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Diabetes<br />
& Primary Care Australia<br />
Vol 2 No 2 2017<br />
The primary care diabetes journal for healthcare professionals in Australia<br />
Pre-gestational diabetes in pregnancy<br />
This <strong>issue</strong> includes guidance on how<br />
to optimise pregnancy outcomes<br />
through pre-conception care and the<br />
resources available for mothers with<br />
pre-gestational diabetes and healthcare<br />
professionals who care for them.<br />
E-learning on pre-conception care for<br />
women with pre-gestational diabetes is<br />
available at www.pcdsa.au.org/cpd.<br />
Page 54<br />
IN THIS ISSUE<br />
Bone health<br />
The relationship between<br />
diabetes and bone health,<br />
and the impact of poor bone<br />
health on patients. Page 61<br />
Preventing falls<br />
A clinical review of the<br />
screening, assessment and<br />
management of older people<br />
at risk of falls. Page 69<br />
Diabetes and skin<br />
Considering the skin of<br />
people with diabetes and the<br />
importance of skin care before<br />
and after ulceration. Page 75<br />
WEBSITE<br />
Journal content online at<br />
www.pcdsa.com.au/journal
The PCDSA is a multidisciplinary society with the aim<br />
of supporting primary health care professionals to deliver<br />
high quality, clinically effective care in order to improve<br />
the lives of people with diabetes.<br />
The PCDSA will<br />
Share best practice in delivering quality diabetes care.<br />
Provide high-quality education tailored to health professional needs.<br />
Promote and participate in high quality research in diabetes.<br />
Disseminate up-to-date, evidence-based information to health<br />
professionals.<br />
Form partnerships and collaborate with other diabetes related,<br />
high level professional organisations committed to the care of<br />
people with diabetes.<br />
Promote co-ordinated and timely interdisciplinary care.<br />
Membership of the PCDSA is free and members get access to a quarterly<br />
online journal and continuing professional development activities. Our first<br />
annual conference will feature internationally and nationally regarded experts<br />
in the field of diabetes.<br />
To register, visit our website:<br />
www.pcdsa.com.au
Contents<br />
Diabetes<br />
& Primary Care Australia<br />
Volume 2 No 2 2017<br />
Website: www.pcdsa.com.au/journal<br />
Editorial<br />
Diabetes and pregnancy 45<br />
Rajna Ogrin introduces this <strong>issue</strong>, which has a focus on pregnancy and pre-conception care for women with pre-gestational diabetes.<br />
From the other side of the desk<br />
Through diagnosis to pregnancy: My journey with diabetes 47<br />
Karen Barrett gives a first-hand perspective on her journey with diabetes and how it affected her pregnancies.<br />
CPD module<br />
Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care 54<br />
Glynis Ross provides guidance to support pre-conception care for women with pre-gestational diabetes.<br />
Articles<br />
Resources to support preconception care for women with diabetes 50<br />
Melinda Morrison, Ralph Audehm, Alison Barry and colleagues describe the resources available for health professionals and women with<br />
diabetes and provide up-to-date, evidence-based information on pregnancy and diabetes.<br />
Diabetes and bone health 61<br />
Vidhya Jahagirdar and Neil J Gittoes explore the current literature on diabetes and bone health, its impact on patients and the management<br />
strategies that may be considered in primary care to minimise risk of diabetes-related bone disease and to improve outcomes.<br />
Falls prevention in older adults with diabetes: A clinical review of screening, assessment and management recommendations 69<br />
Anna Chapman and Claudia Meyer review the screening, assessment and management recommendations for fall prevention in older people.<br />
The effect of diabetes on the skin before and after ulceration 75<br />
Roy Rasalam and Lesley Weaving look at the changes that occur in the skin of people with diabetes and the importance of skin care in<br />
relation to ulceration.<br />
Editor-in-Chief<br />
Rajna Ogrin<br />
Senior Research Fellow, RDNS<br />
Institute, St Kilda, Vic<br />
Associate Editor<br />
Gary Kilov<br />
Practice Principal, The Seaport<br />
Practice, and Senior Lecturer,<br />
University of Tasmania,<br />
Launceston, Tas<br />
Editorial Board<br />
Ralph Audehm<br />
GP Director, Dianella Community<br />
Health, and Associate Professor,<br />
University of Melbourne,<br />
Melbourne, Vic<br />
Werner Bischof<br />
Periodontist, and Associate<br />
Professor, LaTrobe University,<br />
Bendigo, Vic<br />
Jessica Browne<br />
Senior Research Fellow, School of<br />
Psychology, Deakin University,<br />
Melbourne, Vic<br />
Anna Chapman<br />
Research Fellow, School of<br />
Primary Health Care, Monash<br />
University, Melbourne, Vic<br />
Laura Dean<br />
Course Director of the Graduate<br />
Certificate in Pharmacy<br />
Practice, Monash University, Vic<br />
Nicholas Forgione<br />
Principal, Trigg Health Care<br />
Centre, Perth, WA<br />
John Furler<br />
Principal Research Fellow and<br />
Associate Professor,<br />
University of Melbourne, Vic<br />
Mark Kennedy<br />
Medical Director, Northern Bay<br />
Health, Geelong, and Honorary<br />
Clinical Associate Professor,<br />
University of Melbourne,<br />
Melbourne, Vic<br />
Peter Lazzarini<br />
Senior Research Fellow,<br />
Queensland University of<br />
Technology, Brisbane, Qld<br />
Roy Rasalam<br />
Head of Clinical Skills and<br />
Medical Director,<br />
James Cook University, and<br />
Clinical Researcher, Townsville<br />
Hospital, Townsville, Qld<br />
Suzane Ryan<br />
Practice Principal, Newcastle<br />
Family Practice, Newcastle, NSW<br />
Editor<br />
Olivia Tamburello<br />
Editorial Manager<br />
Richard Owen<br />
Publisher<br />
Simon Breed<br />
© OmniaMed SB and the Primary Care<br />
Diabetes Society of Australia<br />
Published by OmniaMed SB,<br />
1–2 Hatfields, London<br />
SE1 9PG, UK<br />
All rights reserved. No part of this<br />
journal may be reproduced or transmitted<br />
in any form, by any means, electronic<br />
or mechanic, including photocopying,<br />
recording or any information retrieval<br />
system, without the publisher’s<br />
permission.<br />
ISSN 2397-2254<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 43
Call for papers<br />
Would you like to write an article<br />
for Diabetes & Primary Care Australia?<br />
The new journal from the Primary Care Diabetes Society of Australia<br />
To submit an article or if you have any queries, please contact: gary.kilov@pcdsa.com.au.<br />
Title page<br />
Please include the article title, the full names of the authors<br />
and their institutional affiliations, as well as full details of<br />
each author’s current appointment. This page should also have<br />
the name, address and contact telephone number(s) of the<br />
corresponding author.<br />
Article points and key words<br />
Four or five sentences of 15–20 words that summarise the major<br />
themes of the article. Please also provide four or five key words<br />
that highlight the content of the article.<br />
Abstract<br />
Approximately 150 words briefly introducing your article,<br />
outlining the discussion points and main conclusions.<br />
Introduction<br />
In 60–120 words, this should aim to draw the reader into the<br />
article as well as broadly stating what the article is about.<br />
Main body<br />
Use sub-headings liberally and apply formatting to differentiate<br />
between heading levels (you may have up to three heading levels).<br />
The article must have a conclusion, which should be succinct and<br />
logically ordered, ideally identifying gaps in present knowledge and<br />
implications for practice, as well as suggesting future initiatives.<br />
Tables and illustrations<br />
Tables and figures – particularly photographs – are encouraged<br />
wherever appropriate. Figures and tables should be numbered<br />
consecutively in the order of their first citation in the text. Present<br />
tables at the end of the articles; supply figures as logically labelled<br />
separate files. If a figure or table has been published previously,<br />
acknowledge the original source and submit written permission<br />
from the copyright holder to reproduce the material.<br />
References<br />
In the text<br />
Use the name and year (Harvard) system for references in the<br />
text, as exemplified by the following:<br />
● As Smith and Jones (2013) have shown …<br />
● As already reported (Smith and Jones, 2013) …<br />
For three or more authors, give the first author’s surname<br />
followed by et al:<br />
● As Robson et al (2015) have shown …<br />
Simultaneous references should be ordered chronologically first,<br />
and then alphabetically:<br />
● (Smith and Jones, 2013; Young, 2013; Black, 2014).<br />
Statements based on a personal communication should be<br />
indicated as such, with the name of the person and the year.<br />
In the reference list<br />
The total number of references should not exceed 30 without prior<br />
discussion with the Editor. Arrange references alphabetically first,<br />
and then chronologically. Give the surnames and initials of all<br />
authors for references with four or fewer authors; for five or more,<br />
give the first three and add “et al”. Papers accepted but not yet<br />
published may be included in the reference list as being “[In press]”.<br />
Journal article example: Robson R, Seed J, Khan E et al (2015)<br />
Diabetes in childhood. Diabetes Journal 9: 119–23<br />
Whole book example: White F, Moore B (2014) Childhood<br />
Diabetes. Academic Press, Melbourne<br />
Book chapter example: Fisher M (2012) The role of age. In: Merson<br />
A, Kriek U (eds). Diabetes in Children. 2nd edn. Academic Press,<br />
Melbourne: 15–32<br />
Document on website example: Department of Health (2009)<br />
Australian type 2 diabetes risk assessment tool (AUSDRISK).<br />
Australian Government, Canberra. Available at: http://www.<br />
health.gov.au/preventionoftype2diabetes (accessed 22.07.15)<br />
Article types<br />
Articles may fall into the categories below. All articles should be<br />
1700–2300 words in length and written with consideration of<br />
the journal’s readership (general practitioners, practice nurses,<br />
prescribing advisers and other healthcare professionals with an<br />
interest in primary care diabetes).<br />
Clinical reviews should present a balanced consideration of a<br />
particular clinical area, covering the evidence that exists. The<br />
relevance to practice should be highlighted where appropriate.<br />
Original research articles should be presented with sections<br />
for the background, aims, methods, results, discussion and<br />
conclusion. The discussion should consider the implications<br />
for practice.<br />
Clinical guideline articles should appraise newly published<br />
clinical guidelines and assess how they will sit alongside<br />
existing guidelines and impact on the management of diabetes.<br />
Organisational articles could provide information on newly<br />
published organisational guidelines or explain how a particular<br />
local service has been organised to benefit people with diabetes.<br />
— Diabetes & Primary Care Australia —
Editorial<br />
Diabetes and pregnancy<br />
It is well known that diabetes is a systemic<br />
condition and, if not managed efficiently,<br />
can have a life-changing impact on the eyes,<br />
feet and kidneys. In this <strong>issue</strong>, we consider<br />
the impact of uncontrolled hyperglycaemia on<br />
other body systems and functions – from skin<br />
to bone, and from pregnancy to older age. On<br />
page 75, Roy Rasalam and Lesley Weaving<br />
discuss the practical aspects of maintaining<br />
healthy skin in people with diabetes, and<br />
Neil Gittoes and Vidhya Jahagirdar provide a<br />
clinical review of the potential complications<br />
to bone health as a result of diabetes (page 61).<br />
There is a special section on diabetes and<br />
pregnancy covering preconception care in<br />
primary care and the resources available<br />
for women with diabetes and health care<br />
professionals (starting from page 47). Finally,<br />
there is a paper by Anna Chapman and<br />
Claudia Meyer on the increased risk of falls<br />
in older people with diabetes and what can be<br />
done to lower the risk (page 69). This topic is<br />
especially pertinent with the growing ageing<br />
population seen in Australia and globally.<br />
Diabetes and pregnancy<br />
One relatively new area of research in<br />
diabetes and pregnancy that has caught my<br />
eye is epigenetics – the effect of environment<br />
on genetics. Questions are being raised<br />
as to whether the maternal environment<br />
(e.g. maternal obesity, poor nutrition and<br />
hyperglycaemia) may “program” type 2<br />
diabetes in offspring. There is some evidence<br />
that suggests that shared genetic and<br />
environmental risk, as well as developmental<br />
programming, may lead to children born to<br />
women with diabetes during pregnancy at<br />
greater risk of developing type 2 diabetes in<br />
later life (Berends and Ozanne, 2012). If the<br />
female offspring then have their own children,<br />
it is thought that an intergenerational<br />
cycle of diabetes risk could be established<br />
(Dabelea and Crume, 2011). The intricacies<br />
of this are important to understand, as many<br />
women with pre-existing type 2 diabetes<br />
are often overweight or obese. They often<br />
continue to gain weight with each additional<br />
pregnancy and are sometimes reluctant to<br />
engage with health services (Bandyopadhyay<br />
et al, 2011). Women of South East Asian<br />
origin are at particularly high risk of diabetes<br />
during pregnancy, so by developing effective<br />
strategies to specifically address these factors,<br />
the risk of future diabetes to offspring may be<br />
reduced (Greenhalgh et al, 2015).<br />
What other considerations need to be<br />
made to avoid the increased risk of adverse<br />
pregnancy outcomes as a result of diabetes?<br />
Pre-gestational diabetes (type 1 and<br />
type 2 diabetes) is present in approximately<br />
1% of pregnant women in Australia and the<br />
prevalence is increasing not only here, but<br />
around the world. Women with pre-existing<br />
diabetes are at high risk of complications<br />
during pregnancy, with up to four times<br />
the rate of congenital malformations, and<br />
up to a five-fold increased risk of stillbirth<br />
and perinatal mortality compared to women<br />
without diabetes. By safely optimising blood<br />
glucose management, women can significantly<br />
reduce their risk of complications, and<br />
preconception care has been shown to reduce<br />
these risks (Inkster et al, 2006).<br />
Women of child-bearing age with diabetes<br />
need to be informed of the availability and<br />
importance of preconception care, which<br />
can be provided by both primary and<br />
specialised diabetes services; many women<br />
with type 1 diabetes access diabetes specialist<br />
services, while the majority of women with<br />
type 2 diabetes are managed in primary care.<br />
Included in preconception care is appropriate<br />
contraception advice. Here, primary care<br />
providers can make a real difference in<br />
promoting and providing appropriate<br />
contraception to women with diabetes to<br />
prevent unplanned pregnancies.<br />
In this pregnancy special, there are three<br />
pieces related to pregnancy and diabetes. There<br />
is a CPD module outlining the requirements<br />
of preconception care for women with<br />
Rajna Ogrin<br />
Editor of Diabetes & Primary Care<br />
Australia, and Senior Research<br />
Fellow, RDNS Institute,<br />
St Kilda, Vic.<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 45
Editorial<br />
“By considering the<br />
health and wellbeing of<br />
women with diabetes<br />
prior to pregnancy,<br />
we anticipate<br />
that meaningful<br />
improvements in<br />
pregnancy outcomes<br />
are possible.”<br />
diabetes, including practical information for<br />
health care providers, as well as case studies to<br />
highlight the application of this information<br />
in clinical practice (page 54). There is also<br />
a wealth of resources for the clinician and<br />
woman with diabetes to optimise healthy<br />
pregnancy outcomes. Melinda Morrison from<br />
the National Diabetes Services Scheme and<br />
colleagues outline the resources available,<br />
such as apps, booklets and online resources<br />
(page 50). We also have the first “From<br />
the other side of the desk” feature – a<br />
new series to inform clinical care from the<br />
perspectives of people with diabetes. In the<br />
first of the series, Karen Barrett discusses her<br />
journey with diabetes and how it affected her<br />
pregnancies (page 47).<br />
By considering the health and wellbeing<br />
of women with diabetes prior to pregnancy,<br />
and utilising the resources that have been<br />
developed specifically to support this group<br />
before, during and after pregnancy, we<br />
anticipate that meaningful improvements in<br />
pregnancy outcomes are possible. n<br />
2017 NATIONAL CONFERENCE<br />
Saturday 6th May 2017 – Melbourne Convention and Exhibition Centre, Victoria, Australia<br />
The conference has been specifically designed for all primary care health<br />
professionals working in diabetes care to:<br />
Advance their education and learning in the field of diabetes health care<br />
Promote best practice standards and clinically effective care in the management of diabetes<br />
Facilitate collaboration between health professionals to improve the quality of diabetes<br />
primary care across Australia<br />
6TH MAY 2017 CONFERENCE PROGRAM<br />
The 2017 PCDSA national conference program will combine cutting edge scientific content with<br />
practical clinical sessions, basing the education on much more than just knowing the guidelines.<br />
The distinguished panel of speakers will share their specialised experience in an environment<br />
conducive to optimal learning. The Speaking faculty include, amongst others:<br />
Associate Professor<br />
Neale Cohen<br />
Director Clinical Diabetes<br />
Baker Heart and<br />
Diabetes Institute<br />
“Diabetes management<br />
and research in primary<br />
care – key components<br />
to improving outcomes”<br />
Doctor Christel<br />
Hendrieckx<br />
Senior Research Fellow<br />
The Australian Centre<br />
for Behavioural Research<br />
in Diabetes<br />
“The emotional health of<br />
people living with diabetes”<br />
For further information including the full 2017 program<br />
and to register for the conference please visit:<br />
www.eventful.com.au/pcdsa2017<br />
If you have any questions regarding the conference,<br />
please contact the Conference Secretariat;<br />
Toll free telephone: 1800 898 499<br />
Email: pcdsa@eventful.com.au<br />
Ms Renza Scibilia<br />
Manager - Type 1 Diabetes<br />
and Consumer Voice<br />
Diabetes Australia<br />
“Engaging people with<br />
diabetes, the diabetes<br />
online community and<br />
apps for diabetes”<br />
Doctor Gautam<br />
Vaddadi<br />
Consultant Cardiologist<br />
Alfred Health, Northern Health,<br />
University of Melbourne<br />
“The emerging importance<br />
of cardiac failure diagnosis<br />
and management in people<br />
with type 2 diabetes”<br />
pcdsa.com.au<br />
Bandyopadhyay M, Small R, Davey MA et al (2011) Lived<br />
experience of gestational diabetes mellitus among immigrant<br />
South Asian women in Australia. Aust N Z J Obstet Gynaecol<br />
51: 360–4<br />
Berends LM, Ozanne SE (2012) Early determinants of type 2<br />
diabetes. Best Pract Res Clin Endocrinol Metab 26: 569–80<br />
Dabelea D, Crume T (2011) Maternal environment and the<br />
transgenerational cycle of obesity and diabetes. Diabetes 60:<br />
1849–55<br />
Greenhalgh T, Clinch M, Afsar N et al (2015) Socio-cultural<br />
influences on the behaviour of South Asian women with<br />
diabetes in pregnancy: qualitative study using a multi-level<br />
theoretical approach. BMC Med 13: 120<br />
Inkster ME, Fahey TP, Donnan PT et al (2006) Poor glycated<br />
haemoglobin control and adverse pregnancy outcomes in<br />
type 1 and type 2 diabetes mellitus: Systematic review of<br />
observational studies BMC Pregnancy Childbirth 6: 30<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017
From the other side of the desk<br />
From the other side of the desk:<br />
Patient perspective<br />
Through diagnosis to pregnancy:<br />
My journey with diabetes<br />
Karen Barrett<br />
I<br />
was diagnosed with type 1 diabetes on Valentine’s<br />
Day, 1983, a day meant for chocolates, roses<br />
and sweets. What an irony it turned out to be.<br />
Dressed in my school uniform and ready for school,<br />
my Mum, being a nurse, had known for some time<br />
that something wasn’t right. I had lost a substantial<br />
amount of weight and the bathroom seemed to<br />
be my best friend, as did my unquenchable thirst.<br />
“Oh what a bombshell!” my Mum’s colleague said<br />
that day after hearing my diagnosis. I never really<br />
comprehended the significance of the diagnosis at<br />
the time. I had felt fine.<br />
In the early days after my diagnosis, to see my<br />
diabetes specialist meant a day off school and a trip<br />
to Canberra – that was the good part. The not-sogood<br />
part became the endless questions from the<br />
doctor – what was I putting in my mouth and at<br />
exactly what time of the day – measurements on the<br />
scales, numbers in books, pathology results and eye<br />
tests. On and on it went. Would I pass or fail? Had<br />
I been good or bad? I hated it.<br />
There was never a time that I let my diabetes<br />
stand in the way. I was quite sporty growing up<br />
in a small country town, later trying triathlons<br />
and endurance sports. But in my school life, I was<br />
sometimes left out, missing the first school camp<br />
because everyone was so very nervous to have a<br />
person with diabetes at camp and friends’ parents<br />
being reluctant to have me over, afraid of what or<br />
what not to feed me.<br />
As an adolescent, I was studious and quite fit and<br />
healthy, with an obsessive personality. That was<br />
until my late teens, when I seemed to burn out with<br />
school, with life and with diabetes. Life became<br />
tricky. I found solace in food and subsequently paid<br />
the price, gaining weight.<br />
My family, of course, was concerned, but the<br />
constant questions about how many blood sugar<br />
tests I was doing and whether I was looking after<br />
myself was a continuous reminder of my diabetes,<br />
something I wanted to forget. I ate in secret and lied<br />
to keep them satisfied while continuing to silently<br />
struggle. I was tired of all the rules, tired of all the<br />
questions and tired of being different and feeling<br />
restricted. As I entered adulthood, I thought I kept<br />
my struggles well hidden from others for many<br />
years. I went on to study nursing at university and<br />
the big wide world gave me even more freedom<br />
to hide from the reality of diabetes. Somehow,<br />
I stayed on the tightrope of avoiding routine<br />
doctor’s appointments while also avoiding more<br />
serious hospital admissions. A visit to the doctor<br />
would mean tests, which I knew I would fail, and<br />
questions that I would be ashamed to answer – I<br />
wasn’t up for the interrogations and judgements.<br />
But, I didn’t feel like I was failing! I was eating what<br />
I wanted, when I wanted, and being like the rest of<br />
my friends and peers.<br />
Time to get real<br />
Then I found out I was pregnant…unplanned.<br />
For me, I realised it was not fair to have a child,<br />
with the high risk of complications to me and my<br />
baby as a result of me not looking after myself.<br />
A decision, that I feel to this day, even though I<br />
agreed, had already been made for me. Time to get<br />
real. If I was to ever create a family of my own, it<br />
meant facing the <strong>issue</strong>s I had so long avoided – the<br />
medical world testing me on passing or failing at<br />
diabetes.<br />
Unable, and not allowing myself, to be anything<br />
other than perfectly controlled, I became a<br />
Citation: Barrett K (2017) Through<br />
diagnosis to pregnancy: My journey<br />
with diabetes. Diabetes & Primary<br />
Care Australia 1: 47–8<br />
About this series<br />
The aim of the “From the other<br />
side of the desk” series is to<br />
provide a patient perspective on<br />
a topic within diabetes, to reflect<br />
on the doctor–patient relationship<br />
and to inform clinical care.<br />
Author<br />
Karen Barrett, Registered Nurse<br />
and Coordinator, Central Coast,<br />
NSW.<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 47
From the other side of the desk<br />
“As a person with<br />
diabetes, my advice<br />
to the medical world<br />
would be to consider<br />
the person in front<br />
of you without their<br />
diabetes diagnosis.”<br />
champion of the tests. It was an intense time but<br />
my motivation to have healthy babies drove me<br />
to that perfection, and I went on to have three<br />
babies in 3 years. I told the medical team what they<br />
wanted to hear, but this time I wasn’t lying.<br />
It became my obsession to get the numbers<br />
right. Averaging about 12–14 blood sugars daily<br />
and the never-ending specialist appointments were<br />
vital to achieving the desired outcome. I was lucky<br />
that the care I received from my diabetes team<br />
during my pregnancies was excellent and well<br />
planned. I feel that it is vital to have a trusting<br />
relationship with an endocrinologist before, during<br />
and after pregnancies, and I was very fortunate<br />
to have that. But pregnancy with diabetes is not<br />
without its difficulties; the severe hypos during the<br />
first trimesters became frequent and increasingly<br />
exhausting, and with every pregnancy, I had<br />
another toddler to care for. My first-born was<br />
diagnosed with cerebral palsy (totally unrelated<br />
to my diabetes), and as if that was not sufficiently<br />
challenging, I became a single Mum when my<br />
youngest was 11 months old. Juggling three<br />
toddlers, a part-time job to survive financially and<br />
my diabetes became routine. The all-or-nothing<br />
personality has some advantages and in those<br />
3 years, I was switched to “all”, determined to be<br />
a good Mum.<br />
However, as the years went by, I let those<br />
numbers slip again. My three gorgeous children,<br />
my world, were growing up fast, and at aged 6, 7<br />
and 8 years, they kept me busy. I kept the medical<br />
team at length – I knew I wasn’t going to “pass the<br />
test”. My 7-year-old daughter, Presley, had spirit<br />
(sometimes too much!) and when she came down<br />
with a viral illness, as a mum with diabetes would,<br />
I checked her blood sugar. My Mum had suggested<br />
the “D” word as Presley kept sleeping through the<br />
day, which was very much unlike her. I still recall<br />
that moment, and I think I too knew something<br />
wasn’t right. Weeks later, Presley mentioned to me<br />
that she was waking through the night to go to the<br />
bathroom. I knew. I waited.<br />
My beautiful girl was dressed in her swimmers<br />
ready to go swimming. I did her blood sugar and<br />
there I was – the mother of a child with diabetes.<br />
Now it was me answering the questions not as a<br />
person with diabetes, but as a Mum. It was more<br />
than my own tests – I had to pass all of Presley’s<br />
tests as well.<br />
I felt my skills as a parent were put under the<br />
microscope. I believed it was all my fault if her<br />
numbers weren’t right. What was she eating when<br />
I wasn’t there? Was she exerting too much energy<br />
during lunchtime at school? Could she recognise<br />
a hypo? I felt like I had to live in her head, and<br />
I became the “helicopter” Mum. Presley too<br />
hated the medical world, clamming up at all the<br />
questions and hating the scales and numbers. At<br />
home, she dealt with the never-ending motherly<br />
concerns and requests to check her blood sugar,<br />
blaming every ailment or headache on diabetes,<br />
whether or not it was.<br />
Where I am now<br />
Despite some complications of my own, at 44 years<br />
of age, I now take care of myself and feel as well as<br />
I can feel, given my past “bad behaviour”. I have<br />
a good relationship with my team and appreciate<br />
the rapport I have with them, which has taken<br />
many years to establish and develop. I now take<br />
charge of my appointments and we talk about the<br />
concerns I have. The first questions asked are not<br />
“shall we look at the numbers?” or “how many<br />
highs/lows are you having?”; rather, “how are you,<br />
and what’s going on in your world?”<br />
I have had a lovely relationship with my<br />
psychologist who somehow allows me to be proud<br />
of who I am and what I have achieved. I am now<br />
free of the judgement calls that I thought were<br />
placed on me as a person with diabetes and then<br />
as the mother of a child with diabetes. Mistakes<br />
are human. Rough patches enable us all to make<br />
better choices, and experience allows us to call the<br />
shots. It’s OK not to be perfect. I truly hope that<br />
if anything, I can pass this on to my children and<br />
that they reach this point a whole lot sooner than<br />
I did.<br />
As a person with diabetes, my advice to the<br />
medical world would be to consider the person<br />
in front of you without their diabetes diagnosis.<br />
Diabetes management is far more than looking<br />
at the numbers. Consider their state of mind<br />
and the unsaid pressures they may have put on<br />
themselves. The bravest thing one can do is to ask<br />
for help and say that we’re not OK, and creating<br />
an environment where people with diabetes feel<br />
comfortable and safe to do so is vital. n<br />
48 Diabetes & Primary Care Australia Vol 2 No 2 2017
2017 NATIONAL CONFERENCE<br />
Saturday 6th May 2017 – Melbourne Convention and Exhibition Centre, Victoria, Australia<br />
The conference has been specifically designed for all primary care health<br />
professionals working in diabetes care to:<br />
<br />
<br />
<br />
Advance their education and learning in the field of diabetes health care<br />
Promote best practice standards and clinically effective care in the management of diabetes<br />
Facilitate collaboration between health professionals to improve the quality of diabetes<br />
primary care across Australia<br />
6TH MAY 2017 CONFERENCE PROGRAM<br />
The 2017 PCDSA national conference program will combine cutting edge scientific content with<br />
practical clinical sessions, basing the education on much more than just knowing the guidelines.<br />
The distinguished panel of speakers will share their specialised experience in an environment<br />
conducive to optimal learning. The Speaking faculty include, amongst others:<br />
Associate Professor<br />
Neale Cohen<br />
Director Clinical Diabetes<br />
Baker Heart and<br />
Diabetes Institute<br />
“Diabetes management<br />
and research in primary<br />
care – key components<br />
to improving outcomes”<br />
Doctor Christel<br />
Hendrieckx<br />
Senior Research Fellow<br />
The Australian Centre<br />
for Behavioural Research<br />
in Diabetes<br />
“The emotional health of<br />
people living with diabetes”<br />
Ms Renza Scibilia<br />
Manager - Type 1 Diabetes<br />
and Consumer Voice<br />
Diabetes Australia<br />
“Engaging people with<br />
diabetes, the diabetes<br />
online community and<br />
apps for diabetes”<br />
Doctor Gautam<br />
Vaddadi<br />
Consultant Cardiologist<br />
Alfred Health, Northern Health,<br />
University of Melbourne<br />
“The emerging importance<br />
of cardiac failure diagnosis<br />
and management in people<br />
with type 2 diabetes”<br />
For further information including the full 2017 program<br />
and to register for the conference please visit:<br />
www.eventful.com.au/pcdsa2017<br />
If you have any questions regarding the conference,<br />
please contact the Conference Secretariat;<br />
Toll free telephone: 1800 898 499<br />
Email: pcdsa@eventful.com.au<br />
pcdsa.com.au
Article<br />
Resources to support preconception care<br />
for women with diabetes<br />
Citation: Morrison M, Audehm R,<br />
Barry A et al (2017) Resources to<br />
support preconception care for<br />
women with diabetes. Diabetes &<br />
Primary Care Australia 2: 50–3<br />
Article points<br />
1. Women with diabetes are<br />
at increased risk of adverse<br />
pregnancy outcomes. Early<br />
intervention and planning<br />
can reduce the risks.<br />
2. Primary health care<br />
professionals have a key role<br />
in providing appropriate<br />
contraception to women with<br />
diabetes to prevent unplanned<br />
pregnancies, as well as<br />
encouraging optimal pregnancy<br />
planning and preparation.<br />
3. To address the gap in<br />
information for women with<br />
diabetes who are seeking<br />
or already accessing prepregnancy<br />
advice and<br />
care, Diabetes Australia<br />
has developed a suite of<br />
resources with funding<br />
through the National<br />
Diabetes Services Scheme.<br />
Key words<br />
– Diabetes in pregnancy<br />
– Education<br />
– Preconception care<br />
– Pregnancy<br />
– Resources<br />
– Type 1 diabetes<br />
– Type 2 diabetes<br />
Authors<br />
See page 53 for details.<br />
Melinda Morrison, Ralph Audehm, Alison Barry, Christel Hendrieckx,<br />
Alison Nankervis, Cynthia Porter, Renza Scibilia, Glynis P Ross<br />
Preconception care has been shown to reduce the rates of adverse pregnancy outcomes<br />
in women with pre-existing type 1 or type 2 diabetes. With an increasing prevalence of<br />
diabetes among women of child-bearing age, health professionals working in primary<br />
care have an important role in encouraging women with diabetes to plan and prepare<br />
for pregnancy. New resources, described here, are available for health professionals and<br />
women with diabetes and provide up to date, evidence-based information on pregnancy<br />
and diabetes.<br />
Pre-existing diabetes (type 1 or<br />
type 2 diabetes) is estimated to affect<br />
approximately 1% of pregnant women<br />
in Australia (Australian Institute of Health and<br />
Welfare, 2016), and evidence suggests that the<br />
prevalence is increasing (Abouzeid et al, 2014).<br />
In particular, the prevalence of type 2 diabetes in<br />
pregnant women is expected to increase as a result<br />
of older maternal age, high rates of obesity and an<br />
ethnically diverse population (Cheung et al, 2005;<br />
Temple and Murphy, 2010).<br />
Diabetes in pregnancy has many welldocumented<br />
risks to both mother and baby<br />
(Macintosh et al, 2006; Dunne et al, 2009;<br />
Kitzmiller et al, 2010); however, these risks can<br />
be mitigated by effective preconception and<br />
pregnancy care, and most women with diabetes<br />
will go on to have a healthy pregnancy and a<br />
healthy baby (Ray et al, 2001; Wahabi et al, 2010;<br />
Holmes et al, 2017).<br />
While most women with type 1 diabetes access<br />
specialist services, the majority of women with<br />
type 2 diabetes are managed in primary care.<br />
Health professionals in primary care are often the<br />
first point of contact for women seeking pregnancy<br />
information, and have a key role in promoting and<br />
providing appropriate contraception to women<br />
with pre-existing diabetes to prevent unplanned<br />
pregnancies, and in specialist referral. They are<br />
also critically important in encouraging diabetesspecific<br />
preconception care in all women with<br />
pre-existing diabetes to optimise maternal and<br />
fetal outcomes (Temple and Murphy, 2010). In<br />
the National Diabetes Services Scheme (NDSS)*<br />
Contraception, Pregnancy & Women’s Health<br />
Survey (2015) women with type 1 or type 2<br />
diabetes (n=967) indicated that diabetes specialists<br />
(endocrinologists and diabetes educators) and<br />
general practitioners were the health professionals<br />
with whom pregnancy and diabetes was most<br />
frequently discussed. Interestingly, the majority<br />
of women reported that they, rather than health<br />
professionals, initiated the conversation about<br />
pregnancy and diabetes.<br />
Preconception care in the primary<br />
health setting<br />
Despite the documented benefits of preconception<br />
care for women with pre-existing diabetes (Ray<br />
et al, 2001; Wahabi et al, 2010), many women<br />
with diabetes do not plan their pregnancies. Zhu<br />
et al (2012) reported that 45% of pregnancies in<br />
women with diabetes attending a tertiary obstetric<br />
hospital in Western Australia during 2009–2010<br />
*The National Diabetes Services Scheme (NDSS) is an<br />
initiative of the Australian Government administered<br />
with the assistance of Diabetes Australia.<br />
50 Diabetes & Primary Care Australia Vol 2 No 2 2017
Resources to support preconception care for women with diabetes<br />
were unplanned. While in an earlier Australian<br />
multicentre study of pregnancies complicated<br />
by diabetes, pre-pregnancy counselling was<br />
documented in only 20% of women – 28% of<br />
those with type 1 diabetes and 12% of those with<br />
type 2 diabetes (McElduff et al, 2005).<br />
Planning for pregnancy<br />
The primary health care setting is where many<br />
women with diabetes seek advice on reproductive<br />
<strong>issue</strong>s and access contraception. However, in the<br />
NDSS Contraception, Pregnancy & Women’s<br />
Health Survey (2015) only 49% of Australian<br />
women with type 1 or type 2 diabetes could<br />
recall being advised by a health professional to<br />
use some form of contraception to prevent an<br />
unplanned pregnancy, and 55% could recall being<br />
advised by a health professional that they should<br />
access diabetes-specific pre-pregnancy care before<br />
becoming pregnant or planning a pregnancy.<br />
These results differed by type of diabetes, with<br />
those with type 2 diabetes being less likely to recall<br />
receiving advice. These findings are consistent<br />
with those reported in the TRIAD (Translating<br />
Research into Action for Diabetes) preconception<br />
study of US women aged 18–45 years enrolled<br />
in managed care (Kim et al, 2005). Of these<br />
women, 52% recalled discussions with a health<br />
professional regarding glucose control before<br />
conception, and 37% could recall receiving family<br />
planning advice.<br />
Due to the impact of an unplanned pregnancy<br />
on both the developing fetus and mother, adequate<br />
contraception should be maintained until<br />
glycaemia and all aspects of care are optimised.<br />
The longer-acting reversible contraceptives are an<br />
excellent choice (e.g. intrauterine contraceptive<br />
devices or implant) and are safe for women with<br />
diabetes to use. When reviewing contraception in<br />
women with diabetes, timing of pregnancy should<br />
be discussed. Preconception planning for women<br />
with diabetes should occur well before conception.<br />
If available, involvement of a specialist diabetes in<br />
pregnancy service is recommended.<br />
New NDSS resources to support<br />
preconception care<br />
To address the gap in information for<br />
women with diabetes who are seeking or<br />
already accessing pre-pregnancy advice<br />
and care, Diabetes Australia has developed<br />
a suite of resources with funding through<br />
the NDSS. These resources were developed<br />
following extensive consumer and stakeholder<br />
consultation, and provide up-to-date, evidencebased<br />
pregnancy information for women living<br />
with type 1 or type 2 diabetes. The NDSS<br />
resources available include the following:<br />
l www.pregnancyanddiabetes.com.au: A<br />
website dedicated to pregnancy and diabetes<br />
information.<br />
l Pregnancy planning checklist: A checklist<br />
to help women with diabetes prepare for a<br />
healthy pregnancy. The checklist can be<br />
completed as an online tool or downloaded<br />
as a printable checklist (Figure 1).<br />
l Having a Healthy Baby booklets: Booklets<br />
providing comprehensive information on<br />
planning and managing pregnancy. Separate<br />
booklets are available for women with<br />
type 1 or type 2 diabetes (Figure 2).<br />
l NDSS pregnancy and diabetes factsheet:<br />
Available for download in English, Arabic,<br />
Chinese, Vietnamese, Korean, Turkish,<br />
Urdu, Greek, Italian and Spanish.<br />
l Plan for the best start e-newsletter: A<br />
quarterly e-newsletter for women with<br />
diabetes and health professionals. It<br />
provides information on planning and<br />
preparing for pregnancy, and there is access<br />
to the latest NDSS resources and research<br />
updates.<br />
l Health professional continuing professional<br />
development learning: E-learning modules<br />
for primary health care providers on the<br />
topic of preconception care for women<br />
with type 1 or type 2 diabetes. The course<br />
includes three modules with two nonassessed<br />
case studies and can be accessed<br />
from the NDSS pregnancy and diabetes<br />
website. CPD points are available for<br />
eligible health professionals.<br />
These resources for patients and health<br />
care professionals can be accessed at<br />
www.pregnancyanddiabetes.com.au. Hard<br />
copies of the booklets can be ordered online or<br />
by phoning the NDSS Helpline (1300 136 588).<br />
Page points<br />
1. Due to the impact of an<br />
unplanned pregnancy on<br />
both the developing fetus and<br />
mother, adequate contraception<br />
should be maintained until<br />
glycaemia and all aspects of<br />
care are optimised.<br />
2. Preconception planning for<br />
women with diabetes should<br />
occur well before conception.<br />
3. Resources for patients and<br />
health care professionals<br />
can be accessed at www.<br />
pregnancyanddiabetes.com.au.<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 51
Resources to support preconception care for women with diabetes<br />
Pregnancy Planning Checklist<br />
Plan and prepare at least 3-6 months before you start<br />
trying for a baby<br />
What you need to do BEFORE you fall pregnant<br />
Use contraception until you are ready to start trying for<br />
a baby (ask your doctor if this is the most reliable<br />
contraception suitable for you)<br />
Talk to your doctor for general pregnancy planning advice<br />
Make an appointment with health professionals who<br />
specialise in pregnancy and diabetes<br />
Aim for an HbA1c of less than 53mmol/mol (7%) if you<br />
have type 1 diabetes or 42mmol/mol (6%) or less if<br />
you have type 2 diabetes<br />
Review your diabetes management with your diabetes<br />
health professionals<br />
Have all your medications checked to see if they are<br />
safe to take during pregnancy<br />
Start taking a high-dose (2.5mg-5mg) folic acid<br />
supplement each day<br />
Have a full diabetes complications screening and<br />
your blood pressure checked<br />
Aim for a healthy weight before you fall pregnant<br />
For women<br />
with type 1<br />
or type 2<br />
diabetes<br />
Use this checklist as a guide to discuss with your health professionals<br />
www.pregnancyanddiabetes.com.au<br />
This checklist is intended as a guide only. It should not replace individual medical advice and if you have any<br />
concerns about your health or further questions, you should contact your health professional.<br />
The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered with the assistance of Diabetes Australia.<br />
Figure 1. Pregnancy planning checklist, to help women with diabetes<br />
prepare for a healthy pregnancy. Produced by the National Diabetes<br />
Service Scheme.<br />
Other resources<br />
The Australasian Diabetes in Pregnancy<br />
Society (ADIPS)-endorsed Pregnant<br />
with Diabetes app has been developed<br />
for pregnant women with diabetes, and<br />
women with diabetes who intend to<br />
become pregnant (Figure 3). It is written by<br />
Prof. Elisabeth R Mathiesen and Prof. Peter<br />
Damm and is based on the recommendations<br />
of the Centre for Pregnant Women with<br />
Diabetes at Rigshospitalet in Copenhagen,<br />
Denmark. The Australian version has been<br />
adapted by an Australian working party<br />
to reflect the ADIPS guidelines. The app<br />
can be downloaded from app stores free<br />
of charge. The information covered in the<br />
app is suitable for women with gestational,<br />
type 1 and type 2 diabetes and covers<br />
topics such as: how to plan for pregnancy,<br />
Figure 2. Booklets for women with type 1 and type 2<br />
diabetes. Produced by the National Diabetes Services<br />
Scheme.<br />
goal blood glucose levels, gestational weight<br />
gain, diet and carbohydrate intake, physical<br />
activity and insulin dosing.<br />
52 Diabetes & Primary Care Australia Vol 2 No 2 2017
Resources to support preconception care for women with diabetes<br />
National Development Program Expert<br />
Reference Group (2013–16). We acknowledge<br />
D. Charron-Prochownik for permission<br />
to reproduce questions from the RHAB<br />
questionnaire and V. Holmes for permission to<br />
use reproductive health knowledge questions<br />
in the NDSS Contraception, Pregnancy &<br />
Women’s Health Survey.<br />
Abouzeid M, Versace VL, Janus ED et al (2014) A population-based<br />
observational study of diabetes during pregnancy in Victoria,<br />
Australia, 1999–2008. BMJ Open 4: e005394<br />
Australian Institute of Health and Welfare (2016) Australia’s<br />
mothers and babies 2014-in brief. Perinatal statistics. AIHW,<br />
Canberra, ACT. Available at: http://www.aihw.gov.au/<br />
publication-detail/?id=60129557656 (accessed 14.03.17)<br />
“Primary care health<br />
professionals are<br />
also ideally placed to<br />
increase the awareness<br />
of women with<br />
diabetes about the<br />
available resources<br />
which are being<br />
actively reviewed and<br />
developed to meet<br />
their needs.”<br />
Cheung N, McElduff A, Ross G (2005) Type 2 diabetes in<br />
pregnancy: a wolf in sheep’s clothing. Aust N Z J Obstet<br />
Gynaecol 45: 479–83<br />
Figure 3. The Australasian Diabetes in Pregnancy<br />
Society (ADIPS)-endorsed Pregnant with Diabetes app.<br />
Conclusion<br />
Primary health care providers play an important<br />
role in promoting effective contraception use<br />
and encouraging women with pre-existing<br />
type 1 or type 2 diabetes to plan and prepare<br />
for pregnancy. They are also ideally placed to<br />
increase the awareness of women with diabetes<br />
about the available resources which are being<br />
actively reviewed and developed to meet their<br />
needs.<br />
n<br />
Acknowledgements<br />
The authors are grateful to the women who took<br />
part in the NDSS Contraception, Pregnancy<br />
& Women’s Health Survey, to the Australasian<br />
Diabetes in Pregnancy Society for approving the<br />
use of the image of the Pregnant with Diabetes<br />
app and to Effie Houvardas and Kaye Farrell,<br />
for their contribution to Diabetes in Pregnancy<br />
Dunne FP, Avalos G, Durkan M et al (2009) ATLANTIC DIP:<br />
pregnancy outcome for women with pregestational diabetes<br />
along the Irish Atlantic seaboard. Diabetes Care 32: 1205–6<br />
Holmes VA, Hamill, LL, Alderdice FA et al (2017) Effect of<br />
implementation of a preconception counselling resource for<br />
women with diabetes: A population based study. Primary Care<br />
Diabetes 11: 37–45<br />
Kim C, Ferrara A, McEwan LN et al (2005) Preconception care in<br />
managed care: the translating research into action for diabetes<br />
study. Am J Obstet Gynecol 192: 227–32<br />
Kitzmiller JL, Wallerstein R, Correa A, Kwan S (2010)<br />
Preconception care for women with diabetes and prevention of<br />
major congenital malformations. Birth Defects Res A Clin Mol<br />
Teratol 88: 791–803<br />
Macintosh MC, Fleming KM, Bailey JA et al (2006) Perinatal<br />
mortality and congenital anomalies in babies of women with<br />
type 1 or type 2 diabetes in England, Wales, and Northern<br />
Ireland: population based study. BMJ 333: 177<br />
McElduff A, Ross GP, Lagstrom JA et al (2005) Pregestational<br />
diabetes and pregnancy: an Australian experience. Diabetes<br />
Care 28: 1260–1<br />
National Diabetes Services Scheme (2015) NDSS Diabetes<br />
in Pregnancy National Development Program, Registrant<br />
Consultation and Needs Assessment Report. NDSS, Canberra,<br />
ACT<br />
Ray JG, O’Brien TE, Chan WS (2001) Preconception care and the<br />
risk of congenital anomalies in the offspring of women with<br />
diabetes mellitus: a meta-analysis. QJM 94: 435–44<br />
Temple RC, Murphy H (2010) Type 2 diabetes in pregnancy - an<br />
increasing problem. Best Pract Res Clin Endocrinol Metab 24:<br />
591–603<br />
Wahabi HA, Alzeidan RA, Bawazeer GA et al (2010)<br />
Preconception care for diabetic women for improving maternal<br />
and fetal outcomes: a systematic review and meta-analysis.<br />
BMC Pregnancy Childbirth 10: 63<br />
Zhu H, Graham D, Teh RW, Hornbuckle J (2012) Utilisation of<br />
preconception care in women with pregestational diabetes in<br />
Western Australia. Aust N Z J Obstet Gynaecol 52: 593–6<br />
Authors<br />
Melinda Morrison, NDSS<br />
Diabetes in Pregnancy Priority<br />
Area Leader*, Diabetes, NSW,<br />
Glebe, NSW; Ralph Audehm,<br />
General Practitioner, Carlton<br />
Family Medical and Department<br />
of General Practice, University<br />
of Melbourne, Vic; Alison Barry,<br />
Credentialled Diabetes Educator<br />
and Midwife, Mater Mothers’<br />
Hospital, South Brisbane, Qld;<br />
Christel Hendrieckx, Senior<br />
Research Fellow, The Australian<br />
Centre for Behavioural Research<br />
in Diabetes, Deakin University,<br />
Geelong, Vic; Alison Nankervis,<br />
Senior Physician to the Diabetes<br />
Service, The Royal Women’s<br />
Hospital and Clinical Head,<br />
Diabetes, Royal Melbourne<br />
Hospital, Parkville, Vic; Cynthia<br />
Porter, Advanced Accredited<br />
Practising Dietitian/Credentialled<br />
Diabetes Educator, Geraldton<br />
Diabetes Clinic, Geraldton, WA;<br />
Renza Scibilia, Manager Type 1<br />
Diabetes and Consumer Voice,<br />
Diabetes Australia, Melbourne,<br />
Vic; Glynis P Ross, Visiting<br />
Endocrinologist, Royal Prince<br />
Alfred Hospital, Camperdown,<br />
NSW, and Senior Endocrinologist,<br />
Bankstown-Lidcombe Hospital,<br />
Bankstown, NSW.<br />
*Melinda Morrison is representing<br />
Diabetes Australia/National<br />
Diabetes Service Scheme.<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 53
CPD module<br />
Optimising pregnancy outcomes for<br />
women with pre-gestational diabetes in<br />
primary health care<br />
Glynis P Ross<br />
Citation: Ross GP (2017) Optimising<br />
pregnancy outcomes for women<br />
with pre-gestational diabetes in<br />
primary health care. Diabetes &<br />
Primary Care Australia 2: 54–9<br />
Learning objectives<br />
After reading this article, the<br />
participant should be able to:<br />
1. Identify the increased<br />
risks of adverse pregnancy<br />
outcomes to mother and<br />
baby that are associated with<br />
pre-gestational diabetes.<br />
2. Describe the ideal<br />
preconception care<br />
consultation and the key<br />
elements of care that a pregnant<br />
woman with pre-existing<br />
diabetes should receive.<br />
3. Implement a checklist for<br />
preconception care for<br />
women with diabetes.<br />
Key words<br />
– Preconception care<br />
– Pre-gestational diabetes<br />
– Pregnancy<br />
– Type 1 diabetes<br />
– Type 2 diabetes<br />
Author<br />
Glynis P Ross, Visiting<br />
Endocrinologist, Royal Prince<br />
Alfred Hospital, Camperdown<br />
NSW, and Senior Endocrinologist,<br />
Bankstown-Lidcombe Hospital,<br />
Bankstown, NSW.<br />
Preconception care for women with pre-existing diabetes (type 1 or type 2) is critical to<br />
optimise pregnancy outcomes and reduce the risk of adverse outcomes, including miscarriage,<br />
congenital anomalies, hypertension, caesarean deliveries and perinatal mortality. Pregestational<br />
diabetes is present in approximately 1% of pregnant women in Australia, and the<br />
prevalence is increasing. Women with pre-gestational diabetes need to be informed on the<br />
availability and importance of preconception care, which can be provided by both primary<br />
care and specialised diabetes services. The key elements of preconception care for women<br />
with diabetes are outlined in this article with two case examples to illustrate.<br />
Women with pre-gestational type 1<br />
or type 2 diabetes are at high risk<br />
of complications during pregnancy<br />
and of adverse outcomes including miscarriage,<br />
congenital anomalies and perinatal mortality.<br />
Despite advances in diabetes management, rates<br />
of congenital anomalies are 2–4 times higher<br />
than that of the background population and<br />
there is a 3–5 fold increased risk of stillbirth<br />
and perinatal mortality for births to women<br />
with diabetes (Macintosh et al, 2006; Dunne et<br />
al, 2009; Kitzmiller et al, 2010). Data from the<br />
Australian Institute of Health and Welfare (2010)<br />
show that in 2005–2007, more than half of all<br />
Australian women with pre-gestational diabetes<br />
underwent caesarean delivery (59%; 71% type 1<br />
and 56% type 2 diabetes), compared to a third of<br />
women without diabetes. Following birth, 58%<br />
of infants born to women with diabetes were<br />
admitted to a special care nursery or neonatal<br />
intensive care unit, compared to 14% of babies<br />
born to mothers without diabetes.<br />
Glycaemic control in early pregnancy is strongly<br />
associated with the risk of adverse pregnancy<br />
outcomes (Nielsen et al, 2004; Guerin et al, 2007,<br />
Jensen et al, 2009). Research shows that for every<br />
10.93 mmol/mol (1%) increase in HbA 1c<br />
above<br />
53 mmol/mol (7%), there is a 5.5% increase in<br />
risk of adverse outcomes (Nielsen et al, 2004). The<br />
American Diabetes Association (2017) states that<br />
the lowest rates of adverse pregnancy outcomes<br />
are seen in association with an early gestation<br />
HbA 1c<br />
of 42–48 mmol/mol (6.0–6.5%).<br />
Preconception care for women with existing<br />
diabetes provides an opportunity to optimise<br />
glycaemic control, as well as other aspects of<br />
maternal health such as folic acid supplementation,<br />
diabetes complications screening and<br />
discontinuation of teratogenic medications prior<br />
to conception (McElduff et al, 2005; Mahmud<br />
and Mazza, 2010; Egan et al, 2015). Attendance<br />
at diabetes-specific preconception care has<br />
been associated with a reduction in congenital<br />
anomalies (relative risk [RR], 0.25), perinatal<br />
mortality (RR, 0.35) and reduced first trimester<br />
HbA 1c<br />
by an average of 26 mmol/mol (2.4%;<br />
Wahabi et al, 2010).<br />
Advice<br />
Preconception planning and assessment is<br />
recommended for all women considering<br />
pregnancy, but it is particularly important for<br />
women with diabetes or other medical disorders.<br />
Primary health care providers are well placed to<br />
complete most of the preconception screening<br />
and risk assessment, and can facilitate many of<br />
54 Diabetes & Primary Care Australia Vol 2 No 2 2017
Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care<br />
the interventions and appropriate referrals that<br />
may be required. A checklist, such as below,<br />
may be useful when undertaking pre-pregnancy<br />
counselling.<br />
ADVICE AND CONSIDERATIONS<br />
FOR ALL WOMEN CONSIDERING<br />
PREGNANCY<br />
o Appropriate contraception until<br />
optimal situation for pregnancy.<br />
o Review ALL current medications<br />
and ensure they are safe and<br />
appropriate for pregnancy.<br />
o Check blood pressure.<br />
o (For women not known to<br />
have diabetes, assess risk,<br />
and test appropriately for<br />
abnormal glucose tolerance.)<br />
o Promote a healthy lifestyle<br />
with regard to diet, exercise<br />
and optimal weight – this is<br />
also advisable for partners!<br />
o Encourage smoking cessation.<br />
o Advise to cease alcohol intake.<br />
o Advise to stop any<br />
recreational drug use.<br />
o Reduce caffeine intake.<br />
o Dental check.<br />
o Complete breast check<br />
and pap smear.<br />
o Assess immunity to rubella<br />
and varicella zoster, and, if<br />
necessary, organise vaccinations<br />
with appropriate waiting<br />
periods before conception.<br />
o Consider vaccinations for<br />
influenza and whooping cough.<br />
o Commence folic acid 3 months<br />
prior to pregnancy at 0.5 mg daily<br />
(see below for dose adjustments<br />
for women with known diabetes).<br />
o Commence an iodine-containing<br />
supplement (unless active<br />
thyrotoxicosis is present).<br />
o Consider checking thyroid<br />
function, iron, B12 (especially if<br />
vegetarian or taking metformin)<br />
and vitamin D status (if at risk).<br />
ADDITIONAL ADVICE AND<br />
CONSIDERATIONS FOR WOMEN<br />
WITH PRE-GESTATIONAL DIABETES<br />
CONSIDERING PREGNANCY<br />
o Refer to a diabetes specialist<br />
or team if not already under<br />
their care for assessment.<br />
o Optimise glycaemic control<br />
o In type 1 diabetes, pre-pregnancy<br />
HbA 1c<br />
should ideally be<br />
Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care<br />
Page points<br />
1. Preconception care should be<br />
individualised.<br />
2. Women should be advised<br />
to continue to use effective<br />
contraception until the best<br />
possible conditions for a<br />
safe pregnancy and birth are<br />
achieved.<br />
3. Regular monitoring and<br />
recording of blood glucose<br />
levels during the preconception<br />
stage and pregnancy can be<br />
helpful in optimising pregnancy<br />
outcomes.<br />
Case studies<br />
Outlined on the following two pages are two case<br />
studies illustrating some of the considerations to<br />
address during the preconception period. Given<br />
the range of situations that may be encountered,<br />
all care needs to be individualised. Ideally, most<br />
women with diabetes should be assessed before<br />
conception by a diabetes specialist or team with<br />
expertise in diabetes and pregnancy. This is<br />
particularly important when there are diabetes<br />
complications or additional medical disorders.<br />
For women in rural and remote areas, review<br />
in a regional centre or via telehealth with a<br />
specialist centre may be an appropriate option.<br />
This is especially important for women with more<br />
complex situations such as type 1 diabetes, type 2<br />
diabetes requiring multiple medications, diabetes<br />
vascular complications and/or other vascular risk<br />
factors.<br />
Case 1<br />
Maria is a 41-year old woman and has come<br />
to see you for a pap smear. You last saw her<br />
4 months ago when she wanted a script for<br />
the oral contraceptive pill (OCP). On routine<br />
questioning when you are completing the<br />
pathology request for cervical cytology she says<br />
that she is considering having a break from the<br />
pill as she and her husband are thinking about<br />
having another baby.<br />
History<br />
Maria has two children aged 9 and 12 years.<br />
The first pregnancy was uncomplicated and she<br />
had spontaneous vaginal delivery at term. Her<br />
daughter weighed 3450 g and was breastfed<br />
for 12 months. Before her second pregnancy,<br />
Maria had gained 8 kg in weight and her BMI<br />
was 28 kg/m 2 . At 28 weeks during her second<br />
pregnancy, Maria was diagnosed with gestational<br />
diabetes. She was able to manage this with diet<br />
modification alone and had spontaneous vaginal<br />
delivery at 39 +3 weeks of a 3720 g son. He was<br />
also breastfed for 12 months.<br />
Three years ago (age 38 years), Maria’s<br />
weight had risen and her BMI was 31 kg/m 2<br />
(class 1 obesity range). Her fasting glucose was<br />
7.2 mmol/L and her HbA 1c<br />
was 49 mmol/mol<br />
(6.6%) and a diagnosis of type 2 diabetes was<br />
made. Initially she was treated with metformin<br />
XR 2 g daily. Despite the metformin and Maria<br />
trying to follow dietary guidelines, 4 months<br />
ago her HbA 1c<br />
was 62 mmol/mol (7.8%) and so<br />
empagliflozin was added to her regimen. She<br />
continued to struggle to find time to exercise.<br />
Maria has a strong family history of<br />
type 2 diabetes (both parents, her older brother<br />
and all grandparents) and hypertension (father<br />
and paternal grandmother). Her father had a<br />
myocardial infarct at the age of 39 years with<br />
subsequent stenting. For 7 years, Maria has also<br />
been treated for hypertension with telmisartan,<br />
and dyslipidaemia for which she is taking<br />
atorvastatin and fenofibrate. She and her husband<br />
smoke, but Maria has said she is trying to stop<br />
so is only smoking in the evenings after dinner.<br />
Discussion<br />
Maria has several factors that increase her<br />
risk of adverse pregnancy outcomes. She is of<br />
advanced maternal age, is obese, a smoker, and<br />
has type 2 diabetes, hypertension, dyslipidaemia<br />
and a family history of early-onset ischaemic<br />
heart disease.<br />
Her glycaemic control is not satisfactory for<br />
pregnancy, and although metformin can be<br />
continued during pregnancy, empagliflozin<br />
will need to be stopped and insulin therapy<br />
commenced and titrated. She will need to increase<br />
her blood glucose monitoring and recording of<br />
results, preferably including dietary information.<br />
Review with a dietitian, diabetes educator and<br />
preferably an exercise physiologist is advisable.<br />
She should be seen by a diabetes physician with<br />
expertise in diabetes and pregnancy.<br />
She has multiple vascular risk factors and a<br />
high risk of developing a hypertensive disorder of<br />
pregnancy. She should be appropriately counselled<br />
regarding smoking cessation. The medication she<br />
is on for hypertension needs to be changed and<br />
the lipid management will need to be stopped<br />
for pregnancy. As she has hypertension it would<br />
be preferable that she is also seen by a renal or<br />
obstetric medicine physician, especially if she<br />
fails to achieve blood pressure targets or if she<br />
has overt proteinuria. Given the multiple vascular<br />
risk factors, she should have a pre-pregnancy<br />
cardiac assessment.<br />
56 Diabetes & Primary Care Australia Vol 2 No 2 2017
Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care<br />
Advice<br />
You advise Maria that she should stay on the<br />
OCP for the time being and that preconception<br />
planning is needed in view of her multiple medical<br />
conditions and medications. If she still wishes to<br />
become pregnant, she should commence highdose<br />
folic acid and have routine pre-pregnancy<br />
checks. If she conceives, her contraception choice<br />
should be reviewed following the pregnancy as it<br />
is not advisable for her to continue on the OCP<br />
given her age and vascular risk status.<br />
Case 2<br />
Jennifer has come to see you for a referral letter to<br />
her gynaecologist. She wants to have her intrauterine<br />
contraceptive device (IUCD) removed as she is<br />
keen to start a family. Jennifer is a 30-year-old<br />
woman who has had type 1 diabetes for 21 years.<br />
For the last 3 years, she has been using insulin<br />
pump therapy. Jennifer’s most recent HbA 1c<br />
of<br />
70 mmol/mol (8.6%) was higher than usual after a<br />
recent overseas holiday with her husband.<br />
History<br />
In her teens, Jennifer struggled with her diabetes<br />
control but in the past 5 years has been managing<br />
quite well. Her last episode of diabetic ketoacidosis<br />
was 18 months ago when there was a problem with<br />
insulin delivery through her pump. She has not<br />
had severe hypoglycaemia (requiring the assistance<br />
of another person) for 5 years and is using a<br />
continuous glucose monitoring system (CGMS)<br />
with predictive low-glucose suspend, as she knows<br />
that she does not reliably sense hypoglycaemia.<br />
Jennifer has diabetic retinopathy that has<br />
previously required laser photocoagulation.<br />
However, she has not had her eyes checked for<br />
about 2 years as she missed an appointment and<br />
did not find time to reschedule. She has overt<br />
proteinuria (0.5 g per day) and is on ramipril for<br />
nephroprotection. Her eGFR is 62 mL/min/1.73 m 2<br />
and she has previously been assessed for other<br />
causes of renal disease by a nephrologist. Her<br />
blood pressure and lipids are normal. She has<br />
a moderate degree of asymptomatic peripheral<br />
neuropathy with loss of distal sensation to light<br />
touch and vibration, as well as loss of ankle<br />
reflexes. She senses a monofilament and has had<br />
no diabetes-related foot complications.<br />
Discussion<br />
If conception is successful, this will be Jennifer’s<br />
first pregnancy. As she is on insulin pump therapy<br />
and uses a CGM device, she will already be under<br />
a specialist diabetes team. Her glycaemic control<br />
is sub-optimal and significantly increases her<br />
risk of adverse pregnancy outcomes, including<br />
miscarriage and congenital anomalies. Even<br />
though the recommended HbA 1c<br />
target for women<br />
with type 1 diabetes in the preconception stage is<br />
≤53 mmol/mol (7%), given her long duration<br />
of type 1 diabetes and poor hypoglycaemic<br />
awareness, it may not be safe to reduce her HbA 1c<br />
below 58 mmol/mol (7.5%) due to the increasing<br />
risk of severe hypoglycaemia at lower levels. She<br />
needs specific specialist assessment and advice<br />
regarding her HbA 1c<br />
as well as review of all<br />
aspects of her diabetes self-management (e.g. diet,<br />
exercise, BGL testing and recording, insulin pump<br />
settings review, pump management skills, driving<br />
considerations, and hypoglycaemia and diabetic<br />
ketoacidosis prevention and management).<br />
Jennifer also needs an urgent diabetes eye<br />
review. If there is active proliferative retinopathy or<br />
macular oedema she will need to delay pregnancy<br />
plans until the retinopathy has been treated and<br />
is stable. As she has overt proteinuria, she should<br />
be assessed pre-pregnancy by a renal or obstetric<br />
medicine physician who will be able to continue<br />
to manage her in pregnancy. Her risk of preeclampsia<br />
and poor fetal outcomes, including<br />
intrauterine growth restriction (IUGR), will be<br />
increased. Although she is not known to have<br />
autonomic neuropathy, she should be assessed for<br />
this by her diabetes specialist.<br />
Advice<br />
You advise Jennifer to not have the IUCD<br />
removed yet and that preconception planning is<br />
needed in view of her complex diabetes situation<br />
– especially her overall glycaemic control,<br />
nephropathy and retinopathy. You also ask her<br />
whether she has discussed pregnancy with her<br />
endocrinologist and check the date of her next<br />
scheduled appointment. Following diabetes<br />
complications assessment and optimising<br />
glycaemic management, Jennifer should<br />
commence high-dose folic acid and have routine<br />
pre-pregnancy checks.<br />
”If a woman has<br />
been diagnosed with<br />
retinopathy, it is<br />
important to ensure<br />
it has been treated<br />
and is stable prior to<br />
pregnancy.”<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 57
Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care<br />
“Primary health<br />
care providers have<br />
critical roles to play<br />
in the assessment<br />
and management of<br />
contraception,<br />
pre-pregnancy<br />
assessment<br />
and care.”<br />
Conclusion<br />
Women of child-bearing age with pre-gestational<br />
type 1 or type 2 diabetes need to be counselled<br />
on the need for appropriate contraception at all<br />
times unless trying for pregnancy in the best<br />
possible circumstances to avoid adverse pregnancy<br />
outcomes. Most women with pre-gestational<br />
diabetes are able to have successful pregnancies.<br />
However, they are at much higher risk of having<br />
adverse pregnancy outcomes than women without<br />
diabetes (Macintosh et al, 2006; Dunne et al,<br />
2009). It has been shown that women who have<br />
had optimal pre-pregnancy care and best practice<br />
management of their diabetes, both before and<br />
throughout pregnancy, will have a substantially<br />
lower rate of adverse outcomes (Ray et al, 2001;<br />
Wahabi et al, 2010).<br />
Ideally, care should involve services that are<br />
specialised in diabetes in pregnancy. However,<br />
primary health care providers also have critical<br />
roles to play in the assessment and management of<br />
contraception, pre-pregnancy assessment and care,<br />
coordination of specialist services and ongoing<br />
support prior to, as well as throughout and<br />
following, the pregnancy. <br />
n<br />
Acknowledgement<br />
The author would like to acknowledge Melinda<br />
Morrison for assistance with article editing and<br />
referencing.<br />
American Diabetes Association (2017) Standards of Medical Care in<br />
Diabetes—2017. Diabetes Care 40(Suppl 1): S4–S5<br />
Australian Institute of Health and Welfare (2010) Diabetes in<br />
pregnancy: its impact on Australian women and their babies.<br />
AIHW, Canberra, ACT<br />
Dunne FP, Avalos G, Durkan M et al (2009) ATLANTIC DIP:<br />
pregnancy outcome for women with pregestational diabetes<br />
along the Irish Atlantic seaboard. Diabetes Care 32: 1205–6<br />
Egan, AM, Murphy HR, Dunne FP (2015) The management of type 1<br />
and type 2 diabetes in pregnancy. QJM: An International Journal<br />
of Medicine 108: 923–7<br />
Guerin A, Nisenbaum R, Ray JG (2007) Use of maternal GHb<br />
concentration to estimate the risk of congenital anomalies in the<br />
offspring of women with prepregnancy diabetes. Diabetes Care<br />
30: 1920–5<br />
Inkster ME, Fahey TP, Donnan PT et al (2006) Poor glycated<br />
haemoglobin control and adverse pregnancy outcomes in type 1<br />
and type 2 diabetes mellitus: Systematic review of observational<br />
studies. BMC Pregnancy Childbirth 6: 30<br />
Jensen DM, KorsholmL, Ovesen P et al (2009) Periconceptional A1C<br />
and risk of serious adverse pregnancy outcome in 933 women<br />
with type 1 diabetes. Diabetes Care 32: 1046–8<br />
Kitzmiller JL, Wallerstein R, Correa A, Kwan S (2010) Preconception<br />
care for women with diabetes and prevention of major congenital<br />
malformations. Birth Defects Res A Clin Mol Teratol 88: 791–803<br />
Macintosh MC, Fleming KM, Bailey JA et al (2006) Perinatal<br />
mortality and congenital anomalies in babies of women with<br />
type 1 or type 2 diabetes in England, Wales, and Northern<br />
Ireland: population based study. BMJ 333: 177<br />
Mahmud M, Mazza D (2010) Preconception care of women with<br />
diabetes: a review of current guideline recommendations. BMC<br />
Womens Health 10: 5<br />
McElduff A, Cheung NW, McIntyre HD et al (2005) The Australasian<br />
Diabetes in Pregnancy Society consensus guidelines for the<br />
management of type 1 and type 2 diabetes in relation to<br />
pregnancy. Med J Aust 183: 373–7<br />
Nielsen LR, Ekbom P, Damm P et al (2004) HbA1c levels are<br />
significantly lower in early and late pregnancy. Diabetes Care 27:<br />
1200–1<br />
Ray JG, O’Brien TE, Chan WS (2001) Preconception care and the risk<br />
of congenital anomalies in the offspring of women with diabetes<br />
mellitus: a meta-analysis. QJM 94: 435–44<br />
Wahabi HA, Alzeidan RA, Bawazeer GA et al (2010), Preconception<br />
care for diabetic women for improving maternal and fetal<br />
outcomes: a systematic review and meta-analysis. BMC<br />
Pregnancy Childbirth 10: 63<br />
58 Diabetes & Primary Care Australia Vol 2 No 2 2017
Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care<br />
Online CPD activity<br />
Visit www.pcdsa.com.au/cpd to record your answers and gain a certificate of participation<br />
Participants should read the preceding article before answering the multiple choice questions below. There is ONE correct answer to each question.<br />
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<br />
successful participation; however, it is possible to take the test a maximum of three times. A short explanation of the correct answer is provided.<br />
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<br />
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<br />
help you to collate evidence for your annual appraisal.<br />
1. What percentage of pregnant women are<br />
affected by pre-gestational diabetes?<br />
Select ONE option only.<br />
A. 0.1%<br />
B. 1%<br />
C. 2.5%<br />
D. 5%<br />
E. 10%<br />
2. A woman with type 2 diabetes has an<br />
HbA 1c<br />
of 69 mmol/mol (8.5%) in early<br />
pregnancy. Which ONE of the following<br />
statements is NOT true?<br />
A. She is at increased risk of miscarriage.<br />
B. She is at increased risk of hypertension<br />
in late pregnancy.<br />
C. She is at increased risk of developing<br />
retinopathy in pregnancy.<br />
D. She will not have an increased risk of<br />
pregnancy complications unless she is<br />
obese.<br />
E. It is safe for her to continue taking<br />
metformin.<br />
3. A 31-year-old woman with type 2 diabetes<br />
has just found she is pregnant. She is<br />
currently being treated with gliclazide and<br />
metformin. Which of the following options<br />
is most appropriate? Choose ONE option<br />
only.<br />
A. Stop gliclazide immediately<br />
B. Continue gliclazide and metformin<br />
initially<br />
C. Check HbA 1c<br />
D. Start self-monitoring of blood glucose<br />
(finger-prick testing)<br />
E. B, C and D<br />
4. Attendance at diabetes-specific<br />
preconception care has been associated<br />
with which one of the following? Choose<br />
ONE option only.<br />
A. A reduction in congenital anomalies<br />
B. A reduction in perinatal mortality<br />
C. A reduction in first trimester HbA 1c<br />
D. A, B and C<br />
E. None of the above<br />
5. Rachel has long-standing type 1<br />
diabetes. Her most recent HbA 1c<br />
is<br />
70 mmol/mol (8.6%). She is keen to<br />
conceive soon. Which of the following<br />
statements is INCORRECT? Select ONE<br />
option only.<br />
A. She should avoid pregnancy until her<br />
HbA 1c<br />
is close to 53 mmol/mol (7%)<br />
while still minimising hypoglycaemia<br />
risk.<br />
B. She should start taking folic acid 5 mg<br />
daily at least 3 months before she starts<br />
trying to conceive.<br />
C. She should be referred to a specialist<br />
diabetes and pregnancy unit to<br />
optimise her diabetes management<br />
prior to conceiving.<br />
D. She should be advised to terminate the<br />
pregnancy if she falls pregnant before<br />
her HbA 1c<br />
has improved as risk to her<br />
and the fetus would be unacceptable.<br />
E. She should delay pregnancy plans if<br />
she has active retinopathy until it has<br />
been treated.<br />
6. A 43-year-old woman with type 2 diabetes<br />
is currently 6 weeks pregnant. She has<br />
a past medical history that includes<br />
pernicious anaemia, hypertension<br />
and hyperlipidaemia. Which of her<br />
medications, if any, should she now STOP?<br />
Choose ONE option only.<br />
A. Metformin<br />
B. Hydroxocobalamin 1 mg 3-monthly<br />
C. Labetalol 200 mg twice daily<br />
D. Simvastatin 20 mg daily<br />
E. None of the above<br />
7. Which of the following antidiabetes<br />
agents, if any, are SAFE to prescribe for<br />
a woman with type 2 diabetes planning<br />
pregnancy? Choose ONE option only.<br />
A. A sodium–glucose co-transporter 2<br />
(SGLT2) inhibitor<br />
B. A dipeptidyl peptidase-4 (DPP-4)<br />
inhibitor<br />
C. A glucagon-like peptide-1(GLP-1)<br />
receptor agonist<br />
D. Thiazolidinedione<br />
E. Insulin<br />
8. A 37-year-old woman with pre-gestational<br />
type 2 diabetes is advised to monitor<br />
her blood glucose levels as she has<br />
recently commenced insulin to control<br />
her diabetes. Which of the following<br />
is the most appropriate to monitor her<br />
glycaemia? Choose ONE option only.<br />
A. HbA 1c<br />
B. Self-monitoring of blood glucose<br />
(finger-prick testing)<br />
C. Fructosamine<br />
D. Continuous blood glucose monitoring<br />
E. A and B<br />
9. Which of the following insulins does not<br />
have regulatory approval for use during<br />
pregnancy? Select ONE option only.<br />
A. Insulin glulisine (Apidra ® )<br />
B. Protaphane/Humulin NPH<br />
C. Insulin detemir (Levemir ® )<br />
D. Insulin aspart (Novorapid ® )<br />
E. None of the above; they are all<br />
approved for use in pregnancy<br />
10. Ideally, what should the pre-pregnancy<br />
HbA 1c<br />
target for women with type 2<br />
diabetes be? Choose ONE option only.<br />
A.
2017 NATIONAL CONFERENCE<br />
Saturday 6th May 2017 – Melbourne Convention and Exhibition Centre, Victoria, Australia<br />
The conference has been specifically designed for all primary care health<br />
professionals working in diabetes care to:<br />
<br />
<br />
<br />
Advance their education and learning in the field of diabetes health care<br />
Promote best practice standards and clinically effective care in the management of diabetes<br />
Facilitate collaboration between health professionals to improve the quality of diabetes<br />
primary care across Australia<br />
6TH MAY 2017 CONFERENCE PROGRAM<br />
The 2017 PCDSA national conference program will combine cutting edge scientific content with<br />
practical clinical sessions, basing the education on much more than just knowing the guidelines.<br />
The distinguished panel of speakers will share their specialised experience in an environment<br />
conducive to optimal learning. The Speaking faculty include, amongst others:<br />
Associate Professor<br />
Neale Cohen<br />
Director Clinical Diabetes<br />
Baker Heart and<br />
Diabetes Institute<br />
“Diabetes management<br />
and research in primary<br />
care – key components<br />
to improving outcomes”<br />
Doctor Christel<br />
Hendrieckx<br />
Senior Research Fellow<br />
The Australian Centre<br />
for Behavioural Research<br />
in Diabetes<br />
“The emotional health of<br />
people living with diabetes”<br />
Ms Renza Scibilia<br />
Manager - Type 1 Diabetes<br />
and Consumer Voice<br />
Diabetes Australia<br />
“Engaging people with<br />
diabetes, the diabetes<br />
online community and<br />
apps for diabetes”<br />
Doctor Gautam<br />
Vaddadi<br />
Consultant Cardiologist<br />
Alfred Health, Northern Health,<br />
University of Melbourne<br />
“The emerging importance<br />
of cardiac failure diagnosis<br />
and management in people<br />
with type 2 diabetes”<br />
For further information including the full 2017 program<br />
and to register for the conference please visit:<br />
www.eventful.com.au/pcdsa2017<br />
If you have any questions regarding the conference,<br />
please contact the Conference Secretariat;<br />
Toll free telephone: 1800 898 499<br />
Email: pcdsa@eventful.com.au<br />
pcdsa.com.au
Article<br />
Diabetes and bone health<br />
Vidhya Jahagirdar, Neil J Gittoes<br />
Diabetes and osteoporosis represent two major public health challenges. Osteoporosis<br />
is characterised by decreased bone mineral density and micro-architectural changes of<br />
the bone leading to increased risk of low trauma (fragility) fractures. Both diabetes and<br />
osteoporosis are associated with significant morbidity, decreased quality of life and reduced<br />
life expectancy. This article will explore the current literature on the inter-relationships<br />
between diabetes and bone health, the impact on patients and the management strategies<br />
that may be considered in primary care to minimise risk of diabetes-related bone disease<br />
and improve outcomes.<br />
Preface<br />
Nick Forgione, General Practitioner, Trigg Health<br />
Care Centre, Perth, WA<br />
The connection between diabetes and<br />
osteoporosis is often overlooked in the<br />
busy management schedule of people<br />
with diabetes. However, there is an accumulation<br />
of evidence suggesting that type 2 diabetes may<br />
be an independent risk factor for osteoporosis.<br />
Despite the fact that bone mineral density<br />
(BMD) is often higher in people with<br />
type 2 diabetes compared to those without, it<br />
is paradoxical that people with type 2 diabetes<br />
have a higher risk of fracture. It is likely that the<br />
explanation for this paradox is multifactorial,<br />
including changes in trabecular bone,<br />
microarchitectural changes in bone leading<br />
to reduced bone strength and changes in the<br />
material property of bone due to accumulation<br />
of advanced glycation end products (AGEs).<br />
Medications used in the management of diabetes<br />
may also play a part.<br />
Diabetes and osteoporosis represent<br />
two major public health challenges.<br />
Osteoporosis is characterised by<br />
decreased bone mineral density (BMD) and<br />
micro-architectural changes of the bone leading<br />
to increased risk of low trauma or fragility<br />
fractures that are sustained as a result of a fall<br />
from standing height or less (Figure 1). Both<br />
There is much that remains unclear about<br />
people with diabetes-related osteoporosis.<br />
Assessment of fracture risk must be approached<br />
with caution as people with diabetes tend to<br />
have a higher fracture risk for a given BMD<br />
t-score compared to those without diabetes.<br />
Also it is unclear whether antiresorptive agents<br />
reduce fracture risk in type 2 diabetes to the<br />
same extent as those without diabetes (Rubin et<br />
al, 2013).<br />
As the number of people with type 2 diabetes<br />
increases and their life is extended through<br />
improvements in management, ensuring early<br />
detection and appropriate management of<br />
osteoporosis in this population becomes another<br />
priority for primary care management. Until<br />
there is further clarification of whether or not<br />
individuals with type 2 diabetes should be<br />
screened and managed differently to the rest<br />
of the population, it is important to at least<br />
ensure that the current RACGP guidelines for<br />
the detection and treatment of osteoporosis are<br />
followed.<br />
diabetes and osteoporosis are associated with<br />
significant morbidity, decreased quality of life<br />
and reduced life expectancy. In Australia, the<br />
total number of adults with diabetes is projected<br />
to rise to between 2 and 3 million by 2025<br />
(Magliano et al, 2009). Osteoporosis is also<br />
a condition that increases in prevalence with<br />
ageing (Figure 2). Age-related bone loss and<br />
Citation: Jahagirdar V, Gittoes NJ<br />
(2016) Diabetes and bone health.<br />
Diabetes & Primary Care Australia<br />
2: 61–8<br />
Article points<br />
1. Diabetes and osteoporosis are<br />
increasingly prevalent diseases.<br />
2. Diabetes and its complications<br />
influence important<br />
determinants of bone strength<br />
such as the material properties<br />
of bone, bone density and<br />
mineral content as well as<br />
bone micro-architecture<br />
and bone turnover.<br />
3. Diabetes is an important<br />
clinical risk factor for<br />
osteoporosis and fracture,<br />
and as clinicians it is<br />
important to remember this<br />
association when managing<br />
people with diabetes.<br />
Key words<br />
– Bone<br />
– Metabolic disorder<br />
– Osteoporosis<br />
Authors<br />
Vidhya Jahagirdar is Specialty<br />
Trainee Registrar in Diabetes,<br />
Endocrinology and General<br />
Internal Medicine; Neil Gittoes is<br />
Consultant & Honorary Professor<br />
of Endocrinology, Head, Centre<br />
for Endocrinology, Diabetes and<br />
Metabolism. Both are at the<br />
Department of Endocrinology,<br />
University Hospitals Birmingham<br />
NHS Foundation Trust,<br />
Birmingham, UK.<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 61
Diabetes and bone health<br />
Page points<br />
1. The prevalence of osteoporosis<br />
based on bone mass density<br />
(BMD) is significantly lower in<br />
type 2 diabetes compared to<br />
age-matched controls.<br />
2. Age, female gender,<br />
glucocorticoid use and family<br />
history are well-recognised risk<br />
factors for osteoporosis and<br />
osteoporotic fractures, but the<br />
association between diabetes<br />
and osteoporosis is tantalising,<br />
but poorly understood.<br />
3. As type 1 diabetes is usually<br />
diagnosed in children, the early<br />
and chronic alterations in bone<br />
metabolism may result in lower<br />
peak bone mass.<br />
Figure 1. Osteoporosis is characterised by decreased<br />
bone mineral density and micro-architectural changes<br />
of the bone leading to increased risk of low trauma<br />
fractures (Blausen Medical Communications, 2016).<br />
post-menopausal physiological changes result in<br />
an increased prevalence of osteoporosis from 2%<br />
at 50 years to 25% at 80 years of age (NICE,<br />
2012). One in two women and one in five men<br />
sustain one or more osteoporotic fractures in their<br />
lifetime. In 2012, there were 140 822 fractures<br />
as a result of osteoporosis or osteopaenia in<br />
Australians over the age of 55 years, with a total<br />
cost of $2.75 billion. This is expected to increase to<br />
around $3.84 billion by 2022 (Watts et al, 2013).<br />
While age, female gender, glucocorticoid use<br />
and family history are well-recognised risk factors<br />
for osteoporosis and osteoporotic fractures, the<br />
association between diabetes and osteoporosis<br />
is tantalising, but poorly understood. Other<br />
disease conditions associated with diabetes, such<br />
as diabetic nephropathy, retinopathy, neuropathy<br />
and obesity, as well as medication used in<br />
the management of diabetes, may affect bone<br />
health, increase risk of falls and predispose<br />
patients to osteoporotic fractures. These factors<br />
are confounders in attempting to delineate causal<br />
links between diabetes and osteoporosis.<br />
The aim of this article is to explore the current<br />
literature on the inter-relationships between<br />
diabetes and bone health, the impact on patients<br />
and the management strategies that may be<br />
considered in primary care to minimise risk<br />
of diabetes-related bone disease and improve<br />
outcomes.<br />
Epidemiology of fractures in diabetes<br />
The interaction between diabetes and osteoporosis<br />
is poorly understood. Both type 1 and type 2<br />
diabetes are associated with increased risk of<br />
osteoporosis and fracture, and this risk is greater<br />
in type 1 than type 2 (Vestergaard, 2007).<br />
Various factors, such as type of diabetes, onset<br />
and duration, metabolic control, BMI, BMD,<br />
falls risk, diabetic complications and treatment,<br />
may influence bone health in diabetes. There are<br />
no well-designed randomised controlled trials<br />
(RCTs) or carefully evaluated epidemiological<br />
studies that have looked into all the above<br />
factors as potential attributors to fracture risk in<br />
diabetes.<br />
Figure 2. Peak bone mass is reached at 30 years of age. Bone mass then decreases with age, more<br />
so in women (Anatomy & Physiology, 2013).<br />
Type 1 diabetes<br />
BMD is lower in children and adolescents with<br />
type 1 diabetes than children without diabetes.<br />
As type 1 diabetes is usually diagnosed in<br />
children, the early and chronic alterations in<br />
bone metabolism may result in lower peak<br />
bone mass. This may contribute to osteoporosis<br />
and an increased risk of fracture in later life<br />
(Bonjour and Chevalley, 2014).<br />
According to a recent meta-analysis, type 1<br />
diabetes is associated with three times increased<br />
background risk of any fracture and the risk is<br />
elevated in both men and women. In individuals<br />
62 Diabetes & Primary Care Australia Vol 2 No 2 2017
Diabetes and bone health<br />
Secondary causes<br />
associated with diabetes<br />
l Coeliac disease<br />
l Graves thyrotoxicosis<br />
l Hypothyroidism<br />
l Hypogonadism<br />
l Vitamin D deficiency<br />
Anti-diabetes medication<br />
l TZDs<br />
l GLP-1 receptor agonists<br />
l DPP-4 inhibitors<br />
l SGLT2 inhibitors<br />
Falls risk<br />
l Diabetic retinopathy<br />
l Diabetic neuropathy<br />
l Obesity<br />
l Hypoglycaemia<br />
Decreased bone<br />
turnover<br />
CKD–MBD secondary to<br />
diabetic nephropathy<br />
Fracture risk<br />
Abnormal bone architecture<br />
Decreased bone mineral density<br />
via collagen cross links<br />
Decreased osteoblast differentiation<br />
Osteoblast dysfunction<br />
Increased osteoclast activity<br />
Increased adipogenesis<br />
Increased AGE<br />
Increased PPAR-gamma<br />
Decreased insulin/<br />
IGF-1 secretion<br />
Oxidative stress<br />
Figure 3. The factors influencing bone health and fracture risk in diabetes. AGE=advanced glycation end-products; CKD–MBD=chronic kidney<br />
disease–mineral and bone disorder; DPP-4=dipeptidyl peptidase-4; GLP-1=glucagon-like peptide-1; IGF-1=insulin-like growth factor-1; PPAR-gamma=<br />
peroxisome proliferator-activated receptor-gamma; SGLT2=sodium–glucose cotransporter 2; TZD=thiazolidinedione.<br />
with type 1 diabetes compared to people<br />
without the condition, the relative risk (RR) for<br />
hip fracture was 3.78 (95% confidence interval<br />
[CI], 2.05–6.98; P
Diabetes and bone health<br />
Page points<br />
1. Insulin deficiency and reduced<br />
insulin-like growth factor-1 have<br />
been linked to the inhibition of<br />
osteoblast differentiation and<br />
osteopaenia in type 1 diabetes.<br />
2. People with diabetes are at<br />
increased risk of falls and this is<br />
multifactorial due to advancing<br />
age, diabetes complications,<br />
hypoglycaemia and high BMI.<br />
3. Cortical bone mass is reduced<br />
in the feet and hands in severe<br />
diabetic peripheral neuropathy<br />
and may predispose to<br />
metatarsal fracture and diabetic<br />
Charcot’s osteoarthropathy.<br />
Fracture risk has also been reported to be<br />
independent of other usually reliable predictors<br />
of fracture risk in type 2 diabetes, including age,<br />
physical activity and BMI (RR 2.6 [95% CI],<br />
1.5–4.5; Janghorbani et al, 2007).<br />
How does diabetes affect bone?<br />
Diabetes and its complications influence<br />
important determinants of bone strength such<br />
as the material properties of bone, bone density<br />
and mineral content as well as bone microarchitecture<br />
and bone turnover (Figure 3).<br />
Oxidative stress<br />
Diabetes is reported to affect bone metabolism<br />
adversely through several mechanisms. Advanced<br />
glycation end-products (AGE) are produced as<br />
a result of oxidative stress in diabetes and are<br />
important mediators of diabetic complications<br />
such as diabetic retinopathy, nephropathy,<br />
neuropathy and atherosclerosis (Goh and<br />
Cooper, 2008). AGE accumulation in bones is<br />
also detrimental and leads to abnormal structure<br />
and alignment of collagen, contributing to bone<br />
fragility (Katayama et al, 1996).<br />
Insulin deficiency<br />
Insulin has an anabolic effect on bone. Insulin<br />
deficiency and reduced insulin-like growth<br />
factor-1 (IGF-1) have been linked to inhibition<br />
of osteoblast differentiation and osteopaenia<br />
in type 1 diabetes (Kanazawa et al, 2011).<br />
Treatment with insulin has been reported to<br />
stabilise BMD (Hofbauer et al, 2007). Hence,<br />
adequate optimisation of glycaemic control<br />
with insulin in type 1 diabetes may prevent<br />
osteopaenia and osteoporosis later in life.<br />
Diabetic nephropathy and chronic kidney<br />
disease (CKD)<br />
Diabetic nephropathy often leads to CKD and<br />
is the most common cause of end-stage renal<br />
disease in Australia (Kidney Health Australia,<br />
2015). The risk of developing moderate to severe<br />
CKD (stages 3b, 4 and 5) is eight times greater<br />
in women and twelve times greater in men with<br />
type 1 diabetes than in people without diabetes<br />
(Hippisley-Cox and Coupland, 2010). Similar to<br />
diabetes and osteoporosis, the risk of developing<br />
CKD increases with age.<br />
Clinical expression of mineral and bone disorders<br />
in CKD (CKD–MBD) is often asymptomatic<br />
until late in its course. Abnormalities in<br />
bone turnover and mineralisation can result<br />
in osteitis fibrosa cystica (brown tumours;<br />
Figure 4), adynamic bone disease, osteomalacia<br />
and secondary hyperparathyroidism caused by<br />
phosphate retention, decreased calcium and<br />
1,25-dihydroxy(OH) vitamin D (calcitriol)<br />
concentration, and uraemic osteodystrophy.<br />
These conditions increase the risk of fractures due<br />
to changes in bone quality. While abnormalities<br />
in calcium and phosphate levels are detected<br />
even at CKD stages 1 and 2, the clinical<br />
significance of these abnormalities is unclear.<br />
Hence, management is focussed on optimising<br />
calcium and phosphate levels in CKD stages 3,<br />
4 and 5.<br />
Factors affecting falls risk<br />
People with diabetes are at increased risk of falls<br />
and this is multifactorial due to advancing age,<br />
diabetes complications, hypoglycaemia and high<br />
BMI (Figure 3).<br />
Peripheral neuropathy<br />
The ABC health study showed that individuals<br />
with type 2 diabetes who develop fractures<br />
are more likely to have peripheral neuropathy,<br />
cerebrovascular disease and falls compared<br />
with people with diabetes without fractures<br />
(Strotmeyer et al, 2005). Cortical bone mass is<br />
reduced in the feet and hands in severe diabetic<br />
peripheral neuropathy and may predispose<br />
to metatarsal fracture and diabetic Charcot’s<br />
osteoarthropathy (Cundy et al, 1985), which can<br />
cause foot deformity and gait disturbance, further<br />
increasing fracture risk by increasing falls. People<br />
with diabetic peripheral neuropathy are more<br />
likely to fall when compared to age-matched<br />
controls. While the underlying causative factors<br />
are not entirely understood, reduced muscle<br />
strength and stability (Handsaker et al, 2014)<br />
and foot deformity are likely to be contributing<br />
factors.<br />
Retinopathy<br />
The Blue Mountain Eye study showed that, in<br />
64 Diabetes & Primary Care Australia Vol 2 No 2 2017
Diabetes and bone health<br />
Page points<br />
1. Individuals with diabetic<br />
retinopathy or cataracts, or<br />
both, with reduced visual acuity<br />
are prone to falls.<br />
2. Obesity is also associated with<br />
decreased bioavailability of<br />
vitamin D due to distribution in<br />
the subcutaneous t<strong>issue</strong> leading<br />
to vitamin D deficiency, another<br />
risk factor for osteoporosis.<br />
3. There is a high incidence of<br />
fragility fracture in people who<br />
experience hypoglycaemic<br />
events.<br />
Figure 4. Brown tumours of the hands in an individual with hyperparathyroidism (Gaillard, 2008).<br />
people with diabetes, there was a significantly<br />
increased risk of proximal humerus fracture<br />
associated with diabetic retinopathy, cortical<br />
cataract, longer diabetes duration (>10 years) and<br />
insulin treatment (Ivers et al, 2001). Individuals<br />
with diabetic retinopathy or cataracts, or both,<br />
with reduced visual acuity are prone to falls. Thus,<br />
the attendant increased risk of falls contributes to<br />
greater risk of fracture.<br />
Obesity<br />
In total, 90% of people with type 2 diabetes are<br />
overweight or obese. Obesity is commonly thought<br />
to have a protective effect on bone as BMD tends<br />
to increase with load bearing associated with<br />
being overweight. In post-menopausal women,<br />
obesity increased the risk of fractures at the<br />
humerus and ankle while decreased the risk at<br />
the hip, pelvis and wrist (Gonnelli et al, 2014).<br />
Fewer data are available for men. The reasons for<br />
site-specific fractures in obesity could be related<br />
to fat padding protecting the hip and pelvis and<br />
a tendency to fall backwards or sideways rather<br />
than fall forward on outstretched arm leading<br />
to wrist fracture. Obesity is also associated with<br />
decreased bioavailability of vitamin D due to<br />
distribution in the subcutaneous t<strong>issue</strong> leading<br />
to vitamin D deficiency, another risk factor<br />
for osteoporosis. Hence, in spite of increased<br />
BMD, obesity is associated with increased risk<br />
of fracture at particular sites, which is likely<br />
to be due to the pattern of fall and vitamin D<br />
deficiency.<br />
Hypoglycaemia<br />
There is a higher incidence of fragility fracture<br />
in people who experience hypoglycaemic events<br />
(Signorovitch et al, 2013). Intensive glycaemic<br />
control (HbA 1c<br />
Diabetes and bone health<br />
Page points<br />
1. Type 1 diabetes can be<br />
associated with other<br />
autoimmune conditions such as<br />
coeliac disease, hypothyroidism<br />
and Graves’ thyrotoxicosis,<br />
which also increase this risk of<br />
fracture and osteoporosis.<br />
2. Hyperthyroidism and overtreated<br />
hypothyroidism are<br />
associated with lower bone<br />
mineral density and increased<br />
risk of fracture.<br />
3. It is important to be aware<br />
of the effect different antidiabetes<br />
medication can have<br />
on bone mineral density and<br />
osteoporosis.<br />
relationship between hypoglycaemia and<br />
falls risk. It is intuitive, however, to speculate<br />
that with frequent hypoglycaemic episodes<br />
contributing to loss of consciousness, falls risk<br />
would increase. Thus, hypoglycaemia-induced<br />
falls with underlying low bone density in diabetes<br />
would increase risk of fragility fracture.<br />
Secondary causes for osteoporosis associated<br />
with diabetes<br />
Type 1 diabetes can be associated with other<br />
autoimmune conditions such as coeliac disease,<br />
hypothyroidism and Graves’ thyrotoxicosis.<br />
About one-third of people with coeliac disease<br />
have osteoporosis and may be at a higher risk of<br />
fractures. Both hyperthyroidism and over-treated<br />
hypothyroidism are associated with lower BMD<br />
and increased risk of fracture (Mirza and Canalis,<br />
2015). Hypogonadotrophic hypogonadism (low<br />
gonadotropins and low testosterone) is found<br />
in 25% of people with type 2 diabetes. Low<br />
testosterone levels in men are associated with<br />
low BMD and hypogonadism is a recognised<br />
cause of osteoporosis, but there are no reliable<br />
data available on fracture rates in people with<br />
type 2 diabetes and hypogonadism (Dandona<br />
and Dhindsa, 2011). Though epidemiological<br />
observational studies have shown associations<br />
between vitamin D deficiency and type 1 and<br />
type 2 diabetes, the evidence is inconclusive<br />
(Suzuki et al, 2006; Tahrani et al, 2010), as it<br />
is for many associations between suboptimal<br />
vitamin D and major health outcomes.<br />
Anti-diabetes medication<br />
Thiazolidinediones<br />
Expression of peroxisome proliferator-activated<br />
receptor-gamma (PPAR-gamma) is increased<br />
in diabetes. This induces adipogenesis and<br />
inhibits osteogenesis (Botolin and McCabe,<br />
2006; Montagnani and Gonnelli, 2013).<br />
Thiazolidinediones (pioglitazone and rosiglitazone)<br />
are PPAR-gamma agonists. They improve insulin<br />
sensitivity through their action on adipose t<strong>issue</strong><br />
and liver by increasing glucose utilisation and<br />
decreasing glucose production. Thiazolidinediones,<br />
through their action on PPAR-gamma, enhance<br />
the effect of inhibiting osteoblast formation and<br />
increase risk of fracture in type 2 diabetes.<br />
Both pioglitazone and rosiglitazone are<br />
associated with increased fractures in women<br />
but not in men. A meta-analysis by Zhu et al<br />
(2014) reported this risk as independent of age<br />
and with no clear association with duration of<br />
treatment. Thiazolidinedione use was associated<br />
with significant changes in BMD and increased<br />
fractures not only in the upper and lower limbs<br />
but also at the lumbar spine and femoral neck<br />
(Zhu et al, 2014). The benefit of improving<br />
glycaemic control versus the risk of fracture<br />
should be assessed carefully on an individual<br />
case basis, especially in post-menopausal women,<br />
before commencing treatment with pioglitazone<br />
in type 2 diabetes.<br />
Incretin-based medicines<br />
Glucagon-like peptide 1 (GLP-1) agonists are<br />
recommended in the management of obese people<br />
with type 2 diabetes and their effect on the risk<br />
of bone fractures is beginning to be established.<br />
In a meta-analysis of RCTs, liraglutide was<br />
associated with significantly reduced risk of<br />
fracture and exenatide was associated with an<br />
elevated risk of incident bone fractures (Su<br />
et al, 2015). Protective effects of dipeptidyl<br />
peptidase-4 (DPP-4) inhibitors on bone have<br />
also been reported in a recent meta-analysis.<br />
These data should be interpreted with caution as<br />
the trials included in the meta-analysis were not<br />
sufficiently long to assess fracture risk and the<br />
effect on bone was not assessed as a primary endpoint<br />
(Monami et al, 2011). The effects of DPP-4<br />
inhibitors and GLP-1 agonists on bone health<br />
need to be confirmed with well-designed RCTs.<br />
Sodium–glucose cotransporter 2 (SGLT2)<br />
inhibitors<br />
In October 2015, the US Food and Drug<br />
Administration (FDA; 2015) <strong>issue</strong>d a warning<br />
for the SGLT2 inhibitor canagliflozin relating to<br />
increased risk of hip fractures and fractures of the<br />
lower spine. More evidence is needed to ascertain<br />
if this is a drug class effect.<br />
Insulin<br />
One large longitudinal study, using a German<br />
database of over 100 000 people with type 2<br />
diabetes in general practice found non-significant<br />
66 Diabetes & Primary Care Australia Vol 2 No 2 2017
Diabetes and bone health<br />
increase in risk of fracture in people on basal<br />
insulin (glargine, insulin detemir and NPH<br />
insulin) compared to oral hypoglycaemia agents<br />
(Pscherer et al, 2016). This could possibly be<br />
due to increased insulin-induced hypoglycaemiarelated<br />
falls as discussed above, rather than direct<br />
effect of insulin on the bone. In the absence of<br />
RCT data at present, there is no clear evidence<br />
to suggest that insulin increases the risk of<br />
osteoporosis or fracture.<br />
Management<br />
There is no specific guideline for the management<br />
of bone disorders in diabetes. Investigations and<br />
treatment of osteoporosis should be based on<br />
patients’ absolute risk of fracture taking into<br />
consideration age, gender, menopausal status,<br />
personal and family history of fractures, body<br />
weight, falls risk, thiazolinediones use and<br />
associated secondary causes of osteoporosis.<br />
Fracture risk assessment based on FRAX,<br />
Garvan or QFracture assessment tools can help<br />
predict the risk of fracture. However, these may<br />
under-estimate fracture risk in type 2 diabetes,<br />
as paradoxically, BMD is often higher than in<br />
those without diabetes, despite the increased risk<br />
of fracture (Schwartz et al, 2011). Type 2 diabetes<br />
is not an explicitly recognised risk factor included<br />
in the risk assessment tool and BMD in type 2<br />
diabetes can be normal or elevated in spite of<br />
increased fracture risk. As BMD does not predict<br />
fracture risk in renal osteodystrophy, it need not<br />
be performed routinely in CKD stages 3–5 in<br />
the presence of CKD-MBD (Kidney Disease:<br />
Improving Global Outcomes [KDIGO] CKD-<br />
MBD Work Group, 2009).<br />
Bone mineral disorders in CKD can be identified<br />
early by detecting decreasing serum calcium,<br />
phosphate and vitamin D concentrations, and<br />
increasing serum parathyroid hormone (PTH)<br />
concentrations. The KDIGO clinical practice<br />
guideline suggests monitoring for serum calcium,<br />
phosphorus, 25-hydroxy vitamin D deficiency<br />
and PTH routinely for CKD stages 3–5 with the<br />
frequency of monitoring based on stage, rate of<br />
progression and whether specific therapies have<br />
been initiated (KDIGO CKD-MBD Work Group,<br />
2009). PTH and bone alkaline phosphatase can<br />
be used to evaluate CKD–MBD.<br />
Anti-resorptive agents such as bisphosphonates<br />
can be used as first-line agents to treat osteoporosis<br />
and high fracture risk in diabetes and in CKD<br />
stages 1, 2 and 3 (estimated glomerular filtration<br />
rate [GFR] >30 mL/min/1.73 m 2 ) in the absence<br />
of abnormal bone mineral markers. The effect of<br />
drug treatment should be reviewed after 5 years<br />
for alendronate and after 3 years for intravenous<br />
zolendronic acid with a view to making a decision<br />
regarding a drug holiday or continuing or switching<br />
treatment. No studies have specifically looked at<br />
optimal treatment for people with fractures where<br />
thiazolidinediones have been implicated.<br />
Screening for coeliac disease with t<strong>issue</strong><br />
transglutaminase antibodies (TTG) is<br />
recommended at the time of diagnosis of type 1<br />
diabetes and if a young adult with type 1 develops<br />
intestinal or extra-intestinal symptoms consistent<br />
with coeliac disease (NICE, 2009). Annual<br />
screening for thyroid status is also recommended.<br />
Screening for hypogonadism in people with type 2<br />
diabetes and replacing with testosterone if found<br />
deficient is also recommended (Dandona and<br />
Dhindsa, 2011).<br />
Good glycaemic control and blood pressure<br />
control delays the progression of microvascular<br />
complications, which are associated with increased<br />
risk of falls and fracture. HbA 1c<br />
targets should be<br />
individualised and less stringent control (HbA 1c<br />
Diabetes and bone health<br />
“It is important,<br />
where possible, to<br />
ensure that messages<br />
from different<br />
clinicians pertaining<br />
to lifestyle factors are<br />
aligned and overlap as<br />
much as possible.”<br />
Conclusion<br />
Diabetes and osteoporosis are increasingly<br />
prevalent diseases. Diabetes is an important<br />
clinical risk factor for osteoporosis and fracture,<br />
and as clinicians it is important to remember this<br />
association when managing people with diabetes.<br />
Diabetes-related complications, hypoglycaemia<br />
and obesity could increase the risk of falls<br />
and fragility fracture. HbA 1c<br />
targets should be<br />
individualised taking into consideration age,<br />
frailty, diabetes complications and falls risk.<br />
While there is much to learn regarding the<br />
associations between diabetes, osteoporosis<br />
and fractures, it is important to recognise the<br />
value of performing a multifactorial fracture<br />
risk assessment, including falls risk. Tools are<br />
available to conveniently assess this risk and<br />
measurement of BMD by performing a DXA<br />
scan may provide additional useful information<br />
to help target those patients who are most<br />
at risk of fracture with appropriate fracture<br />
prevention drug therapies. The value of lifestyle<br />
modification to address fracture and falls risk<br />
cannot be underestimated. It is also convenient<br />
that the lifestyle modifications required to<br />
optimise bone health very much overlap with<br />
the lifestyle guidance that is offered to optimise<br />
the management of the underlying diabetes and<br />
obesity. It is important, where possible, to ensure<br />
that our messages to patients pertaining to<br />
lifestyle factors are aligned and overlap as much<br />
as possible, rather than conveying different sets<br />
of instructions for different disease areas. This<br />
is where diabetes and osteoporosis management<br />
from a self-help perspective very much align. n<br />
Acknowledgement<br />
This article has been modified from one<br />
previously published in Diabetes & Primary Care<br />
(2016, 2: 68–74).<br />
Anatomy & Physiology (2013) Age and Bone Mass. Wikimedia<br />
Commons. Available at: https://commons.wikimedia.org/wiki/<br />
File:615_Age_and_Bone_Mass.jpg (accessed 22.03.16)<br />
Blausen Medical Communications (2016) Osteoporosis locations.<br />
Wikimedia Commons. Available at: https://commons.wikimedia.org/<br />
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68 Diabetes & Primary Care Australia Vol 2 No 2 2017
Article<br />
Falls prevention in older adults<br />
with diabetes: A clinical review of<br />
screening, assessment and management<br />
recommendations<br />
Anna Chapman, Claudia Meyer<br />
Older adults with diabetes have an increased rate of falls, recurrent falls and rate of<br />
fracture following a fall. Falls can contribute to a heightened fear of further falling, social<br />
isolation, avoidance of daily activities, and can increase the likelihood of premature<br />
admission to residential aged-care facilities. The most common risk factors for falls within<br />
this population group include peripheral neuropathy, foot complications, impaired postural<br />
control, polypharmacy and insulin use, sub-optimal glycaemic control and hypoglycaemia,<br />
as well as vision and cognitive impairment. Falls risk screening should be undertaken every<br />
12 months for all older people with diabetes, followed by a more detailed falls assessment<br />
for those deemed high risk to identify the contributory risk factors and management<br />
strategies. Individualised strategies should be co-designed with individuals and where<br />
appropriate, their carer(s), may involve referral to other health professionals, and should<br />
be monitored and reviewed at regular intervals.<br />
Falls are a complication of diabetes and<br />
are being increasingly acknowledged<br />
as impacting the overall health and<br />
wellbeing of older adults (International Diabetes<br />
Federation [IDF], 2013). Within the general<br />
community-dwelling population of older adults,<br />
approximately one in three people fall per<br />
year (Moyer, 2012). The combination of age<br />
(≥65 years) and diabetes increases the risk of<br />
recurrent falls by 67% (Pijpers et al, 2012); and<br />
older adults with diabetes are twice as likely to<br />
have injurious falls (Roman de Mettelinge et al,<br />
2013). At the individual level, falls can contribute<br />
to a loss of confidence and reduced activity levels,<br />
loss of lower-limb muscle and bone strength<br />
(Karinkanta et al, 2010), and a heightened<br />
fear of further falling (Zijlstra et al, 2007). For<br />
the public health system, there are expanding<br />
costs associated with falls-related hospitalisations<br />
(Bradley, 2012).<br />
Key to the prevention of falls is the identification<br />
of at-risk individuals and the implementation of<br />
appropriate interventions. Given the increased<br />
prevalence and negative consequences associated<br />
with falls among older adults with diabetes, falls<br />
prevention should be considered an integral<br />
component of diabetes care, and primary care<br />
practitioners are well-placed to offer proactive,<br />
comprehensive and individualised falls prevention<br />
strategies. This article will assist primary care<br />
practitioners in this role, providing an overview<br />
of potential screening tools and outlining fallsrelated<br />
risk factors pertinent to an older person<br />
with diabetes. In addition, this paper will<br />
consider the evidence and recommend actions<br />
for older adults with diabetes, specifically for the<br />
community-dwelling population (rather than the<br />
hospital or residential aged-care setting).<br />
Falls risk screening<br />
Falls risk screening refers to the process of<br />
identifying individuals who are at-risk of a fall,<br />
to determine if a detailed falls assessment is<br />
appropriate. To be effective, screening tools need<br />
Citation: Chapman A, Meyer C<br />
(2017) Falls prevention in older<br />
adults with diabetes: A clinical<br />
review of screening, assessment and<br />
management recommendations.<br />
Diabetes & Primary Care Australia<br />
2: 69–74<br />
Article points<br />
1. Falls-related risk factors<br />
for older people with<br />
diabetes include peripheral<br />
neuropathy, impaired postural<br />
control, polypharmacy,<br />
visual impairment,<br />
cognitive impairment, foot<br />
complications, and suboptimal<br />
glycaemic control.<br />
3. Valid and reliable risk screens<br />
exist to identify individuals<br />
at-risk of falls. As with all<br />
older adults, individuals with<br />
diabetes should be screened for<br />
falls at least once every year.<br />
4. Individuals at increased risk<br />
of falls require a multifactorial<br />
assessment that examines<br />
the wide range of fallsrelated<br />
risk factors.<br />
5. Falls prevention interventions<br />
should systematically address<br />
the risk factors identified and<br />
should be developed with the<br />
older person with diabetes, and<br />
where applicable their carer(s).<br />
Key words<br />
– Falls<br />
– Older people<br />
Authors<br />
Author details are on page 74.<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 69
Falls prevention in older adults with diabetes<br />
Page points<br />
1. Falls risk screening tools need<br />
to be validated, quick and easy<br />
to administer, cost-effective and<br />
clinically relevant.<br />
2. Falls risk screening should<br />
be incorporated into routine<br />
consultations, involving<br />
assessment of an individual’s<br />
falls history over the last<br />
12 months together with<br />
examination of balance and<br />
mobility.<br />
3. When classified as high risk,<br />
individuals should undergo a<br />
comprehensive falls assessment<br />
in a timely manner to guide<br />
appropriate and individualised<br />
falls prevention strategies.<br />
to be validated, quick and easy to administer,<br />
cost-effective and clinically relevant. The<br />
selection of a screening tool should complement<br />
the setting (community, hospital or residential<br />
aged-care) and the older adult being screened,<br />
particularly with regard to age, ethnicity, as<br />
well as cognitive and functional status.<br />
The Global Guideline for Managing Older<br />
People with Type 2 Diabetes recommends that<br />
falls risk screening be performed during an<br />
initial visit to a health care provider, reviewed<br />
annually at a minimum and additionally<br />
following a fall event (IDF, 2013). Falls<br />
risk screening should be incorporated into<br />
routine consultations, involving assessment<br />
of an individual’s falls history over the last<br />
12 months (frequency of falls, circumstances<br />
surrounding each fall, and number of injurious<br />
falls), together with examination of balance<br />
and mobility. Table 1 provides a summary<br />
of available tools and tests for use in the<br />
primary care setting. As with any screening<br />
procedure, all falls risk screening outcomes<br />
should be documented and discussed with the<br />
older person and their carer(s), and information<br />
provided to individuals.<br />
Falls risk assessment to identify fallsrisk<br />
factors<br />
Falls risk screening identifies individuals at<br />
high risk of falls. When classified as such,<br />
individuals should undergo a comprehensive<br />
falls assessment in a timely manner to guide<br />
appropriate and individualised falls prevention<br />
strategies.<br />
A recommended falls assessment tool can<br />
be used to assess the overall risk of falls (as<br />
summarised in Table 2). In addition, specific<br />
assessment of individual factors known to<br />
contribute to falls risk among older adults with<br />
diabetes can be undertaken. It is important to<br />
acknowledge, that although falls-related risk<br />
factors are often referred to independently,<br />
most falls occur as a result of the interaction<br />
between intrinsic and extrinsic risk factors<br />
(Tinetti et al, 1986). A description of the<br />
specific risk factors that are primarily targeted<br />
for further assessment with older adults with<br />
diabetes are discussed below with assessment<br />
and management recommendations provided<br />
(Australian Commission on Safety and Quality<br />
in Healthcare, 2009; American Geriatrics<br />
Society and British Geriatrics Society, 2010).<br />
Table 1. Summary of validated tools and tests recommended for screening of falls risk.<br />
Falls risk screen Description Time to implement Scoring interpretation*<br />
Balance and mobility tests<br />
Timed Up and Go (TUG) test<br />
(Podsiadlo and Richardson, 1991)<br />
A measure of dynamic balance that assesses the time taken for an individual<br />
to rise from a chair, walk 3 metres, turn around, walk back to the chair, and<br />
sit down. Requires a stop-watch and a 43 cm-high straight-backed chair<br />
with solid seat.<br />
1–2 minutes<br />
≥12 seconds is indicative of<br />
an increased risk of falling.<br />
Five Times Sit To Stand<br />
(FTSTS) test<br />
(Tiedemann et al, 2008)<br />
A measure of lower-limb strength that assesses the time taken for an<br />
individual to stand up and sit down as quickly as possible five times, with<br />
their arms folded across their chest. Requires a stop-watch and a 43 cm-high<br />
straight-backed chair with solid seat.<br />
1–2 minutes<br />
≥12 seconds is indicative of<br />
an increased risk of falling.<br />
Alternate Step Test (AST)<br />
(Tiedemann et al, 2008)<br />
A measure of lateral stability that involves weight shifting. An individual<br />
is required to alternately place the right and left feet (no shoes) as fast as<br />
possible on a step that is 18 cm high and 40 cm deep, for a total of eight<br />
steps. A stop-watch is required.<br />
1–2 minutes<br />
≥10 seconds is indicative of<br />
an increased risk of falling.<br />
Multi-item screening tool<br />
Falls Risk for Older People in the<br />
Community (FROP-Com) Screen<br />
(Russell et al, 2009)<br />
A 3-item screening tool that addresses 12-month falls history, self-perceived<br />
need for assistance to perform activities of daily living, and the objective<br />
assessment of steadiness through the observation of an individual standing,<br />
walking a few metres, turning and sitting.<br />
Available at: http://bit.ly/2m6PXZX<br />
1–2 minutes<br />
Responses for each item are<br />
scored from 0–3. A total<br />
score between 0–3 indicates<br />
low-risk. Scores between<br />
4–9 indicate high-risk.<br />
*Scoring criterion based on cut-off scores specified within best practice guidelines for falls prevention (Australian Commission on Safety and Quality in Healthcare, 2009).<br />
Note: Above mentioned tools not specifically validated for older adults with diabetes.<br />
70 Diabetes & Primary Care Australia Vol 2 No 2 2017
Falls prevention in older adults with diabetes<br />
Table 2. Summary of recommended falls assessment tools.<br />
Falls assessment tool Description Time to implement Scoring interpretation*<br />
FallScreen © : Physiological<br />
Profile Assessment<br />
(Lord et al, 2003)<br />
The short form is a validated five-item instrument that includes a single<br />
assessment of vision, peripheral sensation, lower-limb strength, reaction<br />
time and body sway. There is an associated cost for the purchase of the<br />
tool.<br />
Available at: http://bit.ly/2lYqPU7<br />
15–20 minutes<br />
≥1 is indicative of an<br />
increased risk of falling.<br />
FROP-Com<br />
(Russell et al, 2008)<br />
A detailed falls risk factor assessment tool that includes 26 items that<br />
address 13 falls-related risk factors. The tool includes guidelines for<br />
scoring, and evidence-based referrals and interventions. No equipment is<br />
required and the tool is available at no cost.<br />
Available at: http://bit.ly/2mFR8mD<br />
10–15 minutes<br />
Total score range is 0–60.<br />
Scores >18 is indicative of<br />
high risk.<br />
QuickScreen ©<br />
(Tiedemann et al, 2008)<br />
A multifactorial falls assessment tool comprised of the following items:<br />
previous falls, medication usage, vision, peripheral sensation, lower-limb<br />
strength, balance and co-ordination. Minimal equipment is required. There<br />
is an associated cost for the purchase of the tool.<br />
Available at: http://bit.ly/2mlM7P5<br />
10 minutes<br />
≥4 is indicative of an<br />
increased risk of falling.<br />
*Scoring criterion based on cut-off scores specified within best practice guidelines for falls prevention (Australian Commission on Safety and Quality in Healthcare, 2009).<br />
The above scores should be used for the purpose of assessment and re-assessment over time.<br />
Note: Above mentioned tools not specifically validated for older adults with diabetes.<br />
Peripheral neuropathy<br />
The most common falls-related risk factor related<br />
to diabetes is peripheral neuropathy, present<br />
in approximately 50–70% of older adults with<br />
diabetes (Kirkman et al, 2012). Peripheral<br />
neuropathy results in changes to the motor<br />
and/or sensory components of the foot and<br />
ankle, potentially leading to postural instability,<br />
foot complications, altered walking function<br />
and muscle atrophy (Boulton, 2004; Palma et al,<br />
2013; Brown et al, 2015). Clinical emphasis is<br />
placed on the prevention of peripheral neuropathy<br />
by means of optimal glycaemic control, as well as<br />
the early recognition of the condition (Royal<br />
Australian College of General Practitioners<br />
[RACGP], 2016). Peripheral neuropathy should<br />
be assessed annually using either the Diabetic<br />
Neuropathy Symptom (DNS) score (Meijer<br />
et al, 2002) and/or routine sensory tests (i.e.<br />
a 10-g monofilament and palpating foot).<br />
Postural instability<br />
An increase in postural instability is a risk factor<br />
for falls (Ganz et al, 2007; Drootin, 2011), which<br />
is particularly important for people with diabetes<br />
who experience a decrease in the functioning of<br />
the neuromuscular and sensorimotor systems<br />
(Crews et al, 2013). Control of balance to<br />
maintain postural stability involves a complex<br />
interplay of the sensory and motor systems and<br />
integration of, and reaction to, this information<br />
by the central nervous system.<br />
In the primary care setting, the assessment<br />
of postural stability can be easily performed<br />
by balance and mobility tests (e.g. Table 1).<br />
To address postural instability, falls prevention<br />
exercise programs are encouraged (Australian<br />
Commission on Safety and Quality in Healthcare,<br />
2009; Gillespie et al, 2012). Exercise interventions<br />
have recently been found to be effective for older<br />
adults with diabetes with regard to lower-limb<br />
strength, static balance and gait measures<br />
(outcomes vital in the maintenance of postural<br />
stability; Chapman et al, 2016). In particular,<br />
individuals are likely to benefit from exercise<br />
programs that incorporate a challenge to balance,<br />
when delivered with sufficient frequency (e.g. total<br />
of 50 hours, preferably at least 2 hours per week).<br />
It should also be noted that walking programs,<br />
although beneficial for metabolic control and<br />
improvement of cardiovascular disease risk, have<br />
been associated with an increased risk of falls<br />
(Sherrington et al, 2011). Exercise programs<br />
should be tailored to existing levels of fitness<br />
and should consider an individual’s lifestyle<br />
and any medical contraindications. Referral<br />
to an appropriate health professional (e.g. a<br />
physiotherapist or exercise physiologist) may be<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 71
Falls prevention in older adults with diabetes<br />
Page points<br />
1. Foot complications, including<br />
foot pain, foot ulceration and<br />
consequent amputations, are<br />
common among older adults<br />
with diabetes and are significant<br />
contributors to increased falls<br />
risk.<br />
2. Falls risk among adults with<br />
diabetes has been found to<br />
increase steadily at four or more<br />
prescription medications.<br />
3. It is important that primary care<br />
practitioners comprehend the<br />
overall medication burden as<br />
it has the potential to lead to<br />
medication-related problems<br />
including non-adherence,<br />
hypoglycaemia and increased<br />
risk of falls.<br />
warranted for a detailed assessment of balance,<br />
and the design of challenging, yet safe exercise<br />
programs (Australian Commission on Safety<br />
and Quality in Healthcare, 2009).<br />
Foot complications<br />
Foot complications, including foot pain, foot<br />
ulceration and consequent amputations, are<br />
common among older adults with diabetes and<br />
are significant contributors to increased falls<br />
risk (Al-Rubeaan et al, 2015). In brief, foot-care<br />
education should be provided to all people<br />
with diabetes to assist in the prevention of foot<br />
complications. Education should consist of basic<br />
foot-care recommendations and, of particular<br />
relevance to falls, advice regarding appropriate<br />
footwear. Screening and risk stratification for<br />
potential foot complications should also be<br />
performed for all adults with diabetes, with the<br />
intensity of monitoring and review dependent<br />
on the associated level of risk. For individuals<br />
classified as being at intermediate or high risk,<br />
a podiatry assessment is an integral component<br />
of a foot protection program (Menz et al, 2006;<br />
R ACGP, 2016).<br />
Diabetes-related foot ulcers deserve specific<br />
mention when considering falls risk. Offloading<br />
footwear is a common recommendation for<br />
foot ulcers, yet it has a negative effect on<br />
postural stability (van Deursen, 2008). In<br />
particular, total contact casts and removable<br />
or non-removable cast-walkers are problematic<br />
for falls. Given their rigid nature, they do not<br />
allow the foot to make its usual adjustments on<br />
uneven terrain.<br />
Sub-optimal glycaemic control<br />
and hypoglycaemia<br />
Hypoglycaemia, hypoglycaemic unawareness<br />
and severe hyperglycaemia are well-established<br />
risk factors for falls among older adults with<br />
diabetes (Jafari and Britton, 2015; Sinclair et<br />
al, 2015). Optimising an individual’s glycaemic<br />
control can reduce short- and long-term<br />
complications of diabetes, and can improve<br />
quality of life, and functional and cognitive<br />
ability. However, the potential harmful effects<br />
of hypoglycaemia should be considered when<br />
setting individual glycaemic targets. Targets<br />
need be personalised and balanced against<br />
factors such as an individual’s capabilities,<br />
life expectancy, medical comorbidities, and<br />
the potential risk of severe hypoglycaemia,<br />
especially among frail, older adults with an<br />
increased risk of falls (RACGP, 2016). For older<br />
adults with diabetes who have a life expectancy<br />
>10 years and are functionally independent and<br />
fit, an HbA 1c<br />
target of 53 mmol/mol (7.0%) is<br />
often appropriate. However, less stringent HbA 1c<br />
targets (i.e. 64 mmol/mol [8%]) are appropriate<br />
for those with long-standing diabetes, a<br />
history of severe hypoglycaemia, limited life<br />
expectancy, advanced complications, and/or<br />
extensive comorbid conditions (RACGP, 2016).<br />
Medication and polypharmacy<br />
Older adults with diabetes are often required<br />
to take multiple medications in an effort to<br />
control diabetes-related outcomes and other<br />
comorbidities, and a significant proportion of<br />
individuals take upwards of eight medications<br />
(RACGP, 2016). Falls risk among adults with<br />
diabetes has been found to increase steadily at<br />
four or more prescription medications (Huang<br />
et al, 2010). Falls risk can be heightened as a<br />
result of medication interaction, medication<br />
side effects (e.g. dizziness) and even the intended<br />
effects of medications (e.g. glucose-lowering<br />
leading to hypoglycaemia). Certain classes of<br />
medication are more likely to increase the risk<br />
of falls, and those commonly implicated in falls<br />
related to older people with diabetes include<br />
insulin, psychoactive medications (in particular<br />
benzodiazepines), diuretics, antiarrhythmics<br />
(class 1a), digoxin, and antidepressants (Berlie<br />
and Garwood, 2010; Huang et al, 2010).<br />
It is important that primary care practitioners<br />
comprehend the overall medication burden<br />
as it has the potential to lead to medicationrelated<br />
problems including non-adherence,<br />
hypoglycaemia and increased risk of falls.<br />
Medication use (both conventional and<br />
complementary), should be reviewed at least<br />
once per year as part of the annual cycle of<br />
care (RACGP, 2016). Referral for a Home<br />
Medicines Review has the potential to identify<br />
medications implicated in falls and consider the<br />
ongoing need for these medications.<br />
72 Diabetes & Primary Care Australia Vol 2 No 2 2017
Falls prevention in older adults with diabetes<br />
Vision impairment<br />
Vision impairment is an important risk factor<br />
for falls in community-dwelling older adults,<br />
with vision being a key sensory input for the<br />
maintenance of balance and the avoidance of<br />
obstacles. Diabetic retinopathy, occurring as<br />
a result of microvascular disease of the retina,<br />
causes visual impairment and blindness, and<br />
affects more than 30% of adults with diabetes<br />
(Dirani, 2013).<br />
All older adults with diabetes should have a<br />
visual acuity assessment at diagnosis, and at least<br />
every 2 years (more frequently if vision noted to<br />
have concerns). Primary care practitioners can<br />
monitor individuals for retinopathy via retinal<br />
photography or by examining the eyes through<br />
dilated pupils. If practitioners are not confident<br />
with fundoscopy and assessment of the retina,<br />
referral to an eye specialist is recommended.<br />
Older people may additionally benefit from an<br />
assessment by an eye specialist for the provision<br />
of appropriate spectacle correction (RACGP,<br />
2016). The use of bifocal or multifocal lenses<br />
by older people in the community is associated<br />
with a doubled risk of falls as a result of<br />
tripping. Individuals with an increased risk of<br />
falls or established falls history are, therefore,<br />
recommended to wear single-vision distance<br />
spectacles when walking and negotiating steps<br />
(Australian Commission on Safety and Quality<br />
in Healthcare, 2009; Haran et al, 2010). Other<br />
effective fall prevention strategies for vision<br />
include maximising vision through cataract<br />
surgery on the first eye (Lord et al, 2010).<br />
Cognition<br />
Cognitive impairment is a risk factor for falls,<br />
with 50–80% of people with dementia falling<br />
in a given year (Allan et al, 2009), and mild<br />
cognitive impairment linked to greater risk of<br />
injurious and multiple falls (Delbaere et al, 2012).<br />
There appears to be a crucial link between the<br />
decline of cognition and the use of executive<br />
functioning for the purposes of balance, with this<br />
decline evident in decreasing ability to control and<br />
integrate cognitive abilities related to attention<br />
and perception (Liu-Ambrose et al, 2008). People<br />
with cognitive impairment may have difficulty<br />
with planning and executing movements related<br />
to balance and mobility, and may have difficulty<br />
limiting sensory input which affects attention to a<br />
task (e.g. walking while talking; Liu-Ambrose et<br />
al, 2008). Medication use in people with cognitive<br />
impairment also impacts falls risk, particularly<br />
psychotropic medications that may magnify side<br />
effects of other medications (Hill and Wee, 2012).<br />
There is no specific literature relating falls,<br />
diabetes and cognitive impairment. There<br />
is, however, an emerging body of evidence for<br />
effective falls prevention strategies for people with<br />
dementia (Drootin, 2011), with studies showing<br />
“traditional” falls prevention programs to be<br />
unsuccessful with people with dementia (Shaw<br />
et al, 2003). However, a different approach to<br />
adoption of falls prevention strategies may be<br />
beneficial with elements of health professional<br />
involvement, inclusion of the caregiving dyad<br />
and accommodation of individual needs and<br />
preferences likely to be important (Meyer et al,<br />
2013).<br />
Built environment<br />
Environmental hazards are considered a risk for<br />
falls: clutter can be a tripping hazard; lighting<br />
should be sufficient in order to prevent shadows;<br />
flooring should be clear of rugs and provide a<br />
contrast to furniture; and bathroom setup needs<br />
to prevent slippage on wet surfaces, with grab<br />
rails provided as needed. Home safety assessment<br />
and modification interventions are effective in<br />
decreasing falls risk and rates, especially for<br />
people with severe visual impairment, which is of<br />
relevance to the person with diabetes (Gillespie et<br />
al, 2012).<br />
Adaptation and modification of the environment<br />
with an occupational therapist who is trained<br />
to identify and maximise the benefits of the<br />
person–environment fit is the crucial factor in<br />
reducing risk (Clemson et al, 2014). Shared<br />
decision-making processes with the person with<br />
diabetes, and with their carer(s) if appropriate, will<br />
most likely enhance the uptake of environmental<br />
modifications.<br />
Conclusion<br />
Reducing the number of falls among older adults<br />
with diabetes is dependent upon the identification<br />
of at-risk individuals and the coordination of<br />
Page points<br />
1. Vision impairment is an<br />
important risk factor for falls<br />
in community-dwelling older<br />
adults, with vision being a<br />
key sensory input for the<br />
maintenance of balance and the<br />
avoidance of obstacles.<br />
2. There appears to be a crucial<br />
link between the decline<br />
of cognition and the use of<br />
executive functioning for the<br />
purposes of balance.<br />
3. Environmental hazards are<br />
considered a risk for falls, and<br />
efforts should be made to avoid<br />
them where possible.<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 73
Falls prevention in older adults with diabetes<br />
“All primary care<br />
practitioners should<br />
have access to<br />
education about<br />
falls prevention, and<br />
every attempt should<br />
be made to provide<br />
comprehensive<br />
and individualised<br />
education about falls<br />
to older adults with<br />
diabetes and where<br />
appropriate, their<br />
caregivers and family.”<br />
Authors<br />
Anna Chapman, Research Fellow,<br />
School of Primary Health Care,<br />
Monash University, Melbourne, Vic;<br />
Claudia Meyer, Research Fellow,<br />
Centre for Health Communication,<br />
School of Public Health and Human<br />
Biosciences, La Trobe University,<br />
Melbourne, Vic. Both are at the<br />
RDNS Institute, St Kilda, Vic.<br />
appropriate preventive strategies. A diagnosis<br />
of diabetes in an older adult should trigger to<br />
primary care practitioners the potential for<br />
increased falls risk. Systems need to be established<br />
in the diabetes care pathway to enable falls<br />
risk screening to be performed annually. All<br />
primary care practitioners should have access<br />
to education about falls prevention, and every<br />
attempt should be made to provide comprehensive<br />
and individualised education about falls to older<br />
adults with diabetes and where appropriate, their<br />
caregivers and family. <br />
n<br />
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complications and their risk factors from a large retrospective<br />
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of falls in dementia: A prospective study in older people. PLoS ONE<br />
4: e5521<br />
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Prevention of Falls in Older Persons: AGS/BGS Clinical Practice<br />
Guideline. AGS/BGS<br />
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Preventing falls and harm from falls in older people: Best practice<br />
guidelines for Australian community care. ACSQHC, Canberra,<br />
ACT<br />
Berlie HD, Garwood CL (2010) Diabetes medications related to an<br />
increased risk of falls and fall-related morbidity in the elderly. Ann<br />
Pharmacother 44: 712–7<br />
Boulton AJ (2004) The diabetic foot: from art to science. The 18th<br />
Camillo Golgi lecture. Diabetologia 47: 1343–53<br />
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2008-09. Australian Institute for Health and Welfare, Canberra,<br />
ACT. Available at: http://bit.ly/2mlESXq (accessed 08.03.17)<br />
Brown SJ, Handsaker JC, Bowling FL et al (2015) Diabetic peripheral<br />
neuropathy compromises balance during daily activities.<br />
Diabetes Care 38: 1116–22<br />
Chapman A, Meyer C, Renehan E et al (2016) Exercise interventions<br />
for the improvement of falls-related outcomes among older adults<br />
with diabetes mellitus: A systematic review and meta-analyses.<br />
J Diabetes Complications 31: 631–45<br />
Clemson L, Donaldson A, Hill K, Day L (2014) Implementing personenvironment<br />
approaches to prevent falls: a qualitative inquiry in<br />
applying the Westmead approach to occupational therapy home<br />
visits. Aust Occup Ther J 61: 325–34<br />
Crews R, Yalla S, Fleischer A, Wu S (2013) A growing troubling triad:<br />
diabetes, aging, and falls. J Aging Res 2013: 342650<br />
Delbaere K, Kochan NA, Close JC et al (2012) Mild cognitive<br />
impairment as a predictor of falls in community-dwelling older<br />
people. Am J Geriatr Psychiatry 20: 845–53<br />
Dirani M (2013) Out of sight: A report into diabetic eye disease in<br />
Australia. Baker IDI Heart and Diabetes Institute and Centre for Eye<br />
Research Australia, Australia<br />
Drootin M (2011) Summary of the updated American Geriatrics<br />
Society/British Geriatrics Society clinical practice guideline for<br />
prevention of falls in older persons. J Am Geriatr Soc 59: 148–57<br />
Ganz D, Bao Y, Shekelle P, Rubenstein L (2007) Will my patient fall?<br />
JAMA 297: 77–86<br />
Gillespie L, Robertson M, Gillespie W et al (2012) Interventions for<br />
preventing falls in older people living in the community. Cochrane<br />
Database Syst Rev 12: CD007146<br />
Haran MJ, Cameron ID, Ivers RQ et al (2010) Effect on falls of<br />
providing single lens distance vision glasses to multifocal glasses<br />
wearers: VISIBLE randomised controlled trial. BMJ 340: c2265<br />
Hill K, Wee R (2012) Psychotropic drug-induced falls in older people:<br />
A review of interventions aimed at reducing the problem. Drugs<br />
Aging 29: 15–30<br />
Huang ES, Karter AJ, Danielson KK et al (2010) the association<br />
between the number of prescription medications and incident falls<br />
in a multi-ethnic population of adult type-2 diabetes patients: The<br />
Diabetes and Aging Study. J Gen Intern Med 25: 141–6<br />
International Diabetes Federation (2013) IDF Global Guideline for<br />
Managing Older People with Type 2 Diabetes. International<br />
Diabetes Federation, Brussels, Belgium<br />
Jafari B, Britton ME (2015) Hypoglycaemia in elderly patients with<br />
type 2 diabetes mellitus: a review of risk factors, consequences and<br />
prevention. J Pharmacy Practice Research 45: 459–69<br />
Karinkanta S, Piirtola M, Sievanen H et al (2010) Physical therapy<br />
approaches to reduce fall and fracture risk among older adults.<br />
Nature Reviews Endocrinology 6: 396–407<br />
Kirkman MS, Briscoe VJ, Clark N et al (2012) Diabetes in older adults.<br />
Diabetes Care 35: 2650–64<br />
Liu-Ambrose T, Ahamed Y, Graf P et al (2008) Older fallers with poor<br />
working memory overestimate their postural limits. Arch Phys Med<br />
Rehabil 89: 1335–40<br />
Lord SR, Menz HB, Tiedemann A (2003) A physiological profile<br />
approach to falls risk assessment and prevention. Phys Ther 83:<br />
237–52<br />
Lord SR, Smith ST, Menant JC (2010) Vision and falls in older people:<br />
Risk factors and intervention strategies. Clinics Geriatr Med 26:<br />
569–81<br />
Meijer JW, Smit AJ, Sonderen EV et al (2002) Symptom scoring<br />
systems to diagnose distal polyneuropathy in diabetes: the Diabetic<br />
Neuropathy Symptom score. Diabet Med 19: 962–5<br />
Menz G, Morris M, Lord S (2006) Foot and ankle risk factors for falls<br />
in older people: a prospective study. J Gerontol A Biol Sci Med Sci<br />
61: 866–70<br />
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knowledge to community-dwelling older PLWD: A mixed-method<br />
systematic review. Gerontologist 55: 560–74<br />
Moyer VA (2012) Prevention of falls in community-dwelling older<br />
adults: U.S. Preventive Services Task Force recommendation<br />
statement. Ann Intern Med 157: 197–204<br />
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presenting diabetes mellitus type 2 with and without diabetic<br />
polyneuropathy. Arch Endocrinol Metab 57: 722–6<br />
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with diabetes have an increased risk of recurrent falls: analysis<br />
of potential mediating factors: the Longitudinal Ageing Study<br />
Amsterdam. Age Ageing 41: 358–65<br />
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basic functional mobility for frail elderly persons. J Amer Geriatr<br />
Soc 39: 142–8<br />
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Understanding the relationship between type 2 diabetes mellitus<br />
and falls in older adults: A Prospective Cohort Study. PLoS ONE 8:<br />
e67055<br />
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practice management of type 2 diabetes: 2016-18. RACGP, East<br />
Melbourne, Vic<br />
Russell MA, Hill KD, Blackberry I et al (2008) The reliability and<br />
predictive accuracy of the falls risk for older people in the<br />
community assessment (FROP-Com) tool. Age Ageing 37: 634–9<br />
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for Older People in the Community (FROP-Com) screening tool.<br />
Age Ageing 38: 40–6<br />
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after a fall in older people with cognitive impairment and<br />
dementia presenting to the accident and emergency department:<br />
Randomised controlled trial. BMJ 326:<br />
Sherrington C, Tiedemann A, Fairhall N et al (2011) Exercise to prevent<br />
falls in older adults: An updated meta-analysis and best practice<br />
recommendations. N S W Public Health Bull 22: 78–83<br />
Sinclair A, Dunning T, Rodriguez-Mañas L (2015) Diabetes in older<br />
people: new insights and remaining challenges. Lancet Diabetes<br />
Endocrinol 3: 275–85<br />
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ability of eight functional mobility tests for predicting falls in<br />
community-dwelling older people. Age Ageing 37: 430–5<br />
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elderly patients based on number of chronic disabilities. Am J Med<br />
80: 429–34<br />
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Interventions to reduce fear of falling in community-living older<br />
people: A systematic review. J Am Geriatr Soc 55: 603–15<br />
74 Diabetes & Primary Care Australia Vol 2 No 2 2017
Article<br />
The effect of diabetes on the skin<br />
before and after ulceration<br />
Lesley Weaving, Roy Rasalam<br />
Diabetes affects the skin in many different ways at a microcirculatory level, making it<br />
more prone to injury and ulceration. These changes not only have an impact on healing<br />
but also on the resulting scar t<strong>issue</strong>, which is not as strong as the skin was prior to injury.<br />
Eight-five percent of amputations are preceded by ulceration, with re-ulceration rates<br />
reported to be as high as 70% after 5 years. This article looks at the changes that occur<br />
in the skin of people with diabetes and the importance of skin care before and after<br />
ulceration.<br />
A<br />
history of ulceration is considered<br />
to be a significant risk factor for<br />
re-ulceration, and as such, people<br />
with diabetes are classed as high risk if they<br />
have a history of foot ulceration (National<br />
Institute for Health and Care Excellence,<br />
2015). Australia’s amputation rate as a result<br />
of diabetes appears to have increased in the<br />
last decade and is a major contributor to the<br />
national burden of condition (Lazzarini et al,<br />
2012). Eighty-five per cent of amputations are<br />
preceded by ulcers (International Diabetes<br />
Federation, 2016); therefore, the prevention of<br />
re-ulceration is an important consideration in<br />
reducing amputation rates. Varying rates of reulceration<br />
have been reported in the literature,<br />
but the rate of re-ulceration is known to<br />
increase over time from initial ulceration;<br />
Miller et al (2014) reported 34% re-ulceration<br />
at 1 year, 61% at 3 years and 70% at 5 years.<br />
A critical triad of neuropathy, minor foot<br />
trauma and foot deformity is present in >63%<br />
of patients’ causal pathways to foot ulceration<br />
(Reiber et al, 1999). There are many reasons<br />
that determine whether people with diabetes<br />
develop ulcers, including their vascular<br />
status, nutritional status and compliance with<br />
preventative therapies, such as custom-made<br />
shoes or insoles (Miller et al, 2014). Despite<br />
these interventions, one study has reported a<br />
30% re-ulceration rate over a 2-year period,<br />
during which individuals received regular<br />
podiatric review (Westphal et al, 2011). With<br />
this in mind, do we need to consider other<br />
factors, such as the health of the skin? What is<br />
the effect of ulceration on the skin during and<br />
after healing, and does it play a role in the risk<br />
of re-ulceration?<br />
The skin<br />
The skin is the largest organ of the body.<br />
Its main functions are to act as a barrier<br />
to substances entering the body and in the<br />
prevention of moisture loss. It helps to regulate<br />
temperature and provides sensory information<br />
(e.g. pain, touch and temperature). It has<br />
three layers: the epidermis, the dermis and a<br />
fat (subcutaneous) layer (see Figure 1). The<br />
epidermis is the thin outer layer, made of five<br />
layers. The outermost layer is the stratum<br />
corneum, which consists of dead cells and is the<br />
major barrier to chemical and bacterial transfer<br />
through the skin. The epidermis is thicker on<br />
the plantar aspect of the foot and is relatively<br />
waterproof. The second layer of the skin is the<br />
dermis, which contains nerve endings, sweat<br />
glands, oil (sebaceous) glands, hair follicles<br />
and blood vessels. It consists of a thick layer<br />
of fibrous and elastic t<strong>issue</strong>, giving the skin its<br />
flexibility and strength. Below the dermis is a<br />
Citation: Weaving L,<br />
Rasalam R (2017) The effect<br />
of diabetes on the skin before<br />
and after ulceration. Diabetes &<br />
Primary Care Australia 2: 75–9<br />
Article points<br />
1. People with diabetes<br />
are more prone to skin<br />
injury and ulceration.<br />
2. Diabetes impairs the<br />
skin’s ability to heal.<br />
3. Scar t<strong>issue</strong> is not as strong as<br />
the t<strong>issue</strong> was before injury.<br />
4. Skin should be kept in the<br />
best condition possible to<br />
prevent re-ulceration.<br />
Key words<br />
– Healing<br />
– Re-ulceration<br />
– Scar t<strong>issue</strong><br />
– Skin<br />
Authors<br />
Lesley Weaving is diabetes<br />
specialist podiatrist, Leicestershire<br />
Partnership Trust, Coalville<br />
Community Hospital, Coalville,<br />
Leicestershire, UK; Roy Rasalam<br />
is Director of Clinical Studies,<br />
College of Medicine, James Cook<br />
University, Qld, Australia.<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 75
The effect of diabetes on the skin before and after ulceration<br />
80% of the tensile strength of normal skin<br />
(Ousey, 2009). Many factors play a role in<br />
how closely the healed skin resembles the<br />
original uninjured t<strong>issue</strong>, including the size,<br />
depth and location of the wound, as well as<br />
the nutritional status and overall health of the<br />
individual (Teller and White, 2009).<br />
Figure 1. Cross-section through the skin.<br />
Page points<br />
1. Skin conditions, such as<br />
infection, xerosis and<br />
psoriasis, are common in<br />
people with diabetes.<br />
2. Regular moisturising of dry skin<br />
is recommended as part of a<br />
routine foot care regimen.<br />
3. Scar t<strong>issue</strong> is not as strong<br />
as the original uninjured<br />
t<strong>issue</strong> and so is at increased<br />
risk of damage.<br />
subcutaneous layer of fat that helps insulate the<br />
body from heat and cold, provides protective<br />
padding and serves as an energy store (Health<br />
and Safety Executive, 2016).<br />
The healing process<br />
When the skin is damaged, a complex healing<br />
process takes place that can be divided<br />
into four phases (Box 1). The final stage<br />
of healing, maturation, lasts from 21 days<br />
to 2 years. During this process, epithelial<br />
cells reduce the size of the wound. This is<br />
followed by re-organisation of the collagen<br />
by macrophages to form a scar (Brown, 2015).<br />
In healthy individuals, the resulting scar<br />
t<strong>issue</strong> formed after injury has approximately<br />
Box 1. The wound healing process.<br />
l Vascular response (haemostasis): injured<br />
vessels constrict, a clot forms consisting<br />
of a fibrin mesh that forms a scab, and<br />
vasodilation of the vessels commences.<br />
l Inflammation: occurs in acute wounds<br />
3–5 days after injury and is prolonged in<br />
chronic wounds.<br />
l Proliferation: collagen fibres form to<br />
replace lost t<strong>issue</strong>.<br />
l Maturation: in healthy individuals, this<br />
stage commences 21 days after injury.<br />
Scarring develops, and the new t<strong>issue</strong> is<br />
avascular and contains no hair, sebaceous<br />
or sweat glands.<br />
The effect of diabetes on skin healing<br />
Diabetes can affect the skin in different<br />
ways. Autonomic neuropathy is a common<br />
complication of diabetes leading to dry<br />
skin, loss of sweating and the subsequent<br />
development of fissures and cracks that break<br />
the skin barrier, allowing microorganisms to<br />
enter (Vinik et al, 2003).<br />
It is now understood that a complex<br />
relationship exists between sensory<br />
nerve function and vascular response in<br />
type 2 diabetes. Dermal neurovascular<br />
function is regulated by peripheral<br />
C fibre neurons, which are damaged in<br />
diabetic neuropathy. This results in an<br />
imbalance between vasodilators (nitric<br />
oxide, substance P, and calcitonin generelated<br />
peptide) and vasoconstrictors<br />
(angiotensin II and endothelin). This<br />
dysregulation leads to decreased pain and<br />
warm thermal perception, leaving skin<br />
vulnerable to heat and t<strong>issue</strong> injury (Vinik et<br />
al, 2001).<br />
It has also been demonstrated that there is<br />
a reduced oxygen supply within the t<strong>issue</strong> of<br />
people with diabetes, which is accentuated<br />
in the presence of neuropathy (Greenman<br />
et al, 2005). Other skin conditions are also<br />
commonly seen in people with diabetes,<br />
the prevalences of which are reported to be<br />
between 30% and 91.2% (Demirseren et al,<br />
2014). The most frequently reported skin<br />
condition in people with diabetes is cutaneous<br />
infection (mainly fungal), followed by xerosis<br />
(dry skin) and inflammatory skin diseases<br />
such as psoriasis (Figure 2). These conditions<br />
are more common in people with diabetes<br />
who have nephropathy than in those without<br />
nephropathy, and those who have an HbA 1c<br />
of >64 mmol/mol (8%) are at the greatest risk<br />
(Demirseren et al, 2014).<br />
76 Diabetes & Primary Care Australia Vol 2 No 2 2017
The effect of diabetes on the skin before and after ulceration<br />
Figure 2. Psoriasis is one of the most common skin<br />
conditions experienced by people with diabetes.<br />
Vascular endothelial cells line the entire<br />
circulatory system, from the heart to<br />
capillaries. These cells are important for<br />
vascular biology and become impaired not only<br />
with age but also as a result of hyperglycaemia,<br />
which results in the impairment of blood flow<br />
to the t<strong>issue</strong>s (Petrofsky, 2011). When pressure<br />
is applied to healthy skin, the affected t<strong>issue</strong><br />
can become hypoxic; once the pressure is<br />
released there is reactive hyperaemia (increase<br />
in blood flow) to oxygenate the t<strong>issue</strong>. Vascular<br />
endothelial dysfunction can diminish this<br />
response. It has also been demonstrated that<br />
in a standing position, the average person still<br />
has circulation in the skin but in people with<br />
diabetes (even those with normal weight) there<br />
is occlusion to the skin (McLellan et al, 2009).<br />
This occlusion, together with reduced or no<br />
post-occlusive hyperaemia, may be the reason<br />
that feet are so susceptible to wounds and<br />
skin injury, particularly in people with type 2<br />
diabetes (Petrofsky, 2011).<br />
Emollients<br />
Regular moisturising of dry skin is<br />
recommended as part of a routine foot care<br />
regimen to reduce the risk of cracking and<br />
ulceration. What is not always clear is which<br />
emollient to use. There is little evidence<br />
available as to the most effective emollient,<br />
not only for the general population, but also<br />
for people with diabetes. A moisturiser that<br />
the patient is willing or happy to use that<br />
is supported by the available evidence is<br />
preferable. The clinician should also check<br />
that the patient likes the smell, texture and<br />
absorption of the cream before recommending<br />
or prescribing one. There is some evidence<br />
that high-concentration, urea-based emollients<br />
are beneficial, and these have been shown to<br />
improve dryness on the feet of people with<br />
diabetes (Bristow, 2013).<br />
For twice-a-day application, it is<br />
recommended that an emollient is applied just<br />
before getting into bed. Covering the foot with<br />
a damp undersock and then a dry oversock may<br />
enhance the effect of the emollient (Bristow,<br />
2013). For once-a-day application, the cream<br />
should form part of a patient’s daily regimen<br />
of washing, drying and checking their feet<br />
thoroughly. It is recommended that emollients<br />
be used to lubricate the skin, but not between<br />
the toes (International Working Group on<br />
the Diabetic Foot, 2015). A pump dispenser<br />
is considered by some clinicians a more userfriendly<br />
way of delivering the right amount of<br />
emollient than a tub and also decreases the risk<br />
of contamination (Carr et al, 2008), although<br />
tubes are also commonly used.<br />
Silicones<br />
Once skin has healed, silicone gel has been<br />
proven to be effective in scar-t<strong>issue</strong> management<br />
on non-weight-bearing areas; however there<br />
is little evidence to support its use on weightbearing<br />
areas (Westphal et al, 2011). Figure 3<br />
and Figure 4 demonstrate that silicone gel may<br />
be useful in protecting newly healed skin<br />
during the maturation process. A person with<br />
type 2 diabetes who suffered from psoriasis<br />
had developed ulceration and subsequent<br />
osteomyelitis at the base of the fifth metatarsal<br />
Page points<br />
1. Regular moisturising of dry<br />
skin is recommended as<br />
part of a routine foot-care<br />
regimen to reduce the risk<br />
of cracking and ulceration.<br />
2. Once skin has healed,<br />
silicone gel has been proven<br />
to be effective in scar-t<strong>issue</strong><br />
management on non-weightbearing<br />
areas; however there<br />
is little evidence to support its<br />
use on weight-bearing areas.<br />
Diabetes & Primary Care Australia Vol 2 No 2 2017 77
The effect of diabetes on the skin before and after ulceration<br />
Page points<br />
1. There are many factors<br />
affecting a person’s skin<br />
when they have diabetes.<br />
2. From available evidence, the<br />
healing of a diabetic foot ulcer<br />
should not be considered<br />
the end result of a patient’s<br />
journey, but the beginning of<br />
a process to remain healed.<br />
3. Further research is required<br />
on the most-effective<br />
way to care for the skin of<br />
people with diabetes.<br />
head, which had healed well with the use of<br />
a removable cast device. However, once they<br />
returned to wearing their bespoke shoes with<br />
total contact insole, the skin re-ulcerated<br />
(Figure 3). Silicone sheeting was used to protect<br />
the area once epithelisation was achieved and for<br />
8 weeks afterwards, and no further ulceration<br />
occurred during this time (Figure 4). This<br />
suggests that the silicone sheeting provided<br />
some protection to the newly healed skin during<br />
the early stages of the maturation process<br />
(Weaving, 2014). However, a pilot study of<br />
30 people with diabetes found that silicone gel<br />
sheeting did not reduce the risk of ulceration<br />
(Westphal, 2011).<br />
Why it’s important to keep the<br />
skin healthy<br />
There are many factors affecting a person’s skin<br />
when they have diabetes. These factors can lead<br />
to ulceration and contribute to delayed healing.<br />
Poor glycaemic control of diabetes has been<br />
shown to affect the microcirculation, along<br />
with poor oxygen supply, occlusion in the skin<br />
during weight bearing, changes to the vascular<br />
endothelial cells, dry skin and reduction in<br />
elasticity all putting the skin at greater risk<br />
of injury. This is further complicated by the<br />
reduced strength of the scar t<strong>issue</strong> that forms<br />
after the ulcer has healed.<br />
Eighty per cent of ulcers are caused by some<br />
form of trauma and are, therefore, considered<br />
to be preventable (Healy et al, 2013). While<br />
custom-made footwear is used to prevent<br />
re-ulceration, it appears to be most effective for<br />
those with foot deformity (Reiber et al, 2002).<br />
Not every insole or shoe is a perfect fit to each<br />
patient’s foot (Miller et al, 2014). It is therefore<br />
important that the skin on the foot is kept in the<br />
best condition it can be to cope with the stresses<br />
placed upon it, whether it is from shoe wear or<br />
simple day-to-day weight-bearing activities.<br />
Conclusion<br />
There is little evidence on how best to look<br />
after the skin of people with diabetes. From<br />
the available evidence, the healing of a diabetic<br />
foot ulcer should not be considered the end<br />
result of a patient’s journey, but the beginning<br />
Figure 3. A patient with type 2 diabetes and psoriasis<br />
experienced re-ulceration after changing from a<br />
removable cast device back to their bespoke shoes.<br />
Figure 4. The patient continued to use silicone sheeting<br />
for 8 weeks after the ulcer had healed, which prevented<br />
re-ulceration.<br />
of a process to remain “healed”. We want<br />
patients to be active and keep mobile to<br />
help with their overall health and wellbeing;<br />
however, the impact of diabetes on their skin<br />
makes them vulnerable to skin breakdown,<br />
particularly where there is scar t<strong>issue</strong> from<br />
previous ulceration. Further research is<br />
required on the most-effective way to care<br />
for the skin of people with diabetes not just<br />
when dry, but also post-healing during the<br />
maturation process when the stresses and<br />
strains of simple weight bearing could lead<br />
to re-ulceration and, subsequently, potential<br />
78 Diabetes & Primary Care Australia Vol 2 No 2 2017
The effect of diabetes on the skin before and after ulceration<br />
loss of a limb. This is a worthwhile endeavour<br />
when we consider that every 30 seconds a<br />
lower limb is lost somewhere in the world as a<br />
consequence of diabetes (Boulton et al, 2005).<br />
<br />
n<br />
Acknowledgement<br />
This article has been modified from one<br />
previously published in The Diabetic Foot Journal<br />
(2016, 3: 142–8).<br />
Lazzarini PA, Gurr JM, Rogers JR et al (2012) Diabetes foot<br />
disease: the Cinderella of Australian diabetes management?<br />
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McLellan K, Petrofsky JS, Zimmerman G et al (2009) The<br />
influence of environmental temperature on the response<br />
of the skin to local pressure: the impact of aging and<br />
diabetes. Diabetes Technol Ther 11: 791–8<br />
Miller JD, Salloum M, Button A et al (2014) How can I<br />
maintain my patient with diabetes and history of foot ulcer<br />
in remission? Int J Low Extrem Wounds 13: 371–7<br />
“This is a worthwhile<br />
endeavour when we<br />
consider that every<br />
30 seconds a lower<br />
limb is lost somewhere<br />
in the world as a<br />
consequence of<br />
diabetes.”<br />
Boulton AJ, Vilikyte L, Ragnarson-Tennvall G et al (2005)<br />
The global burden of diabetic foot disease. Lancet 366:<br />
1719–24<br />
National Institute for Health and Care Excellence (2015)<br />
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and management. NICE, London, UK. Available at: www.<br />
nice.org.uk/guidance/ng19 (accessed 02.09.2016)<br />
Bristow I (2013) Emollients in the care of the diabetic foot.<br />
The Diabetic Foot Journal 16: 61–6<br />
Ousey K (2009) Chronic wounds – an overview. J Commun<br />
Nursing 21: 4–9<br />
Brown A (2015) Wound management 1: Phases of the wound<br />
healing process. Nursing Times 111: 12–3<br />
Carr J, Akram M, Sultan A et al (2008) Contamination of<br />
emollient creams and ointments with Staphylococcus<br />
aureus in children with atopic dermatitis. Dermatitis 19:<br />
282<br />
Demirseren DD, Emre S, Akoglu G et al (2014) Relationship<br />
between skin diseases and extracutaneous complications<br />
of diabetes mellitus: clinical analysis of 750 patients.<br />
Am J Dermatol 15: 65–70<br />
Greenman RL, Panasyuk S, Wang X et al (2005) Early<br />
changes in the microcirculation and muscle metabolism<br />
of the diabetic foot. Lancet 366: 1711–5<br />
Healy A, Naemi R, Chockalingam N (2013) The effectiveness<br />
of footwear as an intervention to prevent or to reduce<br />
biomechanical risk factors associated with diabetic foot<br />
ulceration: a systematic review. J Diabetes Complications<br />
27: 391–400<br />
Petrofsky JS (2011) The effect of type-2-diabetes-related<br />
vascular endothelial dysfunction on skin physiology and<br />
activities of daily living. J Diabetes Sci Technol 5: 657–67<br />
Reiber GE, Vileikyte L, Boyko EJ et al (1999) Causal pathways<br />
for incident lower-extremity ulcers in patients with diabetes<br />
from two settings. Diabetes Care 22: 157–62<br />
Reiber GE, Smith DG, Wallace C et al (2002) Effect of<br />
therapeutic footwear on foot reulceration in patients<br />
with diabetes. A randomised controlled trial. JAMA 287:<br />
2552–8<br />
Teller P, White TK (2009) The physiology of wound healing:<br />
injury through maturation. Surg Clin North Am 89: 599–<br />
610<br />
Vinik AI, Erbas T, Park TS (2001) Dermal neurovascular<br />
dysfunction in type 2 diabetes. Diabetes Care 24: 1468–75<br />
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functions of the skin. HSE, London, UK. Available at:<br />
http://bit.ly/ZIW36y (accessed 02.09.16)<br />
Vinik AI, Maser RE, Mitchell BD, Freeman R (2003) Diabetic<br />
autonomic neuropathy. Diabetes Care 26: 1553–66<br />
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and the Foot. IDF, Brussels, Belgium. Available at:<br />
http://bit.ly/2cUTPJB (accessed 13.09.16)<br />
Weaving L (2014) KerraPro pressure reducing pads<br />
in preventing pressure ulceration. Harrogate 2014<br />
Conference Posters. Harrogate, Wounds UK, UK. Available<br />
at: http://bit.ly/2m75Rab (accessed 02.09.16)<br />
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a Summary Guidance for daily practice 2015. IWGDF<br />
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http://bit.ly/2kLpS69 (accessed 22.02.16)<br />
Westphal C, Neame IM, Harrison JC, et al (2011) A diabetic<br />
foot ulcer pilot study: does silicone gel shee ting reduce<br />
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Diabetes & Primary Care Australia Vol 2 No 2 2017 79
The PCDSA is a multidisciplinary society with the aim<br />
of supporting primary health care professionals to deliver<br />
high quality, clinically effective care in order to improve<br />
the lives of people with diabetes.<br />
The PCDSA will<br />
Share best practice in delivering quality diabetes care.<br />
Provide high-quality education tailored to health professional needs.<br />
Promote and participate in high quality research in diabetes.<br />
Disseminate up-to-date, evidence-based information to health<br />
professionals.<br />
Form partnerships and collaborate with other diabetes related,<br />
high level professional organisations committed to the care of<br />
people with diabetes.<br />
Promote co-ordinated and timely interdisciplinary care.<br />
Membership of the PCDSA is free and members get access to a quarterly<br />
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in the field of diabetes.<br />
To register, visit our website:<br />
www.pcdsa.com.au