We continue our series highlighting recent presentations from Diabetes Nurses, Nursing in Practice 365 events. anwen jones Provides up-to-date information on key principles of diabetes management in primary care.

the current, An estimated 5.8 million people live with diabetes in the UKOf these, 90% are diagnosed with type 2 diabetes, 8% with type 1 diabetes, and the remaining 2% with other, rarer forms of diabetes.

Although most diabetes management in primary care is related to type 2 diabetes, it is also very important for nurses in this setting to spot potential symptoms and signs of other types, such as type 1 diabetes and LADA (Latent Autoimmune Disease in Adults), to ensure timely diagnosis and treatment.

Diagnosis – Keep all forms of diabetes in mind

Diagnosing diabetes quickly and correctly is important for both the physical and mental health of affected individuals. It provides access to the right medications and a clear focus on the way forward. Accepting a diagnosis can help individuals take responsibility for their condition, self-manage, and improve their overall health.

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type 2 diabetes

Symptoms include excessive urination, excessive drinking, recent unexplained weight loss, fatigue, and slow wound healing. Type 2 diabetes is diagnosed when HbA1c from venous blood is 48 mmol/mol or higher. Consider any conditions that negatively impact red blood cell production and life cycle, as HbA1c can be inaccurate. For example, severe iron deficiency anemia or recent blood transfusions will give inaccurate HbA1c results.

type 1 diabetes

Children or adolescents with random blood glucose levels >11 mmol/L should be considered for type 1 diabetes. This requires same-day emergency testing by a diabetes specialist team. Symptoms include excessive urination, excessive drinking, recent unexplained weight loss, and fatigue.

Lada

This form of diabetes can develop later in life and is often misdiagnosed as type 2 diabetes. Similar to type 1 diabetes, it is an autoimmune disease that requires insulin therapy to treat high blood sugar levels, but it progresses slowly.

HbA1c levels are greater than 48 mmol/mol and may be asymptomatic or present with symptoms such as polyuria, polydipsia, recent unexplained weight loss, and fatigue. It can be initially misdiagnosed as type 2 diabetes because the symptoms are similar, but glucose response to oral medications is slow and insulin therapy is required to improve glycemic control.

Clinicians should be aware of LADA and consider it for people who have co-existing autoimmune diseases such as hypothyroidism, are over 30 years of age and are not overweight, have a family history of diabetes, or have been diagnosed with type 2 diabetes but whose blood sugar levels continue to rise despite well-matched oral medications and lifestyle.

Because the diagnosis of LADA involves testing for glutamate decarboxylase (GAD) antibodies, nurses should follow local guidance for testing and referral.

Take a holistic approach to management

Management of type 2 diabetes should cover both hyperglycemia and cardiovascular protection. of NICE guidelines for the management of type 2 diabetes in adultscurrently being updated, ADA/EASD (American Diabetes Association/European Association for the Study of Diabetes) GuidelinesHere we will advise you on how to prescribe a class of drugs that addresses both.

The risk of hypoglycemia associated with some drugs must also be considered. You should be aware that HbA1c goals may be difficult for some people to achieve, and goals may not be realistic or desirable for everyone. It is important that the clinician performs a complete comprehensive assessment and collaboratively agrees on an HbA1c target with the patient after considering comorbidities, expectations, polypharmacy, and frailty. NICE guidelines for type 2 diabetes in adults recommend individualized targets, taking into account frailty and comorbidities. Note that HbA1c decreases with age. Becomes an inaccurate marker of true blood sugar levelsTherefore, in order for older adults to achieve the usual target HbA1c of 53 mmol/mol, their overall blood glucose levels must be lowered.

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communication is key

The annual review provides an opportunity to discuss any concerns and ensure that all screening tests were completed. Using appropriate communication styles, such as motivational interviewing, can strengthen an individual’s motivation and help identify personal goals.

It is important for clinicians to be aware of how they communicate both verbally and nonverbally during an examination. Make sure the consultation is collaborative and engaging, and avoid words like ‘compliance’ and negative comments. When patients are told to “work harder” or are threatened about “diabetes complications”, this can have a long-term impact on diabetes self-management.

Inadequate prior counseling experiences may leave patients with persistent negative impressions of diabetes and increase the likelihood of not attending future appointments.

Nurses play a critical role in supporting people with diabetes through evidence-based prescribing and open, collaborative and empowering consultation. This not only reduces the burden of disease on patients, but also reduces feelings of stigma.

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Important points

• Consider type 1 diabetes in a child or adolescent who presents with polyuria, polydipsia, unexplained weight loss, or lethargy.
• If drug therapy does not improve blood sugar levels as expected, consider the correct diagnosis for the individual – is it LADA?
• Consider cardiovascular protection when prescribing to reduce risk factors.
• Before agreeing to an HbA1c target, consider it holistically, taking into account other comorbidities and frailties.
• Use your language style appropriately during the consultation so that it has a long-term impact on the individual.
• Support and encouragement will be provided during annual evaluations to ensure all screening tests and care processes are completed.
• Promote education and clear communication to reduce the stigma associated with living with diabetes.

Anwen Jones is a Registered Practical Nurse (NMP) with a special interest in diabetes at Ceredigion.

Source and further information

• Type 2 diabetes in adults: management. [NG28] Last updated 2022
• Davis M et al. Managing hyperglycemia in type 2 diabetes, 2022. Consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). diabetes care2022;45(11):2753–86
• Dubowitz N et al. Aging is associated with increased HbA1c levels, independent of blood glucose and insulin resistance, and is also associated with decreased HbA1c diagnostic specificity.. Diabetic drugs 2014;31(8):927-35

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