DPCA1-3_full issue

Diabetes 

& Primary Care Australia 

Vol 1 No 3 2016 

The primary care diabetes journal for healthcare professionals in Australia 

Raising 

awareness of 

type 1 diabetes 

and DKA in 

children 

The authors cover the symptoms 

and diagnosis of type 1 diabetes 

and diabetic ketoacidosis (DKA), 

and discuss the importance of 

raising awareness among 

parents, carers and the 

community. 

Page 97 

IN THIS ISSUE 

CPD module 

A review of the latest evidence 

and recommendations in 

managing diabetes-related foot 

complications. Page 86 

Medicolegal experience 

A case report demonstrating 

the importance of note-taking 

in general practice. Page 94 

The low-carb debate 

Sunita Date considers the 

evidence for the low-carb diet 

in diabetes management. 

Page 101 

WEBSITE 

Journal content online at 

www.pcdsa.com.au/journal

Call for papers 

Would you like to write an article 

for Diabetes & Primary Care Australia? 

The new journal from the Primary Care Diabetes Society of Australia 

To submit an article or if you have any queries, please contact: gary.kilov@pcdsa.com.au. 

Title page 

Please include the article title, the full names of the authors 

and their institutional affiliations, as well as full details of 

each author’s current appointment. This page should also have 

the name, address and contact telephone number(s) of the 

corresponding author. 

Article points and key words 

Four or five sentences of 15–20 words that summarise the major 

themes of the article. Please also provide four or five key words 

that highlight the content of the article. 

Abstract 

Approximately 150 words briefly introducing your article, 

outlining the discussion points and main conclusions. 

Introduction 

In 60–120 words, this should aim to draw the reader into the 

article as well as broadly stating what the article is about. 

Main body 

Use sub-headings liberally and apply formatting to differentiate 

between heading levels (you may have up to three heading levels). 

The article must have a conclusion, which should be succinct and 

logically ordered, ideally identifying gaps in present knowledge and 

implications for practice, as well as suggesting future initiatives. 

Tables and illustrations 

Tables and figures – particularly photographs – are encouraged 

wherever appropriate. Figures and tables should be numbered 

consecutively in the order of their first citation in the text. Present 

tables at the end of the articles; supply figures as logically labelled 

separate files. If a figure or table has been published previously, 

acknowledge the original source and submit written permission 

from the copyright holder to reproduce the material. 

References 

In the text 

Use the name and year (Harvard) system for references in the 

text, as exemplified by the following: 

● As Smith and Jones (2013) have shown … 

● As already reported (Smith and Jones, 2013) … 

For three or more authors, give the first author’s surname 

followed by et al: 

● As Robson et al (2015) have shown … 

Simultaneous references should be ordered chronologically first, 

and then alphabetically: 

● (Smith and Jones, 2013; Young, 2013; Black, 2014). 

Statements based on a personal communication should be 

indicated as such, with the name of the person and the year. 

In the reference list 

The total number of references should not exceed 30 without prior 

discussion with the Editor. Arrange references alphabetically first, 

and then chronologically. Give the surnames and initials of all 

authors for references with four or fewer authors; for five or more, 

give the first three and add “et al”. Papers accepted but not yet 

published may be included in the reference list as being “[In press]”. 

Journal article example: Robson R, Seed J, Khan E et al (2015) 

Diabetes in childhood. Diabetes Journal 9: 119–23 

Whole book example: White F, Moore B (2014) Childhood 

Diabetes. Academic Press, Melbourne 

Book chapter example: Fisher M (2012) The role of age. In: Merson 

A, Kriek U (eds). Diabetes in Children. 2nd edn. Academic Press, 

Melbourne: 15–32 

Document on website example: Department of Health (2009) 

Australian type 2 diabetes risk assessment tool (AUSDRISK). 

Australian Government, Canberra. Available at: http://www. 

health.gov.au/preventionoftype2diabetes (accessed 22.07.15) 

Article types 

Articles may fall into the categories below. All articles should be 

1700–2300 words in length and written with consideration of 

the journal’s readership (general practitioners, practice nurses, 

prescribing advisers and other healthcare professionals with an 

interest in primary care diabetes). 

Clinical reviews should present a balanced consideration of a 

particular clinical area, covering the evidence that exists. The 

relevance to practice should be highlighted where appropriate. 

Original research articles should be presented with sections 

for the background, aims, methods, results, discussion and 

conclusion. The discussion should consider the implications 

for practice. 

Clinical guideline articles should appraise newly published 

clinical guidelines and assess how they will sit alongside 

existing guidelines and impact on the management of diabetes. 

Organisational articles could provide information on newly 

published organisational guidelines or explain how a particular 

local service has been organised to benefit people with diabetes. 

— Diabetes & Primary Care Australia —

Contents 

Diabetes 

& Primary Care Australia 

Volume 1 No 3 2016 

Website: www.pcdsa.com.au/journal 

Editorial 

Primary care should be seen and heard 78 

Gary Kilov introduces this issue, commenting on the role primary care can, and should, have in policy making for diabetes care in Australia. 

Meeting report 

Inaugural national conference of the Primary Care Diabetes Society of Australia 80 

Mark Kennedy summarises the sessions of the inaugural national conference of the Primary Care Diabetes Society of Australia held in 

Melbourne, Vic. 

From the desktop 

Registrar education on type 2 diabetes: Throwing them in the deep end and ensuring no one drowns 84 

Suzane Ryan shares tips and guidance for educating GP registrars in diabetes management. 

CPD module 

Prevention, screening and referral of people with diabetes-related foot complications in primary care 86 

Rajna Ogrin and Nick Forgione review the latest evidence and recommendations in managing diabetic foot complications. 

Articles 

Medicolegal case of a person with type 2 diabetes: Medical history 94 

Peter Hay presents a medicolegal case that demonstrates the importance of note-taking, especially when managing a person 

with type 2 diabetes on insulin who is non-compliant to treatment. 

Diagnosing type 1 diabetes and diabetic ketoacidosis in children 97 

Fergus Cameron, Gary Kilov and Ralph Audehm cover the symptoms and diagnosis of type 1 diabetes and diabetic ketoacidosis, 

and discuss the importance of raising awareness among parents, carers and the community. 

To carb or not to carb in diabetes management 101 

Sunita Date argues why we should be cautious in prescribing and advocating the low-carb diet. 

Editor-in-Chief 

Gary Kilov 

Practice Principal, The Seaport Practice, and Senior 

Lecturer, University of Tasmania, Launceston, Tas 

Editorial Board 

Ralph Audehm 

GP Director, Dianella Community Health, and 

Associate Professor, University of Melbourne, 

Melbourne, Vic 

Werner Bischof 

Periodontist, and Associate Professor, LaTrobe 

University, Bendigo, Vic 

Nicholas Forgione 

Principal, Trigg Health Care Centre, Perth, WA 

John Furler 

Principal Research Fellow and Associate Professor, 

University of Melbourne, Vic 

Mark Kennedy 

Medical Director, Northern Bay Health, Geelong, 

and Honorary Clinical Associate Professor, 

University of Melbourne, Melbourne, Vic 

Peter Lazzarini 

Senior Research Fellow, Queensland University of 

Technology, Brisbane, Qld 

Rajna Ogrin 

Senior Research Fellow, RDNS Institute, 

St Kilda, Vic 

Suzane Ryan 

Practice Principal, Newcastle Family Practice, 

Newcastle, NSW 

Editor 

Olivia Tamburello 

Editorial Manager 

Richard Owen 

Publisher 

Simon Breed 

© OmniaMed SB and the Primary Care 

Diabetes Society of Australia 

Published by OmniaMed SB, 

1–2 Hatfields, London 

SE1 9PG, UK 

All rights reserved. No part of this journal 

may be reproduced or transmitted in 

any form, by any means, electronic or 

mechanic, including photocopying, 

recording or any information retrieval 

system, without the publisher’s 

permission. 

ISSN 2397-2254 

Diabetes & Primary Care Australia Vol 1 No 3 2016 77

Editorial 

Primary care should be seen and heard 

Gary Kilov 

Editor of Diabetes & Primary Care 

Australia, and Director at Seaport 

Diabetes, Launceston Area, TAS, 

and Senior Lecturer at University 

of Tasmania, Launceston, TAS 

You are probably aware that the most 

recent incarnation of the Australian 

National Diabetes Strategy 2016–2020 

was launched on World Diabetes Day in 

November 2015. It can be downloaded and 

read at http://bit.ly/1XmWkGT (accessed 

12.05.16). The strategy aims to outline 

Australia’s national response to diabetes and 

inform how to best use the existing limited 

health care resources. 

The strategy was developed by representations 

from the Australian Health Ministers’ Advisory 

Council and the Council of Australian 

Governments (COAG) Health Council, and 

was informed by expert advice from the 

National Diabetes Strategy Advisory Group 

and key stakeholders. The Advisory Group was 

set up in 2014, and comprised research leaders, 

emeritus directors, presidents of national 

diabetes associations and Chief Executive 

Officers. After 18 months of consultation, 

they produced a report that identified areas for 

action to improve diabetes prevention and care 

(National Diabetes Strategy Advisory Group, 

2015). 

However, since the publication of the final 

National Diabetes strategy for 2016–2020, 

Professor Paul Zimmet, co-chair of the 

National Diabetes Strategy Advisory Group, 

and Professor Stephen Colagiuri, one of the 

other members of the Advisory Group, have 

raised concerns in the Sunday Morning Herald 

(http://bit.ly/27gzEwj; accessed 12.05.16). 

Both raise concerns at the alleged lack of 

response by government to implement the 

recommendations of the Advisory Group, 

and that there was “considerable evidence of 

selective editing out of the experts’ considered 

advice.” 

If this is true, diluting the recommendations 

or delaying the implementation of this report 

will adversely affect our ability to address the 

burgeoning deleterious impact of diabetes on 

the nation’s collective wellbeing and bank 

account. It would be very disappointing if the 

current review, expensive in time, effort and 

dollars, does not see the light of day, a fate that 

befell the Diabetes Strategy Report for 2000– 

2004 (Commonwealth of Australia, 2000). 

Primary care unseen and unheard 

Primary health practitioners involved in caring 

for people with diabetes often feel unheard and 

unseen by Government despite significantly 

outnumbering specialist colleagues and 

managing the majority of people with diabetes. 

In fact, the National Advisory Group, who 

developed the National Diabetes Strategy, 

included no GPs and only one diabetes 

educator. This is at the same time that primary 

health practitioners are expected to continue 

to bear the brunt of delivering the care, 

under-resourced and poorly supported. 

The PCDSA was formed out of recognition 

for the need for a united, collaborative 

approach to managing diabetes care and 

advocating for people with diabetes in the 

primary care environment. We would cherish 

the opportunity to work with Government 

and our esteemed colleagues to implement 

this strategy, and to contribute to ongoing 

strategies to prevent and manage diabetes in 

our society. 

We believe that if all health practitioners 

caring for people with diabetes are able to stand 

united in developing and implementing the raft 

of measures required to manage this enormous 

national priority, we will achieve far more 

than if we all continue to work in our existing 

fragmented and siloed environments. n 

Commonwealth of Australia (1999) National Diabetes Strategy 

2000–2004. Commonwealth Department of Health and Aged 

Care. Canberra, ACT. Available at: http://bit.ly/29gOyxO 

(accessed 12.05.16) 

National Diabetes Strategy Advisory Group (2015) A Strategic 

Framework for Action: Advice to Government on the 

Development of the Australian National Diabetes Strategy 2016- 

2020. Department of Health, Canberra, ACT 

78 Diabetes & Primary Care Australia Vol 1 No 3 2016

The PCDSA is a multidisciplinary society with the aim 

of supporting primary health care professionals to deliver 

high quality, clinically effective care in order to improve 

the lives of people with diabetes. 

The PCDSA will 

Share best practice in delivering quality diabetes care. 

Provide high-quality education tailored to health professional needs. 

Promote and participate in high quality research in diabetes. 

Disseminate up-to-date, evidence-based information to health 

professionals. 

Form partnerships and collaborate with other diabetes related, 

high level professional organisations committed to the care of 

people with diabetes. 

Promote co-ordinated and timely interdisciplinary care. 

Membership of the PCDSA is free and members get access to a quarterly 

online journal and continuing professional development activities. Our first 

annual conference will feature internationally and nationally regarded experts 

in the field of diabetes. 

To register, visit our website: 

www.pcdsa.com.au


Inaugural national conference of the 

Primary Care Diabetes Society of Australia 

University of Melbourne, Parkville Victoria, Vic, 30 th April 2016 

The inaugural national conference of the Primary Care Diabetes Society of Australia was held at the University of 

Melbourne on 30 th April 2016. We were delighted to welcome 170 attendees to the conference, comprising health 

professionals, exhibitors and students. 

Mark Kennedy (Honorary 

Clinical Associate Professor, 

Department of General 

Practice, The University of Melbourne, 

Melbourne, Vic, and Chair, PCDSA) 

welcomed all attendees to the 

conference and wished delegates an 

educationally engaging and rewarding 

conference experience. He highlighted 

the wonderful opportunities for 

learning presented by having attendees 

and speakers from such diverse areas of 

primary health care. 

Sir Michael Hirst 

Diabetes and obesity: Changing the 

paradigm, a whole community problem 

needs a whole community solution 

Sir Michael Hirst, Past President, International 

Diabetes Federation, Scotland, UK 

Kicking off the conference was 

a passionate call to arms by 

Sir Michael Hirst to address the 

accelerating rates of obesity and 

diabetes in Australia. He explained how 

the new Global Diabetes Scorecard 

(www.idf.org/global-diabetes-scorecard/) 

can be used to track nations’ 

progress for action on diabetes, 

hold governments to account and 

set a baseline for future monitoring. 

Thirty-seven countries, including 

Australia, have agreed to adopt the 

global monitoring framework. We as 

health professionals have a key role in 

addressing the diabetes crisis, hopefully 

averting the appalling prospect raised 

by the World Health Organization 

(WHO) that without such intervention, 

today’s children may be the first 

generation in recorded history who 

have a shorter life expectancy than their 

parents. 

Following Sir Michael’s talk we were 

honoured to have speakers from the 

fields of endocrinology, psychology, 

general practice, obesity research 

and allied health to provide practical 

insights to assist us provide evidencebased 

care to our patients with 

diabetes. 

Diabetes diagnosis – HbA 1c 

Professor Peter Colman, Director, Department 

of Diabetes and Endocrinology, Royal 

Melbourne Hospital, Melbourne, Vic 

Professor Peter Colman explained the 

rationale of using HbA 1c 

as a diagnostic 

test for diabetes, as well as the appropriate 

population groups who should be 

considered for HbA 1c 

test screening and 

its limitations. 

Practical take-home messages 

l It is not recommended that we 

consider those with an HbA 1c 

between 

42–46 mmol/mol (6.0–6.4%) as 

“pre-diabetic”, but that those in 

that group may have an increased 

risk of cardiovascular disease. 

l HbA 1c 

provides a better index of overall 

glycaemic exposure and risk of longterm 

complications with substantially 

less biologic variability and pre-analytic 

instability than fasting glucose or 

oral glucose tolerance testing. 

l While an HbA 1c 

value of 48 mmol/mol 

(6.5%) is recommended as the cut-off 

point for a diagnosis of diabetes, 



a value of less than 48 mmol/mol 

(6.5%) does not exclude a diagnosis 

of diabetes using other tests. 

Engaging people with non-insulintreated 

type 2 diabetes in selfmanagement: 

Taking a structured 

approach to glucose monitoring 

Professor Jane Speight, Foundation Director, 

The Australian Centre for Behavioural 

Research in Diabetes, Melbourne, Vic 

Professor Jane Speight outlined 

a number of strategies for better 

engaging people with diabetes in selfmanagement. 

In the midst of the current 

controversy surrounding funding 

for self-monitoring of blood glucose 

(SMBG), she explained that, although 

SMBG is costly, it is less costly than 

treating diabetes complications. She 

pointed out that unstructured SMBG 

is random, confusing, frustrating and 

ineffective but that structured SMBG is 

effective, engaging and economical. 


l Structured SMBG is effective, 

engaging and economical. 

l In the “STeP IT UP” study a structured 

SMBG approach was implemented 

– blood glucose was measured seven 

times daily (before and after each 

meal and before bed) for 3 consecutive 

days in the week before seeing a 

GP or diabetes educator. This was 

associated with an HbA 1c 

reduction of 

almost 1% (11 mmol/mol) along with 

improvements in emotional well-being 

and confidence in diabetes self-care, 

and a reduction in therapeutic inertia. 

Diabesity 

Professor John Dixon, Head of Clinical Research, 

Baker IDI Heart and Diabetes Institute, 


Professor John Dixon gave a very 

thought-provoking overview of obesity 

and diabetes where he explained that 

the obesity and diabetes epidemics are 

so linked that they are inseparable, 

hence the use of the term diabesity. He 

said they share the same environmental 

determinants associated with changes 

over the last 40 years and that the factors 

contributing to the increased prevalence 

of obesity go far beyond just dietary 

intake and physical activity changes (e.g. 

smoking rates, epigenetic factors and 

maternal age). 

Professor Dixon concluded by 

explaining that obesity and diabetes are 

both conditions of dysregulation and 

need to be addressed simultaneously. 

He said we have clear clinical pathways, 

therapies and responsibilities for 

managing diabetes, but have negligible 

services directed to clinically severe 

obesity. He reiterated Sir Michael’s call 

for a whole-society, parallel approach to 

achieve effective prevention in the future. 


l Aiming for a BMI of


importance of prevention in relation to 

episodes of hyperglycaemia and gave 

many practical examples of how this 

can be done as part of normal diabetes 

care. She spoke of the importance 

of identifying times when illness is 

more likely for the individual, of 

educating the individual and their 

family or carers about appropriate 

self care generally and during illness, 

of providing preventative health care 

(e.g. influenza and travel vaccination 

and regular medication reviews), of 

optimising metabolic control and of 

regularly screening for complications 

for diabetes. 


l Sick day plans must be personalised 

and should be developed when the 

person is well. They should include 

details on who and how to contact 

for advice, blood glucose targets and 

medication (anti-diabetes and other) 

management. Instructions for sick 

days and how to prevent dehydration 

should also be covered. Individuals 

and their carers should have their 

knowledge of sick day management 

assessed on a regular basis. 

l Clinics should educate patients to 

recognise deterioration of glucose 

control early, to seek advice 

early when control deteriorates, 

and to monitor blood glucose 

and ketones accordingly. 

l Regular general health checks 

for comorbidities and dental 

care should be implemented. 

The new class wars: Which class after 

metformin: DPP-4i, SGLT2i, GLP-1 

receptor agonist, or is it still SU? 

Dr Gary Kilov, Principal, Seaport Diabetes, 

Launceston, Tas 

In the last 20 years the number of 

classes of anti-diabetes medication has 

more than tripled, and Dr Gary Kilov 

explained that it is often a daunting 

From left to right: Professor Trisha Dunning and Dr Gary Kilov. 

prospect for clinicians to sort through 

the drug choices to recommend the best 

option for the individual with diabetes 

in the consultation room. 


The first step in choosing a second line 

therapy is selecting the appropriate 

target. The paradigm has shifted from 

setting glycaemic targets for groups 

of people with diabetes (e.g. newly 

diagnosed individuals or people with 

known cardiovascular disease) to a 

more individualised approach based on 

a number of biopsychosocial factors. 

l More aggressive HbA 1c 

targets of 

42–48 mmol/mol (6–6.5%) are 

appropriate for individuals who are 

motivated, have a shorter disease 

duration and are at low risk of 

hypoglycaemia. Less stringent 

targets of 58–64 mmol/mol 

(7.5–8%) might be more appropriate 

for people with diabetes at the 

opposite end of the spectrum. 

l Choice of suitable medications can 

vary according to patient age, body 

weight, existing complications, 

duration of diabetes, life expectancy 

and ability to pay for treatment. 

We would like to thank all of 

our speakers, sponsors, exhibitors 

and organisers for their support 

of the PCDSA. The PCDSA is 

your society – so please contact us 

at info@pcdsa.com.au with your 

suggestions for what, or who, you 

would like to see at next year’s 

conference, to contribute to Diabetes & 

Primary Care Australia, or if you would 

like an education seminar in your area. 

We look forward to seeing you at our 

second national conference on April 29, 

2017 in Melbourne, Vic. n 

Citation 

Kennedy M (2016) Inaugural national conference 

of the Primary Care Diabetes Society of Australia. 

Diabetes & Primary Care Australia 1: 80–2 


Save the date: 

The 2 nd PCDSA 

National Conference 

29 th April 2017 

Melbourne, VIC 

The 2017 PCDSA conference will be held on 29 th April 2017 in 

Melbourne, VIC. 

The conference has been specifically designed for all primary care 

clinicians working in diabetes care, with the aims of: 

l Advancing education and learning in the field of diabetes 

healthcare. 

l Promoting best practice standards and clinically effective care in 

the management of diabetes. 

l Facilitating collaboration between health professionals to improve 

the quality of diabetes primary care across Australia. 

Program 

The 2017 PCDSA National Conference program will combine cutting-edge 

scientific content with practical clinical sessions, basing the education on 

much more that just knowing the guidelines. The distinguished panel of 

speakers will share their specialised experience in an environment conducive 

to optimal learning. Ample question time and the opportunity for audience 

participation will feature on the agenda. 

Steering committee 

• Clinical A/Prof Ralph Audehm 

• Dr Nicholas Forgione 

• Clinical A/Prof Mark Kennedy 

• Dr Gary Kilov 

• Dr Jo-Anne Manski-Nankervis 

• Dr Rajna Ogrin 

• Dr Suzane Ryan



Registrar education on type 2 diabetes: 

Throwing them in the deep end and 

ensuring no one drowns 

Suzane Ryan 

Citation: Ryan S (2016) Registrar 

education on type 2 diabetes: 

Throwing them in the deep end and 

ensuring no one drowns. Diabetes & 

Primary Care Australia 1: 84–5 

About this series 

The aim of the “From the desktop” 

series is to provide practical 

expert opinion and comment 

from the clinic. In this issue, 

Suzane Ryan shares the diabetes 

education provided to registrars at 

the surgery where she practices. 

Author 

Suzane Ryan is Practice Principal, 

Newcastle Family Practice, 

Newcastle, NSW. 

Working in a busy inner-city family 

practice in Newcastle, NSW, 

diabetes is a large topic to discuss 

with GP registrars. Diabetes management 

can be daunting for registrars; throwing 

them in the deep end and ensuring no one 

drowns requires thorough training and a solid 

education base from which to develop. At 

our practice, initial education about diabetes 

includes the following: 

l Developing a systematic approach to a 

person with type 2 diabetes, including 

diagnosis, medicines and management. 

l Being familiar with patient education 

material and resources. 

l Developing a primary care team with 

particular focus of the practice nurse and 

other allied health professionals. 

l Understanding Medicare requirements of 

care plans and reviews, and the diabetes 

cycle of care. 

l Having a working knowledge of the 

Royal Australian College of General 

Practice (2014) diabetes guidelines as an 

educational base that can be built on over 

time. 

Education sessions on diabetes with 

registrars take the form of a series of questions 

leading to further discussion. For example, 

“You have a newly diagnosed individual with 

type 2 diabetes – how did you make the 

diagnosis?” In this way, we discuss the use of 

HbA 1c 

, fasting glucose and glucose tolerance 

tests to diagnose and also touch on the 

role of diabetes screening at this point. For 

registrars, it is important to remember that 

the Royal Australian College of General 

Practice (2014) diabetes guidelines is the 

“go-to” resource. We recommend that it is 

always on the desktop for easy access. 

What should be covered in the initial 

consultation? 

The sessions also include discussion on what 

to include at the initial diabetes diagnosis 

appointment. 

l Let’s assume our newly diagnosed person 

with diabetes has an appointment to discuss 

the new diagnosis. What do you say to the 

patient? 

l Can you discuss diabetes in a way that is 

easily understandable to the patient? 

l Do you have relevant printed or online 

information to give the patient? Are these 

readily available in your practice? 

When providing education for registrars, it 

is important that an attempt is made to cover 

the following in the initial consultation with 

a person with diabetes: 

l Diabetes as a chronic, progressive 

multi-system condition. 

l The concept of the pancreas not producing 

enough insulin, and addressing the 

individual’s requirements. 

l The importance of lifestyle modification, 

especially diet and exercise. 

l Assessment and management of 

co-morbidities and complications. 



l Discussion about medications – why they 

are required, how they work and when they 

should be introduced. 

l The concept of a team approach – 

introducing the practice nurse and 

discussing the GP management plan and 

diabetes cycle of care. 

This is usually a good time to discuss with 

registrars whether it is better to plan one 

long consultation or provide all the relevant 

information over several patient visits. 

Discussion about the importance of involving 

the practice nurse early in management to 

support the patient and prescribed treatment 

is essential. It is important that the practice 

nurse develops a good relationship with those 

with newly diagnosed diabetes because the 

nurse will often be their main point of contact 

at the practice and will spend additional 

time with the patient reinforcing diabetes 

education and lifestyle modifications. 

Time should be allocated to discuss 

Medicare and PBS regulations and how these 

can be utilised to provide effective care. 

Registrars should be aware that National 

Diabetes Services Scheme (NDSS) enrolment 

may provide additional resources to the 

patient, and this should be encouraged to 

be completed early in the management plan. 

They also need to remind patients that if they 

hold a driver’s licence, they must notify the 

driver licensing authorities in their respective 

state or territory of the diagnosis, even if 

they are treated with diet and exercise only. 

This will subsequently result in periodic 

medical examinations prior to re-issuing of 

their licence. Conditions may be attached 

to a driver’s licence, such as requiring a 

medical certificate for particular anti-diabetes 

medicines. 

Physical examination 

Registrars should be comfortable with 

completing physical examinations, especially 

to assess cardiovascular health and exclude 

existing complications of diabetes. Appropriate 

investigations should be initiated as clinically 

appropriate, or referred to a specialist. These 

should include those required as part of the 

diabetes cycle of care. 

Primary care diabetes team 

Adequate time should be allocated to discuss 

the primary care diabetes team, and how 

the various members can be accessed. Does 

the registrar understand how to refer to 

the local diabetes service and when it is 

appropriate? Are they aware of how dietitians, 

diabetes educators, podiatrists and exercise 

physiologists can be accessed under an 

Enhanced Primary Care program? Having 

relationships with allied health professionals 

in the local area is very helpful, and knowing 

out-of-pocket costs for allied health services 

is essential. 

Anti-diabetes medication 

Once the basis of diagnosis and referral are 

understood, the next topic of discussion tends 

to be anti-diabetes medicines and initiation. 

Case-based learning can be useful to illustrate 

teaching points. It can be easily altered 

and using practice patients as examples can 

highlight real-world decision-making and 

clinical outcomes. 

Final thoughts 

Registrars need to gain experience over time 

of varying presentations of people with type 2 

diabetes, from new diagnosis to making endof-life 

decisions. Hopefully gaining experience 

and confidence will allow type 2 diabetes 

management to remain firmly in the domain 

of primary care. 

n 

The Royal Australian College of General Practitioners, Diabetes 

Australia (2014) General practice management of type 2 

diabetes – 2014–15. RACGP, Melbourne, Vic 

“Hopefully GP 

registrars gaining 

experience and 

confidence will 

allow type 2 diabetes 

management to 

remain firmly in the 

domain of primary 

care.” 


CPD module 

Prevention, screening and referral 

of people with diabetes-related foot 

complications in primary care 

Rajna Ogrin, Nicholas Forgione 

Citation: Ogrin R, Forgione N (2016) 

Prevention, screening and referral 

of people with diabetes-related foot 

complications in primary care. Diabetes 

& Primary Care Australia 1: 86–93 

Learning objectives 

After reading this article, the 

participant should be able to: 

1. Outline how to perform 

foot screening quickly and 

effectively using validated and 

accepted screening tools. 

2. Describe foot ulcer risk 

stratification following 

foot screening. 

3. Understand referral pathways 

and describe when, where 

and who to refer. 

4. Discuss effective and targeted 

foot health education for 


Key words 

– Diabetic foot 

– Diabetic peripheral neuropathy 

– Peripheral arterial disease 

– Screening 

– Ulcer risk status 

Author 

Rajna Ogrin, Senior Research 

Fellow, Royal District Nursing 

Service, Melbourne, Vic; 

Nicholas Forgione, General 

Practitioner, Trigg Healthcare 

Centre, Perth, WA. 

The prevalence of diabetes and its related complications, such as foot ulcers and 

amputations, are increasing. Foot complications lead to reduced quality of life and 

significant health and societal costs, and there is also an associated significant morbidity 

and mortality risk for those affected. Up to 85% of major amputations can be prevented. 

Prevention involves regular screening and stratifying for risk of amputation, integrated 

with comprehensive and structured foot care pathways. This article describes methods for 

identifying and stratifying the risk of foot ulceration, and outlines management and referral 

pathways for people with diabetes-related foot conditions. Being diligent and using these 

simple methods will reduce amputation rates in people with diabetes. 

The global prevalence of diabetes has 

steadily risen over the last few decades to 

reach approximately 422 million in 2014 

(World Health Organization [WHO], 2016), and 

it is projected to increase to 642 million by 2040 

(International Diabetes Federation [IDF], 2015). 

Currently more than 1.2 million Australians are 

estimated to be living with diabetes (National 

Diabetes Strategy Advisory Group, 2015) with 

some 2–3 million Australians projected to 

have diabetes by 2025 (Magliano et al, 2009). 

Approximately 85% have type 2 diabetes. The 

majority of Australians with diabetes are affected 

by cardiovascular disease, a comorbidity of 

diabetes, with foot complications as a result 

of neuropathy a close second (Lazzarini et al, 

2012a). Up to 25% of people with diabetes will 

develop foot ulcers in their lifetime (Singh et al, 

2005), and 85% of amputations are preceded 

by foot ulcers (Reiber et al, 1999). Annually, 

3500 Australians require an amputation related 

to diabetes (Australian Institute for Health and 

Welfare [AIHW], 2014), although these figures 

are likely an underestimate as many cases may 

be missed due to coding issues (Wraight et 

al, 2006). Furthermore, risk of ulceration and 

amputation increases with increasing age and 

diabetes duration (Tapp et al, 2003). Given the 

ageing population, these figures are expected to 

increase further. After a major amputation, 50% 

of people with diabetes will require their other 

limb to be amputated within 2 years (Armstrong 

et al, 1997). The mortality rate 5 years after 

amputation is up to 55% (Moulik et al, 2003), 

with higher rates of mortality in those with 

impaired renal function (Ghanassia et al, 2008). 

The hospital costs associated with managing 

foot complications related to diabetes are high, 

with direct costs averaging AUS$31 435 per 

amputation (€18 547 Euro rate in 2003; Ray et 

al, 2005). 

The negative effect of diabetes on quality of 

life is high; people with diabetes who have foot 

ulcers have significantly lower quality of life 

and higher rates of depression compared to the 

general population and to those who do not have 

foot complications (Ribu et al, 2007). 

Since 1989, one aim of the WHO has been 

to reduce amputations by 50% (The Saint 

Vincent Declaration, 1997). Unfortunately, 

despite increasing knowledge, research and 

guidelines relating to this issue, data suggest 


Prevention, screening and referral of people with diabetes-related foot complications in primary care 

there has been a 30% increase in diabetesrelated 

amputations in Australia over the past 

decade, with 8% of diabetes-related deaths 

being attributable to foot disease (Payne, 2000; 

AIHW, 2008). Guidelines have been developed 

to assess, prevent and manage diabetes-related 

foot complications nationally and internationally 

(Baker Institute and the International Diabetes 

Institute, 2011; International Working Group 

on the Diabetic Foot [IWGDF], 2015). The 

IDF advised that a 49–85% risk reduction for 

amputation can be achieved by implementing 

these guidelines (e.g. foot screening, improving 

multidisciplinary management, close monitoring, 

improved education of both clients and health 

practitioners, and appropriate organisational 

structure [Krishnan et al, 2008; IWGDF, 2015]). 

Australia has resources available for preventative 

foot care within the community for people with 

diabetes, with care being provided in the acute, 

sub-acute, community and private health sectors 

by healthcare providers, including podiatrists, 

diabetes educators, GPs, community nurses and 

medical and surgical specialists. In Victoria, 

there are also a number of specific programs 

funded by Hospital Admission Risk Prevention 

(HARP), which is a program targeting people 

with chronic disease to prevent re-hospitalisation. 

These programs increase specialist access in the 

community such as endocrinologists and hospital 

diabetes foot services. Despite this, the levels 

of amputations have not reduced (Bergin et al, 

2012). GPs can provide a systematic approach 

to care to prevent diabetes-related amputations 

by following The Royal Australian College of 

General Practitioners (RACGP) and Diabetes 

Australia (2014) guidelines for people with 

type 2 diabetes. This includes regular screening 

for risk factors of amputation and timely referral 

to appropriate providers or services to address 

identified issues. 

Evidence-based practice for the 

prevention and management of 

diabetes-related foot complications 

Over the last 25 years, much research has 

been done to identify who is most at risk 

of amputation. The IWGDF, a peak body of 

international experts from different disciplines, 

is focussed on preventing amputations in people 

with diabetes. The IWGDF has developed 

systematic reviews in the areas of prevention of 

amputation, peripheral arterial disease (PAD), 

footwear and offloading, infection and wound 

healing. In addition, they have developed 

guideline documents based on their systematic 

reviews combined with international expert 

opinion on the same areas (which can be viewed at 

www.iwgdf.org/guidelines-2/systematic-reviews). 

Table 1 describes practice recommendations 

for the prevention of amputations in diabetes 

developed for the Australian context, using 

Page points 

1. The International Diabetes 

Federation advises that a 

49–85% risk reduction for 

amputation can be achieved 

by foot screening, improving 

multidisciplinary management, 

close monitoring, improved 

education of both clients 

and health practitioners, and 

appropriate organisational 

structure. 

2. Australia has resources available 

for preventative foot care within 

the community for people with 

diabetes. Despite this, levels of 

amputations have not reduced. 

Table 1. Key evidence-based, recommended practices for prevention of diabetes-related 

amputations. 

Recommended practices 

1 

Screen all people with diabetes for foot complications using a standard assessment form to assess for the following: 

l Presence of neuropathy. 

l Presence of peripheral arterial disease. 

l Presence of joint or nail deformity or skin issue. 

l Ability to self care. 

l Past history of foot ulceration. 

l Past history of lower-extremity amputation. 

2 To generate a risk of amputation for each person with diabetes who is screened. 

3 To educate a person with diabetes on their risk level for amputation. 

4 Refer people with diabetes for management of identified risk factors. 

5 

Base frequency of screening on risk of foot complications: 

l Low risk: screen annually. 

l Increased risk: screen every 3–6 months. 

l High risk: screen every visit. 


www.pcdsa.com.au/cpd – Prevention, screening and referral of people with diabetes-related foot complications in primary care 

Page points 

1. The presence of neuropathy 

is the single most common 

risk factor for foot ulcer 

development. 

2. If there is a current ulcer or 

previous lower extremity 

amputation or foot ulceration, 

the person is classified at highrisk 

of amputation for the rest of 

their lives. 

3. Until adequately assessed, 

all Aboriginal and Torres 

Strait Islander people with 

diabetes are considered to be 

at high-risk of developing foot 

complications and, therefore, 

will require foot checks at every 

clinical encounter and active 

follow-up. 

best available evidence (Baker Institute and the 

International Diabetes Institute, 2011). 

Risk factors for amputation 

There are four dominant pathways for foot ulcer 

development (Lavery et al, 2008a): 

1. Loss of protective sensation, deformity, callus 

and elevated peak plantar pressure. 

2. PAD. 

3. Penetrating trauma. 

4. Ill-fitting shoes. 

The presence of neuropathy is the single most 

common risk factor for foot ulcer development 

(Reiber et al, 1999). Approximately 50% of 

people with diabetes will develop peripheral 

neuropathy (Dyck et al, 1993). Interrupting one 

key component of the foot ulceration causal 

pathway may avoid significant morbidity down 

the pathway to amputation (Lavery et al, 2008b). 

By undertaking foot assessments to identify 

risks for amputation, early intervention can be 

implemented and reduce the escalation of foot 

problems to requiring amputation (Canavan et 

al, 2008). 

Approximately 50% of people with diabetes in 

Australia have foot assessments (Tapp et al, 2004), 

despite this being a key component of preventing 

amputation. Foot assessments are necessary to 

identify risk factors, and only then can actions 

be implemented to address them. Table 2 outlines 

the risk factors and the assessments that can 

identify risk factor presence. If there is a current 

ulcer or previous lower extremity amputation or 

foot ulceration, the person is classified at highrisk 

of amputation for the rest of their lives. 

Any healthcare providers, with some training, 

can undertake foot assessments. In Australia 

podiatrists, GPs, credentialled diabetes educators 

and practice and community nurses generally 

undertake these assessments. 

Stratification of risk for amputation in 

people with diabetes 

Once the risk level for amputation has been 

identified in a person with diabetes, a management 

plan can be tailored to their risk level as shown 

in Table 3. Assessment alone will not reduce 

amputations (Mayfield et al, 2000); therefore, 

integrating management with risk assessment is 

essential. Early and timely intervention in people 

with diabetes with foot risk factors can prevent 

many amputations (Krishnan et al, 2008). 

The average prevalence of ulceration in 

community settings is approximately 1.7% 

(Abbott et al, 2002); however, indigenous 

populations are considered at higher risk of 

developing foot complications and have 

increased rates of amputation when compared 

to non-indigenous populations (Norman et al, 

2010). Until adequately assessed, all Aboriginal 

and Torres Strait Islander people with diabetes 

are considered to be at high-risk of developing 

foot complications and, therefore, will require 

foot checks at every clinical encounter and active 

follow-up (Baker Institute and the International 

Diabetes Institute, 2011). It is estimated that 

approximately 20% of people with diabetes are 

at increased risk of developing a foot ulcer (Tapp 

et al, 2003), although in some groups this may be 

an underestimation of the real frequency (Bergin 

et al, 2009). 

Ulceration management 

Full description of the management of foot ulcers 

in people with diabetes requires considerable 

resources and expertise, and is beyond the scope 

of this article. The authors refer readers to the 

IWGDF consensus documents and guidelines 

(2015) and NHMRC best practice guidelines 

(Baker Institute and the International Diabetes 

Institute, 2011). A standardised, consistent patient 

and wound assessment to guide management 

is essential, and the involvement of multiple 

clinicians with expertise in this area is required 

(Apelqvist et al, 2008). Assessment of people 

with diabetes who have a foot ulcer should 

include the following: 

l Systemic medical issues to be identified 

and addressed, particularly glycaemic 

management. 

l Psychosocial factors must be identified and 

addressed, as they significantly impact on 

the outcome of clinical management (Prince, 

2008). 

l Ulcer aetiology must be identified, as 

management is specific to each one. There are 

three main types of ulceration associated with 



Table 2. Amputation risk factors and the corresponding screening tests. 

Amputation risk factor 

Screening tests required 

Loss of protective sensation (LOPS) 

Inability to sense the pressure applied with 

10 g Semmes–Weinstein monofilament. 

l 10 g monofilament testing at three sites, shown 

in Figure 1, is valid and reliable. Absent sensation 

at any one of the three sites indicates loss of 

protective sensation (Bakker et al, 2012). 

l When recommended equipment is not available, 

a validated, simple screening test called the 

Ipswich Touch Test can be used (Rayman et al, 

2011). This involves lightly resting an index finger 

on the tips of the first, third, and fifth toes of 

the person with diabetes for 1–2 seconds while 

their eyes are closed. A similar technique to the 

10 g monofilament is used, where the individual is 

instructed to respond when they have sensation. 

Figure 1. Sites to be tested with monofilaments. The monofilament 

should be applied to each site shown in orange until it bends into a 

“C-shape” for 1 second (Apelqvist et al, 2008). 

Peripheral arterial disease (PAD) 

Obstructive atherosclerotic vascular disease 

with clinical symptoms, signs or abnormalities 

on non-invasive vascular assessment, 

indicating disturbed or impaired circulation in 

one or more extremity. 

l Complete a vascular assessment. 

l Classic symptoms, such as intermittent claudication (pain or cramping of the calves or thighs) and night or rest 

pain, are present in only about a quarter of people with diabetes who have PAD (Stoffers et al, 1996; Hooi et al, 

2001). 

l Diabetes may reduce the symptoms of PAD (American Diabetes Association, 2003); however, fatigue during 

walking distances, particularly up hills, may help indicate PAD (Frykberg et al, 2006). 

l Visual examination of skin, hair and nail growth can provide further information (Frykberg et al, 2006). 

l Palpate pulses at each visit. Should pulses be impalpable, PAD may be present. Undertaking an ankle-brachial 

index (ABI) may provide further information (Frykberg et al, 2006). 

l In the presence of known arterial disease risk factors, an ABI should be performed. ABI


Table 3. The amputation risk classification system, management for each amputation risk level and recommended healthcare 

professionals to be included in the care team (Apelqvist et al, 2008; Bakker et al, 2012). 

Amputation risk level 

Number of amputation 

risk factors as 

described in Table 2 

Management 

Recommended healthcare providers 

involved in care team 

Low risk 

No risk factors present 

l Annual foot assessment to assess whether risk factors 

have developed. 

l Foot care advice. 

l Ensure ongoing good glycaemic management. 

l Self-inspection of feet daily. Individuals should report 

any changes to the feet as they are detected. 

GP and diabetes educator. Podiatrist can be called 

upon if foot screening is requested. 

Increased risk 

One risk factor present 

l As per “no risk factors present for amputation”, 

and address the identified risk factor (e.g. if painful 

neuropathy or peripheral arterial disease present, referral 

to appropriate specialist is required). 

l Foot care education. 

l May require referral to a podiatrist, especially for 

arthritic problems or presence of callus or nail issues. 

l Formal foot assessment to be undertaken every 

3–6 months. 

GP, podiatrist and diabetes educator. 

High risk* 

Two or more risk factors 

present OR past history of 

foot ulcer/amputation 

l Requires regular podiatry care and a formal foot 

assessment to be undertaken every 3 months. 

l Ensure that current risk factors are addressed with early, 

aggressive management of any skin breakdown. 

l Foot care education. 

Endocrinologist, surgeon (general and/or vascular 

and/or orthopaedic), podiatrist and diabetes nurse 

educator. 

Current foot ulcer 

n/a 

If an ulcer has been present for 4 weeks or longer without 

improvement, refer to a multidisciplinary foot ulcer clinic 

(Baker Institute and the International Diabetes Institute, 

2011). 

Multidisciplinary team – usually as part of a 

tertiary hospital outpatient clinic. Contact the local 

Australian Podiatry Association in your state for 

details. 

*Until adequately assessed, all Aboriginal and Torres Strait Islander people with diabetes are considered to be at high risk of developing foot complications and, therefore, 

will require foot checks at every clinical encounter and active follow-up (Baker Institute and the International Diabetes Institute, 2011). 

diabetes – neuropathic, ischaemic or neuroischaemic 

(Apelqvist et al, 2008). The presence 

of PAD is of particular concern, as this (with 

infection) is the leading cause of amputation 

(Lavery et al, 2008a). To ensure healing and 

prevention of ulcer recurrence, addressing these 

factors is essential. 

l Wound assessment and documentation of site, 

size and depth is important to evaluate progress 

of management. Wound classification according 

to accepted classification systems, such as the 

University of Texas Wound Classification 

System (Armstrong, 1996), can be helpful to 

provide indication of prognosis and whether 

more aggressive intervention is required. 

l The leading cause of hospitalisation in people 

with diabetes is infection, so the presence of 

infection must be assessed at every visit. Foot 

ulcer infection concomitant with PAD is the 

leading cause of amputation in people with 

diabetes (Lavery et al, 2008a). Infection should 

be treated promptly and actively, and risk for 

osteomyelitis must be determined (Lipsky et al, 

2006; Apelqvist et al, 2008). 

Once these factors are addressed, and assessment 

identifies that the wound is likely to heal, moist 

wound healing principles are to be used. This 

includes regular and frequent debridement of 

callus and the wound bed – debridement is only 

to be undertaken in wounds in which there is 

adequate arterial flow to allow healing (Sibbald et 

al, 2003). 

The key to treatment for the majority of diabetesrelated 

foot ulcers is pressure redistribution (Wu 

and Armstrong, 2006), and, therefore, referral 

to appropriate specialists with expertise in this 

area is strongly recommended (Apelqvist et al, 

2008). Unfortunately, this is an area that has 

limited research, and few clinicians implementing 

effective strategies, so working with an expert 

team is strongly advised (Baker Institute and the 



International Diabetes Institute, 2011; Bus, 2012; 

van Houtum, 2012). 

It is important to note that some diabetesrelated 

foot ulcers may not be able to heal, 

and expert multidisciplinary teams are best 

placed to appropriately assess healing capacity 

(Jeffcoate, 2012). 

Australian strategies to prevent 

amputations in people with diabetes 

To prevent or slow the progression of chronic 

disease complications, the Australian Government 

funds five healthcare provider visits annually 

through its Medicare Benefits Scheme (MBS), 

which can include podiatry as well as a number 

of other allied health provider appointments 

(Australian Government Department of Health, 

2014). Unfortunately, there is a lack of co-ordinated 

approach within the health system to prevent 

diabetes-related complications. Recommendations 

have been made by the Australian National 

Diabetes Strategy Advisory Group (2015) to 

develop nationally agreed clinical guidelines, 

local care pathways and complication prevention 

programs to address this. A specific diabetes-related 

amputation prevention strategy was developed by 

key stakeholders (Bergin et al, 2012); however, 

there has still been no national action. Queensland 

has developed and implemented a multi-faceted 

evidence-based approach over most of the state 

to improve diabetes foot-related complication 

management in ambulatory services and reduce 

foot-related hospitalisation and amputations among 

people with diabetes (Lazzarini et al, 2012b). The 

approach includes the following: 

1. Multidisciplinary diabetes foot teams. 

2. Clinical pathways. 

3. Clinician training programs. 

4. Telehealth programs. 

5. Clinical performance indicators. 

After 5 years of the program, there has been a 

significant reduction in the incidence of hospital 

admissions and lower extremity amputations in 

people with diabetes (Lazzarini et al, 2015). 

A new organisation, called Diabetic Foot Australia 

(DFA; https://diabeticfootaustralia.org/about-dfa 

[accessed 06.06.16]), was established in late 2015 as 

a national body for people with diabetes who have 

foot disease, to help reduce the incidence and impact 

of foot disease on the lives of Australians living with 

diabetes. DFA involves key stakeholders across 

the disciplines, including people with diabetes, 

researchers, healthcare professionals and industry. 

The primary objectives of DFA are as follows: 

l Optimise national evidence-based clinical 

practice to prevent, assess and manage diabetesrelated 

foot ulcers. 

l Stimulate national clinical research in diabetesrelated 

foot ulcers. 

l Reduce Australia’s national diabetes amputation 

rate. 

l Empower Australia to become a leading nation 

in the management of people with diabetes who 

have foot ulcers. 

It is early days; however, it is anticipated that 

a co-ordinated approach to increase efforts at 

prevention and improved management of 

people with diabetes will be pursued, and once 

implemented, should lead to positive results. 

Conclusion 

Not everyone with diabetes is at high-risk of 

amputation. It is important to identify those 

who are at increased risk of complications in an 

effort to prevent foot problems from developing. 

The number of amputations can be reduced by 

identifying people with diabetes at high-risk of 

lower-extremity amputation and addressing the 

risk factors appropriately. To achieve this requires 

a community approach and increasing levels of 

foot screening to include all people with diabetes 

to identify risk of amputation, followed by any 

identified problems being addressed quickly and 

aggressively by those healthcare professionals who 

have the skills and expertise to do this. Australia 

has the services available to reduce amputations 

in people with diabetes, but it is increasingly 

apparent that the lack of co-ordination of care 

of people with diabetes is leading to avoidable 

amputations, and the systematic implementation 

of evidence-based measures nationally needs 

to occur. GPs can contribute to prevention 

of amputations right now by ensuring they 

undertake the foot screening as recommended 

by the national guidelines, and address identified 

risk factors promptly. 

n 

“GPs can contribute 

to prevention of 

amputations right 

now by ensuring 

they undertake the 

foot screening as 

recommended by the 

national guidelines, 

and address identified 

risk factors promptly.” 



Abbott CA, Carrington AL, Ashe H et al (2002) The 

North-West Diabetes Foot Care Study: incidence of, 

and risk factors for, new diabetic foot ulceration in a 

community-based patient cohort. Diabet Med 19: 

377–84 

American Diabetes Association (2003) Peripheral arterial 

disease in people with diabetes. Diabetes Care 26: 

3333–41 

Apelqvist J, Bakker K, van Houtum WH, Schaper NC 

(2008) Practical guidelines on the management and 

prevention of the diabetic foot: based upon the 

International Consensus on the Diabetic Foot (2007) 

Prepared by the International Working Group on the 

Diabetic Foot. Diabetes Metab Res Rev 24(Suppl 1): 

S181–7 

Armstrong DG (1996) The University of Texas diabetic 

foot classification system. Ostomy Wound Manage 42: 

60–1 

Armstrong DG, Lavery LA, Harkless LB et al (1997) 

Amputation and reamputation of the diabetic foot. J 

Amer Podiatr Med Assoc 87: 255–9 

Australian Government Department of Health (2014) The 

July 2014 Medicare Benefits Schedule. Canberra, ACT. 

Available at: http://www.mbsonline.gov.au/internet/ 

mbsonline/publishing.nsf/Content/Downloads-201407 


Australian Institute of Health and Welfare (2008) 

Diabetes: Australian facts 2008. AIHW, Canberra, ACT 

Australia Institute of Health and Welfare (2014) 

Cardiovascular disease, diabetes and chronic kidney 

disease: Australian facts mortality. AIHW, Canberra, 

ACT 

Baker Institute and the International Diabetes Institute 

(2011) National evidence-based guideline: Prevention, 

identification and management of foot complications 

in diabetes (part of the guidelines on management 

of type 2 diabetes). Commonwealth of Australia, 


Bakker K, Apelqvist J, Schaper NC, on behalf of the 

International Working Group on the Diabetic Foot 

(2012) Practical guidelines on the management and 

prevention of the diabetic foot 2011. Diabetes Metab 

Res Rev 28: 225–31 

Bergin S, Brand C, Colman P, Campbell D (2009) A 

questionnaire for determining prevalence of diabetes 

related foot disease (Q-DFD): construction and 

validation. J Foot and Ankle Research 2: 34 

Bergin S, Alford J, Allard B et al (2012) A limb lost every 3 

hours: can Australia reduce lower limb amputations in 

people with diabetes? Medical J Austr 197 

Brooks B, Dean R, Patel S et al (2001) TBI or not TBI: that 

is the question. Is it better to measure toe pressure than 

ankle pressure in diabetic patients? Diabet Med 18: 

528–32 

Bus SA (2012) Priorities in offloading the diabetic foot. 

Diabetes Metab Res Rev 28: 54–9 

Canavan RJ, Unwin NC, Kelly WF, Connolly VM (2008) 

Diabetes- and nondiabetes-related lower extremity 

amputation incidence before and after the introduction 

of better organized diabetes foot care: continuous 

longitudinal monitoring using a standard method. 

Diabetes Care 31: 459–63 

Dormandy JA, Rutherford RB (2000) Management of 

peripheral arterial disease (PAD). TASC Working 

Group. TransAtlantic Inter-Society Concensus (TASC). J 

Vasc Surg 31(Suppl 1): S1–S296 

Dyck P, Kratz K, Karnes J et al (1993) The prevalence by 

staged severity of various types of diabetic neuropathy, 

retinopathy, and nephropathy in a population-based 

cohort: the Rochester Diabetic Neuropathy Study. 

Neurology 43: 817–24 

Frykberg RG, Zgonis T, Armstrong DG et al (2006) 

Diabetic foot disorders. A clinical practice guideline 

(2006 revision). J Foot Ankle Surg 45(5 Suppl): S1–66 

Ghanassia E, Villon L, Thuan Dit Dieudonne JF et al 

(2008) Long-term outcome and disability of diabetic 

patients hospitalized for diabetic foot ulcers: a 6.5-year 

follow-up study. Diabetes Care 31: 1288–92 

Hooi JD, Kester AD, Stoffers HE et al (2001) Incidence 

of and risk factors for asymptomatic peripheral 

arterial occlusive disease: a longitudinal study. Amer J 

Epidemiol 153: 666–72 

International Diabetes Federation (2015) IDF Diabetes 

Atlas 7th Edition. International Diabetes Federation, 

Brussels, Belgium 

International Working Group on the Diabetic Foot (2015) 

International Working Group on the Diabetic Foot 

consensus guidelines. IWGDF. Available at: http:// 

iwgdf.org/guidelines (accessed 30.04.16) 

Jeffcoate WJ (2012) Wound healing – a practical 

algorithm. Diabetes Metab Res Rev 28: 85–8 

Krishnan S, Nash F, Baker N et al (2008) Reduction in 

diabetic amputations over 11 years in a defined U.K. 

population: benefits of multidisciplinary team work 

and continuous prospective audit. Diabetes Care 31: 

99–101 

Lavery LA, Armstrong DG, Vela SA et al (1998) Practical 

criteria for screening patients at high risk for diabetic 

foot ulceration. Arch Intern Med 158: 157–62 

Lavery LA, Peters EJ, Armstrong DG (2008a) What are the 

most effective interventions in preventing diabetic foot 

ulcers? Intern Wound J 5: 425–33 

Lavery LA, Peters EJ, Williams JR et al (2008b) 

Reevaluating the way we classify the diabetic foot: 

restructuring the diabetic foot risk classification system 

of the International Working Group on the Diabetic 

Foot. Diabetes Care 31: 154–6 

Lazzarini PA, Gurr JM, Rogers JR et al (2012a) Diabetes 

foot disease: the Cinderella of Australian diabetes 

management? J Foot Ankle Res 5: 24 

Lazzarini PA, O’Rourke SR, Russell AW et al (2012b) 

Standardising practices improves clinical diabetic 

foot management: the Queensland Diabetic Foot 

Innovation Project, 2006–09. Aust Health Rev 36: 

8–15 

Lazzarini P, O’Rourke S, Russell A et al (2015) 

Reduced incidence of foot-related hospitalisation 

and amputation amongst persons with diabetes in 

Queensland, Australia. PLoS ONE 10: e0130609 

Lipsky BA, Berendt AR, Deery HG et al (2006) Diagnosis 

and treatment of diabetic foot infections. Plast Reconstr 

Surg 117(7 Suppl): 212S–38S 

Magliano D, Peeters A, Vos T et al (2009) Projecting the 

burden of diabetes in Australia – what is the size of the 

matter? Aust N Z J Public Health 33: 540–3 

Mayfield JA, Reiber GE, Nelson RG, Greene T (2000) 

Do foot examinations reduce the risk of diabetic 

amputation? J Fam Pract 49: 499–504 

Moulik PK, Mtonga R, Gill GV (2003) Amputation and 

mortality in new-onset diabetic foot ulcers stratified by 

etiology. Diabetes Care 26: 491–4 

National Diabetes Strategy Advisory Group (2015) A 

Strategic Framework for Action: Advice to Government 

on the Development of the Australian National 

Diabetes Strategy 2016–2020. Australian Government, 

Department of Health, Canberra, ACT 

Norman PE, Schoen DE, Gurr JM, Kolybaba ML (2010) 

High rates of amputation among Indigenous people in 

Western Australia. Med J Aust 192: 421 

Payne C (2000) Medical model perspective on the 

psychosocial and behavioural aspects of diabetic foot 

complications. Australas J Podiatr Med 34: 55–60 

Pecoraro RE, Reiber GE, Burgess EM (1990) Pathways 

to diabetic limb amputation: Basis for prevention. 


Price PE (2008) Education, psychology and ‘compliance’. 

Diabetes Metab Res Rev 24(Suppl 1): S101–5 

Ray JA, Valentine WJ, Secnik K et al (2005) Review of the 

cost of diabetes complications in Australia, Canada, 

France, Germany, Italy and Spain. Curr Medical Res 

Opin 21: 1617–29 

Rayman G, Vas PR, Baker N et al (2011) The Ipswich 

Touch Test: A simple and novel method to identify 

inpatients with diabetes at risk of foot ulceration. 


Reiber GE, Vileikyte L, Boyko EJ et al (1999) Causal 

pathways for incident lower-extremity ulcers in 

patients with diabetes from two settings. Diabetes Care 

22: 157–62 

Ribu L, Hanestad BR, Moum T (2007) A comparison 

of the health-related quality of life in patients with 

diabetic foot ulcers, with a diabetes group and a 

nondiabetes group from the general population. 

Qual Life Res 16: 179–89 

Sibbald RG, Orsted H, Schultz GS et al (2003) Preparing 

the wound bed 2003: focus on infection and 

inflammation. Ostomy Wound Manage 49: 23–51 

Singh N, Armstrong DG, Lipsky BA (2005) Preventing foot 

ulcers in patients with diabetes. J Amer Med Assoc 

293: 217–28 

Stoffers HE, Rinkens PE, Kester AD et al (1996) The 

prevalence of asymptomatic and unrecognized 

peripheral arterial occlusive disease. Intern J Epidemiol 

25: 282–90 

Tapp RJ, Shaw JE, de Courten MP et al (2003) Foot 

complications in type 2 diabetes: an Australian 

population-based study. Diabet Med 20: 105–13 

Tapp RJ, Zimmet PZ, Harper CA et al (2004) Diabetes 

care in an Australian population: frequency of 

screening examinations for eye and foot complications 

of diabetes. Diabetes Care 27: 688–93 

The Royal Australian College of General Practitioners 

and Diabetes Australia (2014) General practice 

management of type 2 diabetes – 2014–15. Royal 

Australian College of General Practitioners and 

Diabetes Australia, Melbourne, Vic 

The Saint Vincent Declaration (1997) The Saint Vincent 

Declaration. Acta Ophthalmologica Scandinavica 

75(S223): 63 

van Houtum WH (2012) Barriers to implementing foot 

care. Diabetes Metab Res Rev 28: 112–5 

World Health Organization (2016) Global Report on 

Diabetes. WHO, Geneva, Switzerland 

Wraight PR, Lawrence SM, Campbell DA, Colman 

PG (2006) Retrospective data for diabetic foot 

complications: only the tip of the iceberg? Intern Med 

J 36: 197–9 

Wu SC, Armstrong DG (2006) The role of activity, 

adherence, and off-loading on the healing of diabetic 

foot wounds. Plast Reconstr Surg 117 (7 Suppl): 

248S–53S 



Online CPD activity 

Visit www.pcdsa.com.au/cpd to record your answers and gain a certificate of participation 

Participants should read the preceding article before answering the multiple choice questions below. There may be MORE THAN ONE correct 

answer to each question. After submitting your answers online, you will be immediately notified of your score. A pass mark of 70% is required to 

obtain a certificate of successful participation; however, it is possible to take the test a maximum of three times. A short explanation of the correct 

answer is provided. Before accessing your certificate, you will be given the opportunity to evaluate the activity and reflect on the module, stating how 

you will use what you have learnt in practice. The CPD centre keeps a record of your CPD activities and provides the option to add items to an action 

plan, which will help you to collate evidence for your annual appraisal. 

1. What is the percentage of people with 

diabetes who may develop a foot ulcer 

in their lifetime? 

Select ONE option only. 

A. 1% 

B. 5% 

C. 25% 

D. 50% 

E. 75% 

2. What is the most common single risk 

factor for foot ulcer formation? 


A. Poor glycaemic control 

B. Presence of peripheral neuropathy 

C. Presence of peripheral arterial 

disease 

D. Being overweight 

E. Presence of a foot deformity 

3. What percentage of people with 

diabetes will develop neuropathy? 


A. 1% 

B. 5% 

C. 25% 

D. 50% 

E. 75% 

4. What procedure(s) should be included 

during a foot screening in people 

with diabetes? 


A. Pulse palpation 

B. Evaluation of shoe size and fit 

C. Use of a 10 g monofilament to 

evaluate sensation 

D. Visual examination for callus and 

other lesions 

E. Allocation of a risk status for 

lower-extremity amputation 

F. Referral to a podiatrist if problems 

identified 

G. All of the above 

5. If an individual has had a foot ulcer in 

the past, what is their level of risk that 

they will develop a second foot ulcer or 

require a lower extremity amputation 

in the future? 


A. None 

B. Low 

C. Increased 

D. High 

6. Which of the following situations 

automatically stratifies a person with 

diabetes as having “high-risk” feet? 


A. Absence of one dorsalis pedis 

pulse but no foot deformity 

B. Being registered blind 

C. Inability to reach one’s own feet 

D. Normal foot pulses but inability 

to feel a 10 g monofilament 

E. Presence of callus and a history 

of previous foot ulceration 

7. If a foot ulcer is identified in a 

person with diabetes during a foot 

screening, what is the current 

recommended action? 

Select THREE options. 

A. Ascertain cause, and if possible 

remove causative factor (e.g. illfitting 

footwear) 

B. Apply dressing, prescribe 

antibiotics and review in a week 

C. Where possible, refer to a 

specialist multidisciplinary 

foot team 

D. If pulses are not palpable, refer to 

vascular surgery 

8. In an individual who has one risk factor 

for a lower-limb amputation, what is 

the recommended frequency of formal 

foot assessment? 


A. Every 12 months 

B. Every 2 years 

C. Every 3–6 months 

D. Only when patient complains of 

foot symptoms 

9. Which of the following foot 

ulcer presentations suggest an 

individual should be referred to a 

multidisciplinary team? 


A. Ulcers not improving after 

4 weeks despite appropriate 

treatment 

B. Absent foot pulses 

C. Deep ulcers 

D. Suspected Charcot’s 

neuroarthropathy 

E. Ascending cellulitis 

F. All of the above 

10. Which of the following are 

recommended practice for prevention 

of diabetes-related amputations? 

Select THREE options. 

A. Regular foot assessment based on 

patient-reported symptoms 

B. Determine the amputation risk for 

every patient who is screened 

C. Educate the patient on their level 

of risk for amputation 

D. Assess for patient’s ability to self 

care 

E. All of the above 


Article 

Medicolegal case of a person with 

type 2 diabetes: Medical history 

Peter Hay 

Citation: Hay P (2016) Medicolegal 

case of a person with type 2 

diabetes: Medical history. Diabetes 

& Primary Care Australia 1: 94–6 

Article points 

1. The duty of care of the GP to 

their patients with diabetes is 

to ensure that the appropriate 

interventions are put in 

place and that the potential 

ramifications and complications 

associated with the condition 

are explained to the patient. 

2. It is incumbent on the GP 

to explain the diabetesrelated 

complications 

to the patient, to ensure 

compliance is maintained and 

individualised targets met. 

3. These discussions need to be 

documented in the medical 

notes to ensure that if any 

micro- or macrovascular 

complications develop, there 

is proof that the GP has 

taken the appropriate steps 

to inform their patient. 

Key words 

– Duty of care 

– Medicolegal 

– Negligence 

– Non-compliance 

Author 

Peter Hay is a GP and Director, 

Castle Hill Medical Centre, 

Sydney and an expert 

medicolegal witness. 

The incidence of type 2 diabetes is increasing worldwide and Australia is no exception to 

this increase. According to the Australian Institute of Health and Welfare, the prevalence of 

diabetes doubled between 1989–1990 and 2011–2012 (from 1.5% to 4.2% of Australians). 

And year on year, the total number of people with diabetes continues to increase, from 

around 898 800 in 2007–2008 to around 999 000 in 2011–2012. The care of people 

with diabetes is mainly organised by GPs and primary care, and the role of the GP is to 

manage a complex, multi-system condition with significant and far-reaching micro- and 

macrovascular complications. The author presents a medicolegal case that they were a 

medicolegal expert to. The particular case demonstrates the importance of note-taking, 

especially when managing a person with type 2 diabetes on insulin who is non-compliant 

to treatment. 

The inexorable rise in medicolegal claims 

is evident. In 2009–2010, 2990 claims 

were made against Australian medical 

practitioners (Australian Institute of Health 

and Welfare [AIHW], 2012), increasing to 

4225 claims in 2012–2013 (AIHW, 2014). 

Obstetrics and gynaecology (9%) and general 

practice (18%) are the two most commonly 

ligitated against clinical specialities (AIHW, 

2012), and general practice continues to be 

the speciality most litigated against over recent 

years. 

Within the spectrum of disorders managed 

in general practice, none is more challenging 

than type 2 diabetes. The current treatment 

paradigm recommends an individualised 

approach to the management of glycaemic 

control, as well as the implementation of 

appropriate cardiovascular risk factor 

reduction strategies. The duty of care of the 

GP to their patients with diabetes is to ensure 

that the appropriate interventions are put in 

place and that the potential ramifications and 

complications associated with the condition 

are explained to the patient. It is incumbent on 

the GP to explain these complications to the 

patient to ensure compliance is maintained and 

individualised targets met. These conversations 

with the patient need to be documented in 

the notes to ensure that if any micro- or 

macrovascular complications develop, there is 

proof that the GP has taken the appropriate 

steps to explain this to their patient. 

I present a case where legal proceedings 

were brought against a GP by a patient for 

negligence. Note-taking by the GP was sparse, 

and as a result there was no proof that the 

GP had fully explained the consequences 

of poor compliance to treatment. This case 

demonstrates the potential pitfalls for the GP 

in not maintaining good clinical notes. 

Definition of negligence 

It is important for the GP to understand the 

legal definition of negligence. For a claim to 

succeed, the patient (plaintiff) must prove, on 


Medicolegal case of a person with type 2 diabetes 

the balance of probabilities, a series of steps 

(Kroesche and Jammal, 2015): 

l Duty of care – a relationship needs to be 

established where the duty of care of the 

patient by the medical practitioner was in 

existence. 

l Standard of care – that there was a breach in 

the standard of care, usually judged against 

an accepted standard for a GP practising in 

Australia. 

l Causation – that as a result of the breach of 

duty of care, a harm occurred to the patient 

and that this harm would not have occurred 

but for that breach of duty of care. 

Case report 

MV is a woman who began attending a 

medical centre in 2004 when aged 44 years. 

MV visited her GP once or twice a year, and 

at appointments, an HbA 1c 

test would be 

ordered along with a biochemical screen and 

a urinary albumin:creatinine ratio (ACR). 

The only comment made in the notes at this 

time was “poor compliance”. Between 2006 

to 2013, MV was not near to achieving the 

HbA 1c 

target of 53 mmol/mol (7%; the current 

target cited by Australian guidelines [Gunton 

et al, 2014]). The lowest HbA 1c 

recorded was 

79 mmol/mol (9.4%) in 2006 and the highest 

was 136 mmol/mol (14.6%) in 2013. The 

average HbA 1c 

was 12.8% (116 mmol/mol) over 

this period of time. 

Despite multiple entries in the medical notes 

as to the elevations of blood glucose, there 

was no written confirmation that MV was 

informed of the potential consequences of 

not adhering to the medications she was 

prescribed, or the consequences of the macroand 

microvascular complications that MV was 

at risk of developing by sustaining such high 

HbA 1c 

levels. Neither were there any notes 

recording attempts to ascertain the reason 

behind the high HbA 1c 

results. Pre-mixed 

insulin continued to be prescribed by the GP at 

identical doses, despite no records of self-blood 

glucose monitoring measurements or notes 

from the GP prescribing self-monitoring. 

First noted in 2009, an annual deterioration in 

ACR was observed. The gradual but significant 

deterioration in ACR levels indicates the 

advent of microvascular disease affecting the 

kidneys. No comments were made in the notes 

as to the potential nephropathy developing, 

nor were there any notes indicating that MV 

had been made aware of the abnormality and 

its significance. 

During 2006 and 2013, MV was referred to 

two endocrinologists, of which she attended 

one of the consultations. The correspondence 

from the endocrinologist confirmed poor 

glycaemic control and the almost non-existent 

adherence to insulin. Despite this, there was 

no evidence in the medical notes referring to 

the correspondence, nor any advice to return to 

the endocrinologist for ongoing management. 

Apart from elevated blood pressure 

readings (average 142/94 mmHg), no other 

examinations were recorded. No comment was 

made about peripheral pulses or sensation, and 

no referral was made to check for the presence 

of diabetic retinopathy. 

In 2014, MV presented to her GP complaining 

of a swollen right leg. She had recently been 

issued with standard shoes that were required 

for her job in a nursing home. She had been 

wearing these shoes for a week. 

The history recorded in the notes were: 

“swollen leg for 2 dys [sic], no CP no SOB”*. 

The GP prescribed Lasix ® (furosemide), a 

diuretic to remove fluid build-up by increasing 

the amount of urine produced. No history 

of recent events was taken, and no physical 

examination was recorded – the GP did not 

remove the footwear MV was wearing. 

Three days later, MV presented to hospital 

with a high fever and a gangrenous right 

foot that eventually required an amputation 

below the knee. MV subsequently commenced 

legal proceedings against the GP. This case 

was subsequently settled out of court for an 

undisclosed sum. 

Discussion 

The lack of compliance and the apparent refusal 

to follow-up with the relevant endocrinologists 

will have contributed to the ultimate 

* CP=chest pains; SOB=shortness of breath. 

Page points 

1. It is important for GPs to 

understand the legal definition 

of negligence. 

2. There can be numerous reasons 

why someone is not compliant 

with treatment, such as caring 

for dependent family members 

or having no transport to get to 

appointments. 


Medicolegal case of a person with type 2 diabetes 

Page points 

1. It is within the competence of 

all GPs practising in Australia 

to identify those individuals 

with diabetes who are poorly 

controlled and who are at 

significant risk of developing the 

complications of the condition. 

2. Understanding the reasons why 

someone is non-compliant or 

not reaching their glycaemic 

target requires thorough 

investigation and attempts to 

remedy the situation. 

complications that MV developed, which was 

accepted by their legal representatives. It is 

not known why MV was non-compliant; there 

are multiple causes of non-compliance, such 

as caring for dependent family members or 

having no transport to get to appointments. 

That being said, while it is an issue for the 

treating GP, it should not effect how an 

individual’s care is managed to ensure duty of 

care is maintained. The onus was on the GP to 

ensure an appropriate HbA 1c 

target was set and 

to record discussions of the consequences of 

poor glycaemic control in the medical notes. 

Had this been done, there would have been no 

case for the GP to answer. 

Conclusion 

It is within the competence of all GPs 

practising in Australia to identify those 

individuals with poorly controlled diabetes 

who are at significant risk of developing the 

complications of the condition. HbA 1c 

has 

been the benchmark for assessing glycaemic 

control since the landmark UKPDS (UK 

Prospective Diabetes Study, 1998). The UKPDS 

established that retinopathy, nephropathy and 

possibly neuropathy are benefited by lowering 

blood glucose in type 2 diabetes with intensive 

therapy compared to conventional therapy. 

The intensive treatment arm achieved a 

median HbA 1c 

of 53 mmol/mol (7%) while 

the conventional therapy arm achieved a 

median HbA 1c 

of 63 mmol/mol (7.9%). The 

overall microvascular complication rate was 

decreased by 25% when following the intensive 

treatment (Genuth et al, 2002). It is critical 

that GPs practising in Australia should assess 

the HbA 1c 

level and know that 53 mmol/mol 

(7%) should be the goal for treatment as 

per current individualised targets for HbA 1c 

(Australian Diabetes Society, 2009). That said, 

understanding the reasons why someone is 

non-compliant or not reaching their glycaemic 

target requires thorough investigation and 

attempts to remedy the situation. 

The only way to mitigate the risk of legal 

proceedings is to demonstrate clear and 

effective documentation as to the goals of 

treatment for diabetes. The Chronic Disease 

Management Plan (Medicare item No. 721) is 

a useful tool to use to set goals in a clear and 

evidence-based manner. 

This instructive case serves as a reminder 

to all GPs, regardless of their competence 

in treating type 2 diabetes, of the need to 

communicate the risks of not complying with 

appropriate lifestyle modification and antidiabetes 

medicines, and having very high 

HbA 1c 

levels for a prolonged period of time. 

The dictum of “no notes, no defence” still holds 

true and reminds all GPs to maintain clearly 

structured, detailed, contemporaneous notes 

and to detail issues such as poor compliance 

and its consequences, thereby ensuring the risk 

of litigation is mitigated. 

n 

Australian Diabetes Society (2009) Australian Diabetes Society 

Position Statement: Individualization of HbA 1c 

targets for adults 

with diabetes mellitus. The Australian Diabetes Society, Sydney, 

NSW 

Australian Institute of Health and Welfare (2012) Public and private 

sector medical indemnity claims in Australia 2009–10. Australian 

Government, Canberra, ACT. Available at: http://www.aihw.gov. 

au/WorkArea/DownloadAsset.aspx?id=60129547938 (accessed 

10.05.16) 

Australian Institute of Health and Welfare (2014) Australia’s medical 

indemnity claims 2012–13. Australian Government, Canberra, 

ACT. Available at: http://www.aihw.gov.au/publicationdetail/?id=60129547940 


Genuth S, Eastman R, Kahn R et al (2002) Implications of the United 

Kingdom Prospective Diabetes Study. Diabetes Care 25(Suppl 1): 

S28–S32 

Gunton JE, Cheung NW, Davis TM et al (2014) A new blood glucose 

algorithm for type 2 diabetes. A position statement of the 

Australian Diabetes Society. Med J Aust 201: 650–3 

Kroesche N, Jammal W (2015) A pain in the back: Difficult patient, 

difficult diagnosis. Medicine Today 16: 55–6 

UK Prospective Diabetes Study Group (1998) Intensive bloodglucose 

control with sulphonylureas or insulin compared with 

conventional treatment and risk of complications in patients with 

type 2 diabetes (UKPDS 33). Lancet 352: 837–53 


Article 

Diagnosing type 1 diabetes and diabetic 

ketoacidosis in children 

Fergus Cameron, Gary Kilov, Ralph Audehm 

One in three children present in diabetic ketoacidosis (DKA) when they are diagnosed 

with type 1 diabetes. DKA is a life-threatening complication of hyperglycaemia, therefore 

avoiding DKA and providing a swift diagnosis of type 1 diabetes is paramount. The authors 

cover the symptoms and diagnosis of type 1 diabetes and DKA and provide examples to 

raise awareness with parents, carers and the community. 

Globally, 30% of children newly 

diagnosed with type 1 diabetes 

present in diabetic ketoacidosis (DKA; 

Silverstein et al, 2005). DKA is the combination 

of hyperglycaemia, metabolic acidosis and 

ketonaemia. It may be the first presentation for 

a child with previously undiagnosed diabetes. 

DKA is caused by hyperglycaemia by a total 

omission of insulin production and secretion. 

It can develop over a few hours or days. In 

DKA, as glucose is unable to be used for energy, 

fat is used and, as a result, ketone bodies are 

produced. In high levels, ketone bodies are toxic 

and can ultimately lead to death. 

DKA is the leading cause of diabetes-related 

deaths in children, so it is imperative that 

clinicians are aware of the symptoms and 

act fast when type 1 diabetes and DKA is 

suspected. Delayed DKA diagnosis can lead to 

a detrimental effect on attention and memory. 

Cameron et al (2014) used magnetic resonance 

imaging (MRI) and spectroscopy with cognitive 

assessment to compare cognitive function in 

children who had previously had DKA with 

children who had not (controls). Early brain 

changes caused by DKA resolved after the 

first week; however, 6 months later, these 

brain changes were associated with persisting 

alterations in attention and memory. 

It has been reported that nearly half of 

children presenting with DKA have seen a GP 

in the preceding week and were not diagnosed 

with type 1 diabetes (Bui et al, 2010). In 

2013, the incidence of type 1 diabetes in 

children was 11 per 100 000 of the population 

(Australian Institute of Health and Welfare, 

2015). This means that many primary care 

health professionals will rarely see a case of 

new-onset type 1 diabetes. It is, therefore, 

understandable that diagnosis of type 1 diabetes 

is often delayed. 

Type 1 diabetes and DKA symptoms 

Early identification of type 1 diabetes in children 

and urgent referral can prevent DKA from 

developing. According to the Australian arm 

of the Juvenile Diabetes Research Foundation 

(2015), the following are a list of type 1 diabetes 

symptoms can occur in children: 

l Extreme thirst. 

l Constant hunger. 

l Sudden weight loss. 

l Frequent urination. 

l Nocturnal enuresis (night time bedwetting) 

– especially in a previously dry 

child. 

l Polyuria (production of abnormally large 

volumes of dilute urine). 

l Pollakiuria (frequent urination during 

daylight hours). 

l Blurred vision. 

l Nausea. 

l Vomiting. 

l Extreme tiredness. 

l Infections. 

l Dehydration (sunken eyes, dry skin, dry 

mucous membranes). 

The symptoms of DKA will include the 

symptoms of type 1 diabetes, as well as the 

following: 

Citation: Cameron F, Kilov G, 

Audehm R (2016) Diagnosing type 1 

diabetes and diabetic ketoacidosis 

in children. Diabetes & Primary Care 

Australia 1: 97–100 


1. If left undiagnosed, 

type 1 diabetes and diabetic 

ketoacidosis can lead to death. 

2. Symptoms can be non-specific 

so diagnosis can sometimes 

be delayed for some time even 

though the diagnostic test is 

rapid and straightforward. 

3. It is imperative to raise 

awareness of the symptoms of 

diabetes among parents, carers 

and healthcare professionals. 

Key words 

– Children 

– Diabetic ketoacidosis 

– Type 1 diabetes 

Authors 

Fergus Cameron is Deputy 

Director of the Department of 

Endocrinology and Diabetes, 

Royal Children’s Hospital, 

Melbourne, Vic; Gary Kilov is 

General Practitioner, The Sea 

Port Practice, Tasmania, Tas; 

Ralph Audehm is Honorary 

Fellow, Department of General 

Practice, University of Melbourne, 

Melbourne, Vic. 


Diagnosing type 1 diabetes and diabetic ketoacidosis in children 

Page points 

1. As parents or carers may not 

mention polyuria or bedwetting 

in a previously “dry” 

child during appointments, a 

doctor must carefully draw out 

this information. 

2. It is time to raise the profile of 

type 1 diabetes and ensure it is 

considered in all children who 

present unwell. 

l Abdominal pain. 

l Kussmaul breathing (rapid, laboured 

breathing). 

l Fruity breath – caused by ketone bodies. 

l Confusion. 

l Flu-like symptoms. 

Polyuria and polydipsia are the main symptoms 

of type 1 diabetes in all age groups. As parents or 

carers may not mention these symptoms during 

appointments, a doctor must carefully draw out 

this information. Bed wetting in a previously 

“dry” child can be one of the first symptoms of 

diabetes and was observed in 89% of children 

over the age of 4 years (Vanelli et al 1999; Roche 

et al, 2005). However, diagnosing polyuria and 

polydipsia can be extremely difficult in children 

under 2 years. 

It is important to note that diabetes and DKA 

symptoms can be non-specific (e.g. nausea and 

vomiting, and abdominal pain), even though a 

child can already be pre-comatose and at risk 

of death. 

Interestingly, children who have previously 

been seen by primary care physicians often 

present with worse DKA (Lokulo-Sodipe et 

al, 2013). The reassurance of having seen a 

healthcare professional or the delay caused by 

waiting for test results can ultimately delay 

attendance to the emergency department. In 

a 3-month study in the UK, 46% of delayed 

presentations to secondary care of children 

with new-onset type 1 diabetes and DKA had 

received non-urgent investigations at primary 

care (Lokulo-Sodipe et al, 2014). 

Diagnosing type 1 diabetes 

Given the potentially fatal consequences of 

undiagnosed and untreated type 1 diabetes, 

excluding or confirming a diagnosis of type 1 

diabetes in an unwell child is important and can 

be done quickly and easily. All children who are 

unwell with any of the symptoms above should 

have a urine or finger-prick blood glucose test 

(Wolfsdorf et al, 2009). Glucose in the urine 

or a random blood glucose level ≥11.1 mmol/L 

should alert clinicians to refer the child to the 

nearest emergency department; this goes to say 

that all children newly diagnosed with type 1 

diabetes should be referred to the emergency 

department. A fasting blood glucose test, oral 

glucose tolerance test (OGTT) or HbA 1c 

test 

are not necessary to make a diabetes diagnosis. 

Waiting for confirmatory blood tests can delay 

treatment in children and increase the risk of 

DKA and death. 

Diagnosing DKA in children with 

established type 1 diabetes 

According to the clinical practice guidelines 

of The Royal Children’s Hospital Melbourne 

(2016), children with a blood glucose level 

≥11.1 mmol/L should have blood ketones tested 

on a capillary sample. If this test is positive 

(>0.6 mmol/L), assess for acidosis to determine 

further management. Analysis of urine for 

ketones can also be used if blood ketone testing 

is not available. Again, if ketones are detected 

in a child with new-onset type 1 diabetes, they 

should be immediately referred to the nearest 

emergency department. 

Raising awareness of type 1 diabetes 

It is time to raise the profile of type 1 diabetes 

and ensure it is considered in all children 

who present unwell. A new diagnosis of 

type 1 diabetes is five times more common 

than meningococcal meningitis (Children 

with diabetes in the UK, 2012). Primary care 

physicians are often concerned about missing 

a diagnosis of meningococcal meningitis, yet 

missing a diagnosis of type 1 diabetes has 

equally profound consequences and can also 

lead to death. Compared to the effort that 

goes into raising awareness and supporting the 

early recognition of meningococcal meningitis, 

raising type 1 diabetes awareness is frequently 

overlooked (Children with diabetes in the UK, 

2012). 

Awareness campaigns have been proven to 

increase early identification of type 1 diabetes 

in children and reduce the incidence of DKA. 

Raising parental awareness of the symptoms 

of type 1 diabetes has been shown to be 

protective and reduce the likelihood of a child 

developing DKA (Lokulo-Sodipe et al, 2014). 

In Parma, Italy, an 8-year awareness campaign 

was launched providing information on DKA to 



teachers, students, parents and paediatricians. 

Group 1, who had access to information, were 

compared to group 2, who had no access. In 

the 4 years prior to the program (1987–1991), 

the incidence of DKA were 78% in group 1. 

During the campaign, the incidence of DKA 

fell to 12.5%. In group 2, the control group, 

83% were diagnosed with DKA during the 

study period. In group 1, after the first 2 years 

of the campaign, none of the newly diagnosed 

children with type 1 diabetes were admitted to 

the diabetes unit with severe or moderate DKA 

(Vanelli et al, 1999). 

A campaign in Gosford, Sydney, has also 

demonstrated the positive impact of improving 

DKA education. After a 2-year program to raise 

awareness of the symptoms of type 1 diabetes, 

there was a decrease in the presentation of 

children in DKA by over 60% (King et al, 

2012). In the campaign areas, the proportion 

of children presenting in DKA significantly 

decreased from 37.5% during the 2-year baseline 

period to 13.8% during the 2-year intervention. 

During this time, there was no significant change 

in the control regions, where no awareness 

campaign was in place. The programme offered 

education and provided posters on type 1 

diabetes symptoms to childcare centres, schools 

and doctor’s offices, and offered glucose and 

ketone testing equipment to GP surgeries. 

Conclusion 

The serious complication of DKA and 

undiagnosed type 1 diabetes can be averted 

with rapid diagnosis using a simple glucose 

test. We recommend sharing this article with 

colleagues and using resources from successful 

campaigns and programmes that raise awareness 

for parents, carers and healthcare professionals 

(see Figure 1 overleaf for examples). Although 

produced overseas, these resources are relevant 

for the Australian population. 

Learning points 

l Type 1 diabetes can occur at any age and is 

easily diagnosed if suspected. 

l Polyuria, polydipsia, bed-wetting and 

weight loss are the usual early symptoms. 

l Positive results of glucose in the urine and 

a random finger-prick blood glucose level 

≥11.1 mmol/L in a child with symptoms of 

diabetes is indicative of diabetes. 

l A fasting blood glucose level, OGTT or 

HbA 1c 

are not necessary when diagnosing 

diabetes in a child with suspected 

type 1 diabetes. Carrying out such tests and 

waiting for results can delay treatment. 

l If diabetes is suspected, refer all children 

immediately, and all children newly 

diagnosed with type 1 diabetes should be 

referred to the emergency department. 

l Early diagnosis and immediate referral to 

a doctor experienced in the management 

of type 1 diabetes in children can prevent 

DKA. 

n 

Australian Institute of Health and Welfare (2015) Incidence of 

type 1 diabetes in Australia 2000–2013. AIHW, Canberra, ACT. 

Available at: http://www.aihw.gov.au/how-common-is-diabetes 

(Accessed 17.05.16) 

Bui H, To T, Stein R et al (2010) Is diabetic ketoacidosis at disease 

onset a result of missed diagnosis? J Pediatr 156: 472-7 

Cameron, Scratch SE, Nadebaum C et al (2014) Neurological 

consequences of diabetic ketoacidosis at initial presentation 

of type 1 diabetes in a prospective cohort study of children. 


Children with diabetes in the UK (2012) Could my child have 

diabetes? Children with diabetes in the UK. Children with 

diabetes Advocacy Group, UK. Available at: http://www. 

childrenwithdiabetesuk.org/diabetes-basics/could-my-childhave-diabetes/ 


JDRF (2015) Type 1 diabetes symptoms. JDRF, Sydney, NSW. 

Available at: http://www.jdrf.org.au/type-1-diabetes/ 

symptoms#sthash.EUNM3Gdk.dpuf (accessed 17.05.16) 

King BR, Howard NJ, Verge CF et al (2012) A diabetes awareness 

campaign prevents diabetic ketoacidosis in children at their initial 

presentation with type 1 diabetes. Pediatr Diabetes 13: 647–51 

Lokulo-Sodipe K, Moon RJ, Edge JA et al (2014) Identifying targets 

to reduce the incidence of diabetic ketoacidosis at diagnosis of 

type 1 diabetes in the UK. Arch Dis Child 99: 438–42 

Roche EF, Menon A, Gill D, Hoey H (2005) Clinical presentation of 

type 1 diabetes. Pediatr Diabetes 6: 75–8 

Silverstein J, Klingensmith G, Copeland K et al (2005) Care of 

children and adolescents with type 1 diabetes. Diabetes Care 28: 

186–212 

The Royal Children's Hospital Melbourne (2016) Diabetes mellitus. 

The Royal Children's Hospital Melbourne, Melbourne, Vic. 

Available at: http://www.rch.org.au/clinicalguide/guideline_ 

index/Diabetes_Mellitus/ (accessed 18.05.16) 

Vanelli M, Chiari G, Ghizzoni L et al (1999) Effectiveness of a 

prevention program for diabetic ketoacidosis in children. 


Wolfsdorf J, Craig ME, Daneman D et al (2009) Diabetic 

ketoacidosis in children and adolescents with diabetes. Pediatr 

Diabetes 10 (Suppl 12): 118–33 

"Share this article 

with colleagues and 

use resources from 

successful campaigns 

and programmes 

that raise awareness 

for parents, carers 

and healthcare 

professionals." 



a) 

b) 

Could your Child have 

Type 1 diabeTes? 

If your child is going to the toilet a lot, 

has increased thirst, is more tired than 

usual or is losing weight, it could be a 

sign they have Type 1 diabetes. If not 

diagnosed early enough, Type 1 diabetes 

can be fatal. Don’t delay – if your child is 

experiencing any of the 4 Ts, visit your 

doctor immediately for a test. 

www.diabetes.org.uk/The4Ts 

A charity registered in England and Wales (215199) and in Scotland (SC039136). 

9890/1012/a 

c) 

Figure 1. Examples of simple messages that have been developed to raise awareness among parents and healthcare professionals of the symptoms of 

diabetes: a) Poster produced by the Juvenile Diabetes Research Foundation (available to download at: http://bit.ly/1Ozlfjp [accessed 18.05.16]); 

b) The 4Ts campaign from Diabetes UK (available to download at: https://www.diabetes.org.uk/The4Ts [accessed 09.06.16]); c) Pathway for clinicians 

to diagnose type 1 in children (King et al, 2012). 


Article 

To carb or not to carb in diabetes 

management 

Sunita Date 

The following article aims to provide a brief summary of current dietary guidelines and 

research findings for the dietary management of type 2 diabetes and type 1 diabetes. Lowcarbohydrate, 

high-fat diets have recently become popular, and have caught the attention 

of some members of the scientific community and the public. The author will consider the 

current research and present the evidence demonstrating why we should be cautious of the 

low-carbohydrate diet, citing international guidelines to instead promote an individualised, 

balanced diet. 

The Australian Dietary Guidelines provide 

information for the general population on 

eating for health and wellbeing (National 

Health and Medical Research Council, 2013). 

The guidelines have a strong evidence-base 

and include the principles of achieving and 

maintaining a healthy weight, being physically 

active and choosing amounts of nutritious food 

and drinks to meet energy needs; enjoying a wide 

variety of nutritious foods from the five groups 

every day (Figure 1); and limiting intake of foods 

containing saturated fat, added salt, added sugars 

and alcohol. 

Medical nutrition therapy in diabetes 

Insulin responds directly to food ingested, 

so diet has always been an integral part of 

the management of diabetes and glycaemic 

control. People with diabetes are encouraged to 

follow the dietary guidelines and consume the 

recommended amounts of food from the five 

food groups (grains, vegetables, fruits, dairy and 

protein). 

Over recent years, the term “diet therapy” 

has been replaced with medical nutrition 

therapy (MNT) and encompasses individualised 

nutritional recommendations based on 

assessment and treatment goals and outcomes, 

with consideration to usual eating habits and 

lifestyle factors (Escott-Stump, 2008). MNT 

is considered the first line of treatment in the 

prevention and management of type 2 diabetes 

and is an essential part in the management of 

type 1 diabetes (Marsh et al, 2011). 

In this article, current dietary guidelines for 

adults and children with diabetes are discussed, 

as is the evidence demonstrating why we should 

be cautious of the low-carbohydrate diet – a diet 

that has gained in popularity over recent years. 

MNT guidelines for adults 

with diabetes 

The American Diabetes Association (ADA) 

standards of medical care (ADA, 2016) identifies 

MNT as an integral component of diabetes 

prevention, management and self-management 

education, indicating that all individuals with 

diabetes should receive individualised MNT 

provided by a registered dietitian with the 

appropriate knowledge and skills in diabetes. 

The goals of MNT for adults with diabetes are 

the following: 

l Promote and support healthy eating patterns, 

acknowledging the inclusion of nutrient-dense 

foods in appropriate portion sizes. 

l Acknowledge nutritional needs based on 

individual and cultural preferences, health 

literacy and numeracy skills, access to foods 

and behavioural changes, and barriers to 

change. 

Citation: Date S (2016) To carb or 

not to carb in diabetes management. 

Diabetes & Primary Care Australia 

1: 101–5 


1. Low-carbohydrate diet has 

gained in popularity over recent 

years for people with type 2 

diabetes for weight loss and 

improved glycaemic control. 

2. No diet exists that will work for 

everyone with diabetes and, 

hence, focus on one particular 

type of diet may not be helpful. 

3. Consuming a wide range 

of nutritious foods in 

recommended portion sizes 

to achieve optimal health 

and diabetes management 

is vital and can be achieved 

by seeking individualised 

nutrition care from an 

accredited practising dietitian. 

Key words 

– Carbohydrate 

– Fat 

– Low-carb diet 

– Macronutrients 

– Protein 

Author 

Sunita Date is Senior Diabetes 

Dietitian at Launceston General 

Hospital, Launceston, Tas. 


To carb or not to carb in diabetes management 

and good health. 

l Achieve and maintain an appropriate BMI 

and waist circumference. 

l Achieve a balance between food intake, 

metabolic requirements, energy expenditure 

and insulin action to attain optimum 

glycaemic control. 

l Prevent and treat acute complications of 

diabetes. 

l Reduce the risk of micro and macro-vascular 

complications. 

l Maintain and preserve quality of life. 

l Develop a supportive relationship to facilitate 

behaviour change. 

Page points 

Figure 1. Australian guide to healthy eating (National Health and Medical 

Research Council, 2013). 

1. International dietary guidelines 

for adults and children with 

diabetes recommend that 

individuals follow a balanced 

diet including elements from all 

food groups. 

2. Carbohydrate has been 

considered the predominant 

macronutrient affecting 

postprandial glucose levels. 

3. Choosing low glycaemic 

index foods or lowering the 

total carbohydrate content 

of the meal can decrease the 

glycaemic load of the meal and 

reduce postprandial glucose 

excursion. 

l Provide non-judgmental messages about food 

so that individuals can continue to experience 

the pleasure of eating. 

l Provide practical tools for healthy eating 

patterns rather than focusing on individual 

macro- and micro-nutrients. 

MNT guidelines for children 

with diabetes 

The 2014 International Society for Pediatric 

and Adolescent Diabetes (ISPAD) clinical 

practice consensus guidelines for the nutritional 

management of children and adolescents with 

diabetes identify similar recommendations. The 

recommendations are based on healthy eating 

principles suitable for children and families with 

aims to improve diabetes outcomes and reduce 

cardiovascular risk (Smart et al, 2014): 

l Encourage appropriate eating behaviours. 

l Incorporate a variety of nutritious foods from 

all food groups that will supply essential 

nutrients, maintain a healthy weight and 

prevent bingeing. 

l Provide appropriate energy intake and 

nutrients for optimal growth, development 

Effect of macronutrients on 

glycaemic control 

National guidelines in Australia and Canada for 

adults and children with diabetes recommend 

that 40–60% of energy comes from carbohydrate 

intake, 30–35% of energy comes from fat, with 

less than 10% of energy from saturated fat, and 

15–20% of energy from protein based on an 

individualised assessment (Smart et al, 2014). 

Carbohydrate 

Carbohydrate has been considered the 

predominant macronutrient affecting 

postprandial glucose levels; however, recent 

studies using continuous glucose monitoring 

systems have demonstrated the significant effect 

of fat, protein and glycaemic index (GI) on 

postprandial glucose excursion (Bell et al, 2015). 

Glycaemic index and glycaemic load 

The glycaemic index (GI) is a ranking of 

carbohydrates on a scale of 0 to 100 according 

to the extent to which the carbohydrate raises 

blood glucose levels after eating. High-GI foods 

are rapidly digested and absorbed, and so result 

in fluctuations and spikes in blood glucose level. 

Low-GI foods are digested and absorbed slowly 

and result in gradual rises in blood glucose level 

and insulin levels. Low-GI foods have proven 

benefits for health (Greenwood et al, 2013). The 

“glycaemic load” (GL) combines the quantity 

and quality of carbohydrate to estimate the 

overall effect of ingested carbohydrate on blood 

glucose and insulin levels. GL can be used 



to compare different amounts of foods with 

different GIs and is calculated by multiplying 

the GI by the amount of carbohydrate per 

serving of food in grams. Choosing low GI 

foods or lowering the total carbohydrate content 

of the meal can decrease the GL of the meal and 

reduce postprandial glucose excursion. 

The effect of GI and the GL in people 

with diabetes is complex. Lower GI diets 

may assist in the management of type 1 and 

type 2 diabetes but are not associated with 

weight loss (Greenwood et al 2013; National 

Health and Medical Research Council, 2013). 

Individuals with diabetes are encouraged to 

replace refined carbohydrates and added sugars 

with whole grains, legumes, vegetables and 

fruit and consider avoiding low-fat, non-fat 

products with high amounts of added sugars 

(ADA, 2016). 

nts were recruited, with 27 completing 

participants withdrew prior to com- 

Fat 

In a systematic review of the effect of fat 

on postprandial glycaemic control in 

type 1 diabetes, the evidence suggests that meals 

containing carbohydrates and that are high in 

inical characteristics dietary fat cause of sustained participants late (N postprandial = 27) 

hyperglycaemia (Bell et al, 2015). 

The studies investigated added varying 

amounts of fat (6.6 to 52 g) to a test meal. 

A meal with a high fat content was found to 

delay gastric emptying for up to 2 hours and 

11 

increase the risk of hypoglycaemia followed 

16 

by substantial hyperglycaemia for several 

y, n 14 

hours postprandially, which has an effect on 

ion therapy, n 12 

glycaemic control. This observation may be 

21.7 11.7 

s, years 

attributed to the 

7.8 

increased 

6.8 

free fatty acids, 

%) which induce insulin 52 resistance, 9.1 (6.9 and 0.8) increased 

hepatic glucose output 21 (Roden 3.1 et al, 1996). 

The ADA (2016) identifies inconclusive data 

s means on the SD. 

effect of total fat intake and gives no 

tolerable upper level for intake. The type of 

fat consumed is considered to be of more 

significance than the total amount of fat, with 

resented meals as rich counts in monounsaturated and percentages fat compared for to 

andsaturated mean fat found sd for to have continuous a beneficial effect vari-on 

glycaemic control and blood lipids. 

ch as differences in means, are presented 

nterest with 95% CI. 

Protein 

Meals rich in protein may result in delayed 

and sustained postprandial glucose excursions 

requiring increased insulin in people with 

type 1 diabetes (Paterson et al, 2016). It has 

been suggested that the addition of ≥28 g of 

protein to a mixed meal or consuming ≥75 g 

of protein alone is likely to result in significant 

and sustained postprandial hyperglycaemia 

commencing in the late postprandial period 

and continuing beyond 5 hours in people with 

type 1 diabetes (Paterson et al, 2015). It has 

been demonstrated that there is a continued 

rise in blood glucose levels over 5 hours for a 

75 g to 100 g protein intake compared to 20 g 

glucose (Paterson et al, 2016; see Figure 2). 

Dietary fat and protein have been found 

to impact postprandial glycaemic control 

in people with type 1 diabetes long after 

consuming food, and the effect of protein and 

fat is found to be additive on postprandial 

glucose concentrations (Paterson et al, 2015). 

Insulin dosing algorithms based on the total 

meal composition compared to carbohydrate 

content alone requires further investigation 

(Bell et al, 2015). 

Diabetes & Primary Care Australia Vol 1 No 3 2016 103 

Blood Glocose Excursion 

−2 −1 0 1 2 3 4 5 

Page points 

1. In a systematic review of the 

effect of fat on postprandial 

glycaemic control in type 1 

diabetes, the evidence suggests 

that meals containing 

carbohydrates and are high in 

dietary fat cause sustained late 

postprandial hyperglycaemia. 

2. Meals rich in protein may 

result in delayed and sustained 

postprandial glucose excursions 

requiring increased insulin in 

people with type 1 diabetes. 

3. Dietary fat and protein have 

both been found to impact 

postprandial glycaemic control 

in people with type 1 diabetes 

long after consuming food, 

and the effect of protein and 

fat is found to be additive 

on postprandial glucose 

concentrations. 

DIABETICMedicine 

0 100 200 

Time in minutes 

300 

Control 12.5g Protein 25g Protein 50g Protein 

75g Protein 100g Protein 10g CHO 20g CHO 

Figure 2. Mean postprandial glycaemic excursions (mmol/L) for 27 participants following 

consumption of 8 test drinks containing 0, 12.5, 25, 50, 75 and 100 g of protein; with two 

glucose (CHO) test drinks given for comparison, in amounts of 10 and 20 g without insulin. 

Compared with 0; protein loads of 75 g or 100 g produced significantly higher glycaemic 

excursions from 180–240 min (P=0.002) and 240–300 min (P


Page points 

1. It can be difficult to measure the 

success of the low-carbohydrate 

diet in studies as the definition 

of low carbohydrate can vary 

from study to study. 

2. Although some nutritional 

professionals may consider 

a low-carbohydrate, high-fat 

diet to achieve short-term 

health goals, the effectiveness 

and safety over an extended 

period of time have not been 

examined. 

3. A diet high in total fat and 

saturated fat and low in 

carbohydrates can worsen 

diabetes control in individuals 

with type 1 diabetes. 

For individuals with diabetes with normal 

kidney function, the ADA (2016) suggests 

that the evidence is inconclusive about 

recommending an ideal amount of protein 

for optimal glycaemic control. For those with 

diabetic kidney disease, dietary protein should 

be maintained at the recommended daily 

allowance of 0.8 g/kg body weight per day. 

Low-carbohydrate, high-fat, highprotein 

diet 

In recent times, there has been an increasing trend 

towards following a low-carbohydrate, high-fat, 

high-protein diet for diabetes management to 

promote glycaemic control and encourage weight 

loss. It can be difficult to measure the success of the 

low-carbohydrate diet in studies as the definition 

of low carbohydrate can vary from study to study. 

Feinman et al (2015) suggested the following 

carbohydrate amounts for low, medium or highcarbohydrate 

diets based on recommendations 

from the ADA and National Health and Nutrition 

Examination Survey. 

l Low-carbohydrate diet: 230 g/day of 

carbohydrate (Feinman et al, 2015). 

Dietitians Association of Australia (2015) 

recently released a summary of key conclusions 

regarding the use of low-carbohydrate, highfat, 

high-protein diets in diabetes management 

and identified that no diet exists that works for 

everyone with diabetes and, hence, focus on one 

particular type of diet may not be helpful. 

Low-carbohydrate, high-fat, high-protein diet 

in type 2 diabetes 

Tay et al (2015) recently conducted a randomised 

control trial in 115 obese individuals with 

type 2 diabetes comparing the effect of a verylow 

carbohydrate, high-unsaturated fat diet 

(VLCHF) to a high-carbohydrate, low-fat diet 

(HCLF) for 52 weeks. The energy distribution 

in the LCHF diet was 14% of energy as 

carbohydrate, 28% energy as protein and 58% 

energy as fat, with less than 10% saturated fat. 

The HCLF diet comprised of 53% energy from 

carbohydrate, 17% energy from protein and 

30% of energy from fats, with less than 10% 

energy from saturated fat. Both study groups 

were involved in moderate-intensity aerobic and 

resistance exercises for diabetes management 

3 days a week with regular reviews throughout 

the study period. 

Results identified that both groups were 

able to achieve substantial weight loss and a 

reduction in HbA 1c 

and fasting glucose levels. 

The VLCHF diet, high in unsaturated fat 

and low in saturated fat, achieved greater 

improvements in lipid profile and blood 

glucose levels, and a reduction in anti-diabetes 

medication. The weight loss observed in both 

groups was attributed to the intense lifestyle 

intervention of the study, which included a 

detailed diet and exercise prescription with 

regular professional support. 

The study had some limitations and excluded 

individuals with comorbidities commonly 

associated with diabetes, such as impaired 

renal function, cardiovascular disease and a 

history of smoking. Also, the long-term impacts 

of such diets on health parameters, as well as 

the potential impacts on overall nutritional 

intake in view of whole food groups being 

reduced, warrants further investigation prior to 

recommending this approach at a population 

level, such as a very-low carbohydrate ketogenic 

diet providing 20–50 g carbohydrate per day 

(Evert et al, 2014). Although some nutritional 

professionals may consider a low-carbohydrate, 

high-fat diet to achieve short-term health goals, 

the effectiveness and safety over an extended 

period of time have not been examined 

(Dietitians Association of Australia, 2015). 

In order for similar results to those reported by 

Tay et al (2015) to be replicated in a community 

setting, it may be necessary for medical teams 

to consider a focused multidisciplinary lifestyle 

intervention prescription for the prevention 

and management of diabetes. Individuals with 

diabetes need support from an experienced, 

multidisciplinary healthcare team, and selfmanagement 

advice needs to be tailored to 

individual needs to help them manage their 

diabetes. 




in type 1 diabetes 

A diet high in total fat and saturated fat and low 

in carbohydrates can worsen diabetes control 

in individuals with type 1 diabetes (Dworatzek 

et al, 2013). High-fat, high-protein meals 

require more insulin to control late postprandial 

hyperglycaemia than low-fat and protein meals 

with similar carbohydrate content (Bell et al, 

2015). It is anticipated that a low-carbohydrate, 

high-fat high-protein diet for individuals 

with type 1 diabetes will require insulin dose 

adjustments for excess protein to reduce the risk 

of unstable blood glucose levels (Paterson et al, 

2015). 

One of the challenging aspects of type 1 

diabetes management is carbohydrate counting. 

With high-fat, high-protein diets warranting 

quantification to determine insulin dosing, this 

may further create additional burden that few 

can overcome (Bell et al, 2015). 


in children and adolescents 

Bearing in mind the recent popularity of the 

low-carbohydrate, high-fat, high-protein diet in 

diabetes, there is international agreement that 

carbohydrates should not be restricted in children 

and adolescents with type 1 diabetes as it may 

result in deleterious effects on growth (Smart 

et al, 2014) High-protein diets comprising of 

>25% energy are also not advised in children for 

similar reasons. Meals rich in protein may result 

in delayed and sustained postprandial glucose 

excursions requiring increased insulin in people 

with type 1 diabetes (Paterson et al, 2016). 

Conclusion 

Diabetes is a serious and complex condition, 

and there is no standard eating plan that works 

universally for all people with diabetes. Effective 

nutrition therapy is based on individualised 

health goals, awareness of cultural and personal 

preferences, health literacy and numeracy, access 

to healthy choices and a readiness, willingness 

and ability to change (Evert et al, 2014). 

The evidence-based Australian Dietary 

Guidelines released in 2013 provide the most 

appropriate guide to healthy eating for the 

entire population (National Health and Medical 

Research Council, 2013). Consuming a wide 

range of nutritious foods in recommended 

portion sizes to achieve optimal health and 

diabetes management is vital and can be achieved 

by seeking individualised nutrition care from an 

accredited practising dietitian. 

n 

American Diabetes Association (2016) Foundations of Care and 

Comprehensive Medical Evaluation. Diabetes Care 39(Suppl 1): 

S23–35 

Bell KJ, Smart CE, Steil GM et al (2015) Impact of fat, protein, and 

glycaemic index on postprandial glucose control in type 1 

diabetes: implications for intensive diabetes management in the 

continuous glucose monitoring era. Diabetes Care 38: 1008–15 

Dietitians Association of Australia (2015) Low carbohydrate diets in 

diabetes, Deakin, ACT. Available at: http://daa.asn.au/for-themedia/hot-topics-in-nutrition/low-carbohydrate-high-fat-dietsfor-diabetes/ 


Dworatzek PD, Arcudi K, Gougeon R et al (2013) Canadian 

Diabetes Association Clinical Practice Guidelines Expert 

Committee. Can J Diabetes 37: S45–55 

Escott-Stump S (2008) Nutrition and Diagnosis – Related Care (6 th 

edition). Lippincott Williams & Wilkins, PA, USA. 

Evert A, Boucher JL, Cypress M et al (2014) Nutrition therapy 

recommendations for the management of adults with diabetes. 

Diabetes Care 37(Suppl 1): 120–43 

Feinman RD, Pogozelski WK, Astrup A (2015) Dietary carbohydrate 

restriction as the first approach in diabetes management: 

Critical review and evidence base. Nutrition 31: 1–13 

Greenwood DC, Threapleton DE, Evans CE et al (2013) Glycaemic 

index, glycaemic load, carbohydrates, and type 2 diabetes: 

Systematic review and dose-response meta-analysis of 

prospective studies. Diabetes Care 36: 4166–71 

Marsh K, Barclay A, Colagiuri S, Brand-Miller J (2011) Glycaemic 

index and glycaemic load of carbohydrates in the diabetes diet. 

Curr Diab Rep 11: 120–27 

National Health and Medical Research Council (2013) Australian 

Dietary Guidelines. NHMRC, Canberra, ACT. Available at: 

www.eatforhealth.gov.au (accessed 02.06.16) 

Paterson M, Bell KJ, O’Connell SM et al (2015) The role of 

dietary protein and fat in glycaemic control in type 1 diabetes: 

implications for intensive diabetes management. Curr Diab Rep 

15: 61 

Paterson M, Smart CE, Lopez PE et al (2016) Influence of dietary 

protein on postprandial blood glucose levels in individuals with 

type 1 diabetes mellitus using intensive insulin therapy. Diabet 

Med 33: 592–8 

Roden M, Price TB, Perseghin G et al (1996) Mechanism of free 

fatty acid-induced insulin resistance in humans. J Clin Invest 97: 

2859–65 

Smart CE, Annan F, Bruno LP et al (2014) ISPAD Clinical Practice 

Consensus Guidelines 2014 Compendium: Nutritional 

management in children and adolescents with diabetes. Pediatr 

Diabetes 15(Suppl 20): 135–53 

Tay J, Luscombe-Marsh ND, Thompson CH et al (2015) 

Comparison of low-and high-carbohydrate diets for type 2 

diabetes management: a randomized trial. Am J Clin Nutrition 

102: 780–90 

“Consuming a wide 

range of nutritious 

foods in recommended 

portion sizes to 

achieve optimal 

health and diabetes 

management is vital 

and can be achieved by 

seeking individualised 

nutrition care from an 

accredited practising 

dietitian.” 


The PCDSA is a multidisciplinary society with the aim 

of supporting primary health care professionals to deliver 

high quality, clinically effective care in order to improve 

the lives of people with diabetes. 

The PCDSA will 

Share best practice in delivering quality diabetes care. 

Provide high-quality education tailored to health professional needs. 

Promote and participate in high quality research in diabetes. 

Disseminate up-to-date, evidence-based information to health 

professionals. 

Form partnerships and collaborate with other diabetes related, 

high level professional organisations committed to the care of 


Promote co-ordinated and timely interdisciplinary care. 

Membership of the PCDSA is free and members get access to a quarterly 

online journal and continuing professional development activities. Our first 

annual conference will feature internationally and nationally regarded experts 

in the field of diabetes. 

To register, visit our website: 

www.pcdsa.com.au

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