloudy urine may indicate the sample is contaminated or infection is present. A strong fishy smell may indicate infection and a sweet odour like pear drop sweet may indicate ketones are present.

4. Check the sample is from the correct person and note any medications they are taking (as some medications may affect the result).

5. Wash hands and apply gloves/apron.

6. Remove a test strip from the bottle and replace the lid.

7. Immerse the full length of the test strip in the urine sample, ensuring all the test pads are covered. Remove excess urine on the lip of the sample bottle.

8. Place the test strip on the tissue/absorbent paper to prevent the colours on the pads contaminating each other.

9. Start the timer/note the time.

10. Replace the lid on the urine specimen.

11. When the appropriate amount of time has passed, align the test pads with the corresponding result gauge on the test strip bottle.

12. Be sure to line the pads up with the corresponding test on the container. This is where most errors with urine testing are made!

13. Remove your glove and record the result of the urine test in the person’s medical record. Report any abnormal result to a senior nurse, the diabetes care team or the person’s doctor as appropriate to your role and care setting.

14. Dispose of all equipment in the clinical waste bag.

15. Wash your hands.

Short term (acute) complications

Uncontrolled diabetes can cause metabolic imbalance leading to acute complications that may require immediate medical attention. Hyperglycemia (high levels of glucose in blood) sets the stage for protein glycation, which in turn may lead to chronic conditions requiring constant monitoring and treatment. Individuals with diabetes may also develop high cholesterol and high blood pressure, which require medical management.

Acute complications 

Acute complications will require immediate medical intervention.

Hypoglycaemia

Hypoglycaemia occurs when blood glucose levels is below 4mmol/l. A hypoglycaemia episode can happen quickly therefore it is important to understand the signs and symptoms and treat hypoglycaemia correctly. People will experience different symptoms, but the most common symptoms are sweating, feeling shaky, being anxious or irritable, feeling disorientated, blurred vision, headache, palpitation and fast pulse rate.

Diabetes Ketoacidosis (DKA)

DKA is a serious and life-threatening complication of type 1 diabetes caused by absolute or relative insulin deficiency leading to severe hyperglycaemia with ketosis (fat metabolism). Rare cases occur (1:1000) in acutely unwell people with type 2 diabetes taking SGLT2 inhibitors. Patients in DKA require high intensity ÌÀÍ·ÌõÎÛÁÏ usually within HDU / ICU. 

Insulin is a peptide hormone secreted by the pancreas which enables cellular uptake of glucose, thus maintaining blood glucose levels and proper cellular function. 

Absolute lack of insulin means, despite high levels of glucose in the blood, it cannot be utilised by the cells of the body to fuel cellular processes. As DKA progresses, levels of glucose in the blood increase, but this glucose cannot be utilised by the cells which need it. 

Cells may also  be deprived of glucose if the amount of food intake is low (such as during illness). 

When cells cannot obtain energy from glucose, cells start using fats as a source of energy. Liver cells produce ketone bodies from fatty acids. When blood glucose levels are low, brain cells can use ketone bodies, but not free fatty acids, for energy. High concentrations of ketones can make the urine acidic and cause fruity-smelling / acetone breath. If not managed, this condition can progress to coma (prolonged unconsciousness) and even death. 

Causes of DKA include: 

• complete or relative lack of insulin
• conditions increasing levels of stress hormones e.g. 
  - acute illness 
  - MI 
  - infections 
  - surgical emergencies
  - high dose steroids  
  - pancreatitis.

• errors of Insulin administration or deliberate omission (30%)
• new onset of type 1 diabetes (23 %).

Symptoms of Diabetes Ketoacidosis (DKA)

Symptoms of Diabetes Ketoacidosis (DKA) include:

• high blood sugar levels
• complaints of stomach pains or nausea
• fruity smelling breath
• vomiting
• drowsiness leading in time to unconsciousness
• deep heavy breathing
• excessive thirst
• los of weight
• urinating much more often and in larger amounts
• dehydration: dry mouth and tongue, sore throat, dark circles under the eyes.

Signs of severe DKA include:

• Venous bicarbonate <5mmol/L
• pH <7.0
• Ketones > 6mmol/L
• Hyperventilation
• Hypotension (systolic BP <90)
• Depressed conscious level (document GCS) 
• BLOOD GLUCOSE IS NOT A GOOD GUIDE TO SEVERITY.

Measurement of ketones

Measurement of ketones can provide an effective estimation as to the severity of DKA.

All of these must be present to make the diagnosis: 

• The ‘D’ – a blood glucose concentration of >11.0 mmol/L or known to have diabetes mellitus 
• The ‘K’ – The ‘K’ – a capillary or blood ketone concentration of >3.0 mmol/L or significant ketonuria (2+ or more on standard urine sticks) 
• The ‘A’ – a bicarbonate concentration of <7.3

Management of DKA is complex - updated guidelines have been published by the Joint British Diabetes Societies, and endorsed by the RCN. The guidance contains a .

Hyperosmolar hyperglycaemic state

Hyperosmolar Hyperglycaemic State (HHS) occurs in people with Type 2 diabetes who experience very high blood glucose levels (often over 40mmol/l). It can develop over a course of weeks through a combination of illness (e.g.i nfection) and dehydration (). High blood glucose level triggers increased urination. If liquids are not replaced, the individual can become severely dehydrated. High blood glucose levels can lead to altered mental states, confusion, seizures, coma, and even death.

Further resources

• Joint British Diabetes Societies (JBDS) (2012)  (PDF) in adults with diabetes

The role of Diabetes Specialist Nurses (DSNs)

The DSN role typically involves a high degree of autonomy (especially in community settings) and a range of responsibilities, including clinical care, patient and professional education.

DSNs are fundamental in supporting independence and diabetes self-management for people with diabetes and they play a crucial role in preventing – long-term complications, support patients with complex needs which will otherwise impact on their quality of life, including mental health as well as costly the NHS for preventable complications. DSNs play a key role in supporting primary care teams with specialist expertise to reduce emergency hospital appointments (Diabetes UK, 2011). There is growing body of evidence to support that DSNs are key to cost effective care and improve patient satisfaction (Diabetes UK, 2016). 

Hicks et al (2012) showed that nurse consultant and DSN-led services in the community are clinically effective; patients achieved significant positive clinical outcomes in HbA1c, cholesterol reduction and demonstrated an increased confidence in the patients’ ability to self-manage.

Qualifications, knowledge and skills

New models of care require DSNs to treat, refer, order diagnostic investigations, prescribe medications and create a patient centred care plan. Competencies are crucial to ensure staff are well equipped to manage complex caseloads. 

Career pathways and development in diabetes haven’t been easy to navigate and with a wide range in variety of job titles and job descriptions it has impacted on recruitment to this type role.  (Diabetes UK, 2019; Gosden et al, 2010). 

DSNs should be registered nurses and have practised for a minimum of three years and have proven interests in diabetes management and teaching and counselling. DSNs new to their post are required to undertake have undertaken a diabetes diploma and/ or be working towards or have a related degree.  Senior DSNs should have worked for a minimum of three years as a DSN and are expected to be working towards, or already have a master’s degree.

Diabetes UK (Diabetes UK, 2019)  launched a framework (see Table 1)  to advise on standardising job titles, differentiate levels of practice, inform academic provision and provide a standardise approach to the development of diabetes-specific ÌÀÍ·ÌõÎÛÁÏ skills through competency assessment. 

Table 1: Diabetes Specialist Nurse job titles, minimum qualifications & competencies (Diabetes UK, 2019)

A collaborative approach between TREND-UK (Training, Research and Education for Nurses in Diabetes), Diabetes UK, WAND (Welsh Academy of Nurses in Diabetes), and representatives for DSNs and HEIs from England and Wales, has developed the competency framework. It incorporates diabetes-specific ÌÀÍ·ÌõÎÛÁÏ outcomes within a clear pathway for career development.

The framework defines the development of knowledge, skills and competence needed to support people living with diabetes. It is recommended that nurses provide evidence to demonstrate their level of knowledge, skill and current practice. It should also link to personal development and support re-validation ensuring it is in line with the Nursing and Midwifery Council view of competence and skills.

From the Diabetes UK DSN workforce survey (Diabetes UK, 2016); 99% said that they have a lot of autonomy in their role, with 89% delivering nurse-led clinics, around half trained as nurse prescribers and a quarter providing professional leadership in the role of lead nurse. The survey (Diabetes UK, 2016) also showed a highly-committed workforce under immense pressure as demand for diabetes services rises without a corresponding increase in DSN numbers. 39% consider their current caseload unmanageable and 78% have concerns that their workload is having an impact on patient care and/or safety. 57% will be eligible to retire from the profession within 10 years or fewer. Over the same time period the number of people in the UK with diabetes is expected to increase by at least 700,000 (Diabetes UK, 2020).

Recommended staffing levels and core responsibilities for DSNs were first stated by the British Diabetic Association (BDA) in 1985. The later recommendations from the BDA (1999) stated that there should be “at least a minimum of four whole time equivalent DSN’s per 250,000 population. This was updated again in 2014 to a minimum of five whole time equivalent DSNs per 250,000 populations in a joint position statement from Diabetes UK, TREND-UK and the ÌÀÍ·ÌõÎÛÁÏ (Diabetes UK et al, 2014). It didn’t recommend the banding or skill mix to make up DSN workforce or acknowledge the percentage of people diagnosed with diabetes in that population.

Key messages

• DSNs work wholly in diabetes care and may be employed in primary or secondary care, or in both.
• The title of DSN should only be used if a practitioner has the appropriate qualifications, skills and competences aligned to the Knowledge and Skills Framework (NHS Employers 2019)  and specific diabetes competencies in the Career and Competency Framework for Nurses in Diabetes (TREND-UK, 2019).

References

• British Diabetic Association (1999) Recommendations for the Structure of Specialist Diabetes Care Service. London: British Diabetic Association
• Diabetes UK and NHS Diabetes (2011) Commissioning Specialist Diabetes Services for Adults with Diabetes. A Diabetes UK Task and Finish Group Report.October 2010
• Diabetes UK (2016)
• Diabetes UK (2019)  
• Gosden C, James J, Anderson U, Morrish N (2010) UK workforce survey of DSNs and nurse consultants. Journal of Diabetes Nursing (14): 250–7
• Hicks et al (2012) Evaluation of nurse consultant-led intermediate diabetes care services in England. Practical Diabetes; 29 (2): 54 – 57
• RCN, TREND-UK, Diabetes UK (2014)
• TREND-UK (2019)

Advanced preparation of insulin syringes for adult patients to administer at home - RCN guidance for nurses 

The RCN views the practice of pre-loading insulin as necessary for the small minority of  patients unable to use insulin pen devices, and should only be considered after all other options have been exhausted.

There are potential legal and safety complexities associated with the practice of pre-loading insulin syringes in order to enable people to self-administer in their own homes that health care practitioners must be aware of.

Firstly, the preparation of pre-loaded syringes represents a form of secondary dispensing which, under the terms of the Medicines Act (1968), is classified as an unlicensed activity in all four UK countries. Consequently, health care organisations and practitioners must take full responsibility for the safety of this activity.

Secondly, the safety of individuals using preloaded insulin syringes, as well as the storage, stability and sterility of insulin once drawn up in the syringe, is of paramount importance (Rosindale, 2014).

For this reason the RCN recommends that nurses should operate within the framework of a local pre-loaded insulin syringe clinical policy which details the responsibilities of every individual involved in the practice (employing organisation/patient/GP/community nurse) and standardises how nurses perform the preparation of syringes (essential to assure vicarious liability protection for nurses undertaking this practice). Health care organisations and practitioners are also directed to review the Royal Pharmaceutical Society’s Professional Guidance (2018).

An overview of the local framework requirement is outlined in Rosindale (2014) and an example insulin syringe clinical policy document can be found in the appendix on page 29 of this publication.

The policy, which should be regularly updated by a local diabetes lead nurse and the medicines management team, should contain a clearly defined standard operating procedure to guide and support local health care practitioners.

Guidelines

Introduction

This guidance has been updated and replaces previous guidance. Developed for ÌÀÍ·ÌõÎÛÁÏ practitioners working in a variety of settings, this publication highlights the professional,  organisational and safety issues that must be addressed when pre-loading insulin syringes for later use by a person with diabetes.

Professional consensus statements

Prior to updating these guidelines, the RCN working group undertook an exercise to evaluate the views of senior diabetes nurse specialists and draw on their professional  expertise in the development of these recommendations.

The findings of the consensus statement exercise revealed a significant variation of understanding in relation to the professional risks and legal issues surrounding the practice of pre-loading insulin syringes: just 20 per cent of respondents knew the practice of pre-filling an insulin syringe was outside the Medicines Act, and only 20 per cent were aware that pre-loading insulin syringes is not considered to be best practice.

The consensus participants were, however, clearly in agreement on the imperatives relating to patient safety.

They agreed strongly that:

• only registered nurses should be involved in pre-loading insulin syringes
• patients must have capacity for this practice to be considered
• full patient training and education must be provided
• ÌÀÍ·ÌõÎÛÁÏ staff cannot undertake this practice if there is no organisational policy in place.

The consensus statement exercise provided the group with an invaluable snapshot of the state of knowledge on this topic, highlighting why the re-issue of this updated guidance is both timely and necessary. The responses revealed how the practice of pre-filling insulin syringes has become so embedded in every day practice that it is often considered normal by many health care organisations and their employees.

It is hoped that these guidelines will prompt a reevaluation and discussion of the issues involved while ensuring that appropriate steps are taken to protect all concerned: patients, ÌÀÍ·ÌõÎÛÁÏ staff, and employers.

Context: a growing issue

In recent years the arrival of innovative insulin delivery devices means more people with diabetes have been able to find an insulin pen that suits their needs, reducing the number of people requiring pre-loaded insulin syringes. 

However, there remains a small number of people who will not or cannot use an insulin pen for a variety of reasons: poor manual dexterity; visual impairment; an inability to find a pen device that suits their needs; or a reluctance to make the change from the standard insulin injection syringe they are familiar with (Rosindale, 2014).

As a result, these patients will be unable to autonomously inject once or twice a day and, consequently, will require ÌÀÍ·ÌõÎÛÁÏ support to pre-load the insulin syringes they use in order to maintain their independence. The RCN is aware that the potential number of people requiring such support in the community is likely to increase for two reasons: 

• the number of people with Type 2 diabetes that require insulin treatment is growing: over the past two decades the number of people with diabetes in the UK has more than doubled, from 1.4 million in 1996 to 4.5 million in 2016 (Diabetes UK, 2016)
• Diabetes UK estimates that by 2025, 5.2 million people will have diabetes: most of these cases will be Type 2 diabetes because of the ageing population and the rapidly rising number of overweight people (Diabetes UK, 2016).

The preparation of insulin injections by community nurses for patients to administer in their own homes at a later time has been the practice for many years. Preserving an individual’s convenience and independence, the practice reduces the risk of hypoglycaemia and, by enabling people to administer their insulin at the correct time in relation to meal times, releases ÌÀÍ·ÌõÎÛÁÏ time and resources.

Anecdotally, the practice of pre-loading insulin syringes for people with diabetes to administer themselves has taken place satisfactorily for decades. However, there are no national guidelines currently in place to support this practice (Rosindale, 2014).

The RCN believes the practice of pre-loading insulin syringes should only be considered when all other options to enable patients to self-manage have been exhausted – such as the introduction and use of an insulin pen device.

This guidance outlines the key considerations and essential elements that should be in place when the only alternative is to undertake the advanced preparation of insulin syringes for adult patients to administer at home.

Issues relating to prescribing and medicines management are a leading cause of cases being referred to the NMC for consideration of fitness to practise proceedings against nurses and midwives. Following these guidelines should ensure that nurses avoid finding themselves in a position where they are referred to the NMC for inadvertent or deliberate breaches of medicines management standards. These guidelines therefore provide an essential tool for nurses who work in the treatment of adult diabetics.

Summary of professional issues

The act of pre-loading an insulin syringe is considered a form of secondary dispensing which is not covered by the terms of the Medicines Act (1968). In essence, the act of pre-loading an insulin syringe creates an unlicensed product.

This is an important legal consideration that needs to be taken into account by health 
care professionals and employers. If something were to go wrong, it is the nurse who 
prepares a preloaded insulin syringe outside the bounds of the Medicines Act that would 
be liable (Rosindale, 2014).

These points have significant implications for community nurses. While the pre-loading of insulin syringes is considered to be common practice, ultimately, it is the nurse who is professionally accountable for this action.

For this reason the RCN recommends that, for their own legal protection, nurses must  operate within the requirements of a local policy/protocol for the pre-loading of insulin syringes for patients to administer at home. Therefore, a local policy must be in place to ensure that nurses benefit from vicarious liability, in which the employer takes full responsibility for the safety of this activity.

The pre-loading of insulin syringes should only be undertaken by registered nurses; this 
activity cannot be devolved to health care assistants.

Protecting the safety of an individual with diabetes is of paramount importance. In 2010, the National Patient Safety Agency (NPSA) issued two rapid response reports (NPSA, 2010a; NPSA 2010b) highlighting the potential errors that can occur in relation to insulin  administration: omitted doses, delayed doses and inappropriate use of non-insulin syringes. However, no harm to patients was reported between 2005 and 2013 as a result of using this method (Rosindale, 2014).

Before preparing to pre-load insulin syringes for adults with diabetes to administer at home, the RCN therefore recommends the following:

Ensuring that there is an organisation-wide policy in place covering the use of pre-loaded insulin syringes; this is essential for your protection and the protection of patients (see Appendix 1 for an example policy document).

• Patients must be assessed and have full capacity for this practice to be considered and patient capacity must be routinely and frequently re-assessed (as per local policy).
• A senior diabetes specialist nurse (SDSN) must be involved in the initial patient assessment; this risk assessment should be updated on a regular basis (as per local policy).
• Comprehensive training on pre-drawn insulin for self-administration must have been undertaken.
• A patient care plan must be in place.
• A quality assurance plan must be in place (as per local policy) which is overseen by your local SDSN.
• The patient’s GP is aware, understands and is in agreement that prescribing pre-loaded insulin syringes has associated medical-legal issues, and that there is a policy in place to support this process.

Patient requirements

A number of essential elements need to be checked when assessing an individual with diabetes who requires pre-loaded insulin syringes. At a minimum the patient must:

• have Level 3 mental capacity, as defined by the Mental Capacity Act (2005)
• accept full responsibility for the storage and administration of the insulin-filled syringes
• be assessed to confirm they cannot use any other first-line licensed alternative (such as an insulin pen device)
• receive full training and education in their specific medication (dose, frequency of injections, time/action profile), resuspending the pre-loaded syringe, injection technique and rotation of relevant injection sites
• be able to describe the signs, symptoms and treatment of a hypoglycaemic event
• know who to contact should they encounter any problems between visits.

Registered nurse requirements

To benefit from vicarious liability protection, the registered nurse must adhere to the requirements of their local policy for the pre-loading of insulin syringes.

At a minimum, the nurse must:

• always involve the senior diabetes specialist nurse (SDSN) in each patient case
• undertake an initial, and regularly update, a patient risk assessment (as per local policy)
• never delegate the pre-loading of insulin syringes to a health care assistant
• ensure syringes and storage boxes are clearly labelled with content (drug name, dose), time and date of preparation, and patient’s name (as per local policy)
• ensure the patient is educated on their medication, what they are taking and why they are injecting insulin
• ensure patients understand that pre-loaded syringes are their responsibility and are not the responsibility of their carer
• ensure the patient is trained in the correct injection technique (and is still capable of self-injecting), the rotation of sites, the safe storage of insulation and the disposal of sharps
• ensure the patient has a contact number for any problems between visits.

Storage conditions for pre-loaded insulin

In relation to the storage, stability and sterility of pre-loaded insulin syringes in the home, studies have shown these can remain stable and sterile at refrigerator temperatures for up to 28 days (Rosindale, 2014).

Pre-loaded insulin syringes should be stored in the main part of the refrigerator at between 2ºC and 8ºC, and should not be placed in the freezer or at the back of the refrigerator. The needle should point upwards in mixtures containing isophane insulin to prevent blockage by suspended substances in the insulin (Rosindale, 2014).

Lantus (Glargine) or Abasglar (biosimilar Glargine) are unsuitable for use in pre-loaded syringes as it will become turbid (cloudy). Tresiba and Toujeo are also not suitable and should not be drawn from the cartridge or the pre-filled pen into a syringe as it is available in different doses and can overdose the patient.

Syringes should be stored in a sealable container, and both syringes and container should be clearly labelled. If the patient is required to administer insulin more than once per day (for example, prior to eating breakfast, and again, before the evening meal) there should be a separate container for each administration time – even if the doses that are utilised are the same.

Syringe label

The syringe label should contain the following information:

• date and time of preparation
• patient’s name
• name of insulin
• the dose (in number of units)
• the time the insulin injection should be administered
• initials of the registered nurse who prepared the syringe.

Sealable container label

The sealable container label should contain the following information:

• date and time of preparation
• patient’s name and address
• the name of the insulin preparation
• the dose (in number of units)
• administration instructions; for example, just before or 30 minutes before food, at times 
• agreed with the patient and documented in the ÌÀÍ·ÌõÎÛÁÏ notes
• the number of syringes prepared and left in the container
• the signature of the registered nurse who prepared the syringes.

Separate containers should be used for insulin that is to be delivered at different times of the day.

Whether to re-suspend pre-loaded insulin before injection 

If the pre-loaded dose contains isophane insulin or is a cloudy insulin, the syringe should be gently rotated ‘back and forth’ between the hands at least 20 times until the insulin is uniformly suspended before injection. This also warms the insulin, which is important because injecting cold insulin can be painful and is less effectively absorbed.

Potential patient problems

If morning and evening doses are different, it is possible that the two doses may become confused, particularly if the patient has poor vision.

This should be addressed by the community nurse when assessing a patient’s capabilities and circumstances. Ways of overcoming this risk include the use of different shaped boxes for storage, which should be clearly marked to differentiate each dose.

A further potential problem is the accidental wastage of insulin through spillage or the dropping of a syringe, and community nurses should ensure that patients know who to contact if this happens.

Finally, doses could be self-administered at too close or too long an interval. To minimise this risk, the community nurse should regularly assess the patient’s understanding of their regimen and routine.

Nursing professionals are responsible for overseeing every aspect of patient safety, which should include the provision of education, support and insulin safety awareness training (including infection control and how to test blood glucose levels).

Disposing of syringes after use

Patients should be provided with yellow sharps boxes to dispose of syringes. These are available on prescription or through the local council, and should be returned in accordance with local guideline on clinical waste management.

Summary of key points

Community nurses are under increased pressure to undertake the pre-loading of insulin syringes for people with diabetes to administer at home.

The rising numbers of people with Type 2 diabetes, combined with an ageing population demographic, means the number of people unable to utilise a pen device due to dexterity or other reasons, is growing. Furthermore, in the current economic climate, there is also a potential for the use of pre-loaded insulin syringes to be abused in an attempt to generate perceived efficiencies by reducing community nurse visits/time.

The RCN considers the pre-loading of insulin syringes not to be best practice, and recommends that the use of licensed first-line injection devices (such as an insulin pen) should be promoted to enable patient self-management.

The RCN advises that:

• the pre-loading of insulin into a syringe for use by the patient at a later date must be seen as the final option, and should only be considered when all other options have been exhausted
• pre-preparing insulin syringes is an unlicensed activity that falls outside the Medicines Act (1968): practitioners and health organisations must take responsibility for the safety of this activity
• an organisation-wide policy/protocol on the pre-loading of insulin syringes for patients must be in place; this is essential to ensure patient safety and provide nurses with legal protection through vicarious liability
• the policy/protocol must set out responsibilities for all parties concerned and set out an agreed standard operating framework for every aspect of the practice (patient education, storage, labelling, monitoring of diabetes control and wellbeing etc)
• the specialist diabetes service/a senior diabetes specialist nurse lead must be involved in the preparation of the organisational policy, the initial patient risk assessment, and ongoing quality assurance to ensure policy adherence.

Consensus statement and methodology

View the Consensus statement and methodology.

References

• Diabetes UK (2016)
• National Patient Safety Agency (2010a) Rapid response report: reducing harm from omitted and delayed medicines in hospital, London: NPSA.
• National Patient Safety Agency (2010b) Rapid response report: safer administration of insulin, London: NPSA.
• Parliament (1968) Medicines Act 1968, London: Stationery Office.
• Parliament (2005) Mental Capacity Act 2005, London: Stationery Office.
• Rosindale S (2014) Pre-loading of insulin syringes for people with diabetes to administer at home: new solution to an old practice, Diabetes and Primary Care, 16 (3), pp.137-142.
• Royal Pharmaceutical Society (2018)

Acknowledgements

The RCN would like to thank everyone who contributed to the review and development of this fourth edition.

Samantha Kelly (nee Rosindale), lead author, Diabetes Nurse Consultant for Merton & Wandsworth, Central London Community Healthcare NHS Trust.

Jo Reed, reviewer, Renal Diabetes Specialist Nurse, Imperial College Healthcare NHS Trust

Samantha and Jo are both committee members of the RCN Diabetes Forum.

Case study 1 - Mrs Patel

Mrs Patel is an 89-year-old widow. She has been living in a ÌÀÍ·ÌõÎÛÁÏ home for the past two years because her family have been unable to cope with her ÌÀÍ·ÌõÎÛÁÏ needs following a stroke in 2012, which has affected her right side and her speech. Mrs Patel is unable to manage the normal activities of daily living. She was diagnosed with type 2 diabetes 20 years ago. Mrs Patel had taken a great interest in her diabetes when she was able to but since having the stroke and the death of her spouse in 2013, she has not been able to participate in her own personal and diabetes care.

Over time Mrs Patel has become increasingly frustrated because she is unable to communicate how she is feeling, or what her needs are. Mrs Patel is on Gliclazide 80 mgs twice daily and metformin 1gm twice daily. You notice that Mrs Patel is off her food and has had very little to eat that day. The nurse in charge has given Mrs Patel her medication as prescribed at 10 am. At 2pm you notice Mrs Patel is sweating profusely, she is pale and appears to be drowsy but responds to her name.

You consider the signs and symptoms you are faced with and wonder whether Mrs Patel’s blood glucose level is ok. You inform the nurse in charge of Mrs Patel’s condition and confirm with her that you will do a blood glucose test (based on your level of competence) and take the 'hypo' kit to the bedside in case the blood glucose is less than four.

Following the capillary blood glucose test you discover that Mrs Patel’s blood glucose is 2.4mmols.

What steps do you take next?

1. Record the blood glucose level on the Mrs Patel’s chart and report the result to a registered member of the staff when you have finished with your other patients
2. Record the blood glucose level on the Mrs Patel’s chart and report the result to a registered member of the staff immediately
3. Immediately inform a registered member of staff.

The correct answer is Option 2.

Feedback: You need to write down the glucose level so that there is a record, but this is an emergency so you must act very quickly to prevent Mrs Patel’s lapsing into a hypoglycaemic coma. Inform a registered member of staff immediately.

What is the clinical term for a low blood glucose?

1. Hypoglycaemia
2. Hyperglycaemia

The correct answer is Option 1.

Feedback: Hypoglycaemia (hypo) is described as a blood glucose < than 4 mmols. Glucose is a sugar carried in the blood stream that your body uses for energy. Blood glucose can be erratic at times, sometimes becoming very low when medication is taken and food is restricted or the patient is off their food.

As Mrs Patel is still conscious and responding to her name, and her swallowing reflex is intact you would aim to treat her hypo following the guidelines for the management of hypoglycaemia in the ÌÀÍ·ÌõÎÛÁÏ home. Can you remember what the recommended treatments for hypoglycaemia are?

Feedback: Recommended treatments for hypoglycaemia:

• 10-20g glucose give by mouth
• or five jelly babies,
• or three glucose or dextrose tabs,
• or a small glass of sugary (non-diet) drink
• or a small carton of pure fruit juice
• or two tubes of a glucose gel such as GlucGel®.

If Mrs Patel does not feel better and the blood glucose is still less than than 4 mmols after 10-15 minutes repeat one of the above treatments again. When Mrs Patel starts to feel better it is advisable to give some longer-acting carbohydrate such as 1 slice of bread or 2 biscuits. Providing sustained carbohydrate will minimise further falls in blood glucose.

What was the cause of Mrs Patel’s hypoglycaemia?

1. she has not eaten because she was off her food
2. she had a sickness virus that meant she was not eating
3. she was given her Gliclazide tablets at 10 am but she had not eaten because she had reduced appetite. Gliclazide stimulates the pancreas to produce insulin thus causing Mrs Patel to have hypoglycaemia.

The correct answer is Option 3.

Feedback: Mrs Patel was given her Gliclazide tablets at 10 am but she had not eaten because she had no appetite. Gliclazide stimulates the pancreas to produce insulin thus metabolising more glucose, reducing the circulating blood glucose levels, causing Mrs Patel to have hypoglycaemia.

You also need to be aware that Mrs Patel needs to be assessed to identify the reason for her reduced appetite. She may require a medication review because Gliclazide may not be the best medication for an elderly woman. Her kidneys may not be functioning properly, reducing the excretion of the medication beyond what the manufacturer’s specifications.

The signs and symptoms of hypoglycaemia were that Mrs Patel was sweating heavily and appeared pale.

The other signs and symptoms of hypoglycaemia are feeling anxious, trembling and shaking, tingling of the lips, hunger and palpitations

How would you prevent Mrs Patel from getting hypoglycaemia in the future?

• monitor and record Mrs Patel's fluid and food intake
• report and record any changes in eating habits to nurse in charge
• Mrs Patel may need feeding as she has difficulty with the activities of daily living
• test and record Mrs Patel’s blood glucose as prescribed by the team
• report any abnormal readings to nurse in charge
• be aware that Mrs Patel will need further assessment as to the reasons why she has a reduced appetite. For example, Mrs Patel may be feeling depressed and lonely because she lost her husband
• she may feeling generally unwell for other reasons
• Mrs Patel may require a medication review.

Feedback: All of these ways are correct.

What other factors may you consider when caring for Mrs. Patel that are relevant to management of her diabetes?

• fear and anxiety of hypoglycaemia
• hypoglycaemia unawareness
• lack of mobility and exercise
• always have glucose at Mrs. Patel’s bedside
• reasons for poor eating habits
• constipation or obstruction
• illness
• ill fitting dentures or poor oral hygiene.

Feedback: All of these ways are correct.

Case study 2 - Mary

Mary, 74 years old, lives in a ÌÀÍ·ÌõÎÛÁÏ home. She has had type 2 diabetes for 15 years and in addition to Metformin and Gliclazide takes insulin before bed to control her diabetes.
You have worked at the home for six months and have got to know Mary fairly well. Usually when her blood glucose levels are taken they range between 7 and 13mmol/l.

You are aware that the GP responsible for Mary's care is anxious to improve her blood glucose as much as possible because Mary has leg ulcers that are slow to heal. You have recently been trained to monitor blood glucose levels and have been assessed as competent. On this particular evening you monitor Mary's blood glucose level before her evening meal and the result is 21.4 mmol/l.

What do you do?

1. You know that this reading is unusually high for Mary and wonder what the cause could be. In order to reassure yourself that the test is accurate you check that the blood glucose meter had had the quality assurance check that it should have each day that it is in use as stated in the homes policy. You check the record book and find that the meter had indeed been checked and was reading within the expected target range. You know that you had washed Mary's hand before you had performed the test and so you are certain that the result is as accurate as can be.
2. You know that it is important to keep Mary's levels as good as possible in order to help her leg ulcers to heal. When dealing with Mary you are aware that she is her usual chatty self. There is nothing unusual about her appearance in this particular evening and she has not complained about feeling unwell. You ask her how she is feeling and she reports nothing that would suggest her high blood glucose result is a problem.

The correct answer is Option 1.

Feedback: You should make sure that this meter has been checked each day that it has been used and in line with local policy. If the meter is functioning correctly, then you would report this reading to the nurse in charge as it is outside the normal range. You would also report that Mary is her usual self and not reporting any of the symptoms of high glucose levels. The nurse in charge should then go and review Mary herself.

The symptoms of a high blood glucose level are:

• increased thirst
• feeling tired and unwell
• skin rash
• vomiting
• passing lots of urine.

Mary reports none of these symptoms.

You ask Mary if her day had been unusual in any way that may have led to this high result. Mary tells you that it was her Granddaughter’s birthday and that she had been taken out for lunch by her family. The lunch was much larger than she would usually have eaten and she had had a small piece of birthday cake.

Below are some causes for high blood glucose level. Which do you think explains Mary's increase in her blood glucose level?

1. more food than normal
2. illness
3. infection
4. less exercise than usual
5. forgotten medication.

Feedback: Mary had more food than normal, some of which was sugary.

What are the consequences of a high blood glucose level?

If blood glucose levels are consistently high over a period of time they can leads a person to feeling unwell with the symptoms listed above. In addition they can delay healing if as in Mary’s situation, there are leg ulcers or wounds for example if the person was recovering from surgery. If glucose levels remain high in the very long term they can lead to the development of diabetes complications for example, eye disease, kidney disease, heart disease, peripheral vascular disease, neuropathy and increase your risk of a heart attack, stroke or amputation.

The reason for the raised blood glucose result here is the change in Mary’s daily routine. She does not feel unwell from this high glucose level. You report the high result to the nurse in charge and explain what you feel the reason for it may be. The nurse in Charge decides to re check Mary’s glucose levels during the evening and before bed. This additional testing is to monitor that the levels are returning to more normal limits for Mary and to check that the levels are not rising further. At this point, because Mary is not feeling the effects of this raised result, the nurse in Charge makes the decision not to inform the GP at this point but to continue monitoring the situation. The GP will be informed if the glucose levels rise further or if they do not return to levels more usual for Mary.

Case study 3 - Jason

Jason is 19 years old and lives in student accommodation in the city. He comes into the surgery without having booked an appointment and asks to see the doctor or practice nurse because he is feeling unwell. The doctor is on visits and will be back soon, and the practice nurse is doing the baby vaccine clinic so is really busy. The receptionist asks if you can see him while he is waiting.

You can see that Jason looks unwell. He is a little flushed, looks very skinny and says he is a little breathless. He tells you that over the past couple of weeks he has been really thirsty and has lost over a stone in weight. He was underweight before he became unwell and is now worried because his clothes don’t fit anymore. Jason gets up at night to pass urine almost every hour but attributes this to the fact he is drinking copious amounts of water as he is so thirsty and his vision is blurred.

You wonder what could be the matter and in order to reassure Jason about his weight you decide to weigh him. You check his records and find that when he registered at the surgery when he started college his weight was 11 stone 10 lbs he now weighs 10st 9 Ibs.

What do you suspect could be the cause?

1. he is not eating healthily
2. he is probably drinking too much
3. urine Infection.

The correct answer is Option 3.

Feedback: His symptoms and his frequency of micturition could be due to a urine infection.

What tests can you do to confirm this?

1. urine test
2. blood pressure test
3. blood test.

The correct answer is Option 1.

Feedback: A dip stick urine test will show if there is blood present and quantify it and it will show if there are leukocytes present, these are white blood cells and are high when infection present, as we make white blood cells specifically to fight infections.

You decide to do a urine test in case his frequency of micturition is due to a urine infection. You ask him to provide a urine sample which you dip test using a urine test strip. This shows that he has a very high level of glucose and ketones in the urine and he is not known to have diabetes.

What do you do next?

1. You have been trained to use this and regularly help out in the diabetic clinic so you think he probably has undiagnosed diabetes.
2. You explain to Jason that as the nurse is still busy it might be useful to check his blood glucose reading as the urine has shown positive to glucose. He agrees so you do a quality control test on the meter first as you know it should be checked on a daily basis. He washes his hands to ensure there is no glucose on the fingers and then you do the test. The reading shows a blood glucose of 28.3 mmol/l.

The correct answer is Option 2.

Feedback: Yes, if you have been trained to do a blood glucose test, then you can test Jason to confirm your suspicions. A trained nurse may confirm their suspicions - an unregistered nurse should not discuss the implications of the test with Jason.

What is the diagnostic level for the confirmation of diabetes?

1. Fasting plasma glucose of more than 7.0 mmol/l or a random plasma glucose of more than 11.1 non fasting
2. Fasting plasma glucose of less than 7.0 mmol/l or a random plasma glucose of less than 11.1 non fasting
3. Fasting plasma glucose of more than 5.0 mmol/l or a random plasma glucose of more than 9.0 non fasting.

The correct answer is Option 1.

Feedback: The diagnostic level for confirmation of diabetes is a fasting plasma glucose of more than 7.0 mmol/l or a random plasma glucose of more than 11.1 non fasting. Usually 2 laboratory tests need to be done but as Jasons blood glucose is very high and he has some of the common symptoms of type 1 diabetes there cannot be any doubt about the diagnosis ( see Diabetes UK for information on the diagnosis of diabetes).

What is the relevance of ketonuria in diabetes?

1. Ketones show that the patient is not following the correct diet and he should be given advice about how to correct this
2. Ketones can show which form of diabetes the patient has.
3. Ketones cause the body to become acidotic which can lead to critical illness. If insulin is not received in the next couple of hours his condition will deteriorate.

The correct answer is Option 3.

Feedback: Ketonuria is a sign of either an absolute or relative lack of insulin and confirms the diagnosis of type 1 diabetes when seen with heavy glycosuria. His breath may smell of ketones (pear drop or nail varnish aroma) but not all people can detect this. Ketones are toxic and if the patient does not receive insulin in the next couple of hours his condition will deteriorate quickly and he could become very nauseated or vomit. High levels of ketones can cause the individual to become acidotic so his breathing could become laboured and he could go into coma.

What is the relevance of his thirst and polyuria?

1. His body is trying to quickly remove the excess glucose by filtering it through the kidneys, so he passes copious amounts of urine. He also becomes really thirsty but will be unable to maintain his fluid balance so he has become extremely dehydrated
2. It is the concentration of certain osmolites, such as salt. If the water volume of the body falls below a certain threshold or the osmolite concentration becomes too high, then the brain registers a need 'thirst'. His body has excess salt which has triggered his thirst and he needs to increase his intake of fluids to balance the levels.

The correct answer is Option 1.

Feedback: His body is trying to quickly remove the excess glucose by filtering it through the kidneys, so he passes copious amounts of urine. He will be unable to maintain his fluid balance so will become extremely dehydrated.

What should do you do next?

1. He needs to be given glucose immediately and told to rest.
2. He needs to be given insulin immediately.

The correct answer is Option 2.

Feedback: The young man will need to be given insulin as soon as possible will need to be admitted to hospital as an emergency for initial management and may even require intravenous insulin and intravenous fluids to correct the acidosis and dehydration. Report your findings to the registered nurse immediately – she should call the GP straight away and explain the situation.