DPCA2-2_issue_v3

Diabetes
& Primary Care Australia
Vol 2 No 2 2017
The primary care diabetes journal for healthcare professionals in Australia
Pre-gestational diabetes in pregnancy
This issue includes guidance on how
to optimise pregnancy outcomes
through pre-conception care and the
resources available for mothers with
pre-gestational diabetes and healthcare
professionals who care for them.
E-learning on pre-conception care for
women with pre-gestational diabetes is
available at www.pcdsa.au.org/cpd.
Page 54
IN THIS ISSUE
Bone health
The relationship between
diabetes and bone health,
and the impact of poor bone
health on patients. Page 61
Preventing falls
A clinical review of the
screening, assessment and
management of older people
at risk of falls. Page 69
Diabetes and skin
Considering the skin of
people with diabetes and the
importance of skin care before
and after ulceration. Page 75
WEBSITE
Journal content online at
www.pcdsa.com.au/journal

The PCDSA is a multidisciplinary society with the aim
of supporting primary health care professionals to deliver
high quality, clinically effective care in order to improve
the lives of people with diabetes.
The PCDSA will
Share best practice in delivering quality diabetes care.
Provide high-quality education tailored to health professional needs.
Promote and participate in high quality research in diabetes.
Disseminate up-to-date, evidence-based information to health
professionals.
Form partnerships and collaborate with other diabetes related,
high level professional organisations committed to the care of
people with diabetes.
Promote co-ordinated and timely interdisciplinary care.
Membership of the PCDSA is free and members get access to a quarterly
online journal and continuing professional development activities. Our first
annual conference will feature internationally and nationally regarded experts
in the field of diabetes.
To register, visit our website:
www.pcdsa.com.au

Contents
Diabetes
& Primary Care Australia
Volume 2 No 2 2017
Website: www.pcdsa.com.au/journal
Editorial
Diabetes and pregnancy 45
Rajna Ogrin introduces this issue, which has a focus on pregnancy and pre-conception care for women with pre-gestational diabetes.
From the other side of the desk
Through diagnosis to pregnancy: My journey with diabetes 47
Karen Barrett gives a first-hand perspective on her journey with diabetes and how it affected her pregnancies.
CPD module
Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care 54
Glynis Ross provides guidance to support pre-conception care for women with pre-gestational diabetes.
Articles
Resources to support preconception care for women with diabetes 50
Melinda Morrison, Ralph Audehm, Alison Barry and colleagues describe the resources available for health professionals and women with
diabetes and provide up-to-date, evidence-based information on pregnancy and diabetes.
Diabetes and bone health 61
Vidhya Jahagirdar and Neil J Gittoes explore the current literature on diabetes and bone health, its impact on patients and the management
strategies that may be considered in primary care to minimise risk of diabetes-related bone disease and to improve outcomes.
Falls prevention in older adults with diabetes: A clinical review of screening, assessment and management recommendations 69
Anna Chapman and Claudia Meyer review the screening, assessment and management recommendations for fall prevention in older people.
The effect of diabetes on the skin before and after ulceration 75
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
relation to ulceration.
Editor-in-Chief
Rajna Ogrin
Senior Research Fellow, RDNS
Institute, St Kilda, Vic
Associate Editor
Gary Kilov
Practice Principal, The Seaport
Practice, and Senior Lecturer,
University of Tasmania,
Launceston, Tas
Editorial Board
Ralph Audehm
GP Director, Dianella Community
Health, and Associate Professor,
University of Melbourne,
Melbourne, Vic
Werner Bischof
Periodontist, and Associate
Professor, LaTrobe University,
Bendigo, Vic
Jessica Browne
Senior Research Fellow, The
Australian Centre for Behavioural
Research in Diabetes, Deakin
University, Melbourne, Vic
Anna Chapman
Research Fellow, RDNS Institute,
St Kilda, Vic
Laura Dean
Course Director of the Graduate
Certificate in Pharmacy
Practice, Monash University, Vic
Nicholas Forgione
Principal, Trigg Health Care
Centre, Perth, WA
John Furler
Principal Research Fellow and
Associate Professor,
University of Melbourne, Vic
Mark Kennedy
Medical Director, Northern Bay
Health, Geelong, and Honorary
Clinical Associate Professor,
University of Melbourne,
Melbourne, Vic
Peter Lazzarini
Senior Research Fellow,
Queensland University of
Technology, Brisbane, Qld
Roy Rasalam
Head of Clinical Skills and
Medical Director,
James Cook University, and
Clinical Researcher, Townsville
Hospital, Townsville, Qld
Suzane Ryan
Practice Principal, Newcastle
Family Practice, Newcastle, NSW
Editor
Olivia Tamburello
Editorial Manager
Richard Owen
Publisher
Simon Breed
© OmniaMed SB and the Primary Care
Diabetes Society of Australia
Published by OmniaMed SB,
1–2 Hatfields, London
SE1 9PG, UK
All rights reserved. No part of this
journal may be reproduced or transmitted
in any form, by any means, electronic
or mechanic, including photocopying,
recording or any information retrieval
system, without the publisher’s
permission.
ISSN 2397-2254
Diabetes & Primary Care Australia Vol 2 No 2 2017 43

Call for papers
Would you like to write an article
for Diabetes & Primary Care Australia?
The new journal from the Primary Care Diabetes Society of Australia
To submit an article or if you have any queries, please contact: gary.kilov@pcdsa.com.au.
Title page
Please include the article title, the full names of the authors
and their institutional affiliations, as well as full details of
each author’s current appointment. This page should also have
the name, address and contact telephone number(s) of the
corresponding author.
Article points and key words
Four or five sentences of 15–20 words that summarise the major
themes of the article. Please also provide four or five key words
that highlight the content of the article.
Abstract
Approximately 150 words briefly introducing your article,
outlining the discussion points and main conclusions.
Introduction
In 60–120 words, this should aim to draw the reader into the
article as well as broadly stating what the article is about.
Main body
Use sub-headings liberally and apply formatting to differentiate
between heading levels (you may have up to three heading levels).
The article must have a conclusion, which should be succinct and
logically ordered, ideally identifying gaps in present knowledge and
implications for practice, as well as suggesting future initiatives.
Tables and illustrations
Tables and figures – particularly photographs – are encouraged
wherever appropriate. Figures and tables should be numbered
consecutively in the order of their first citation in the text. Present
tables at the end of the articles; supply figures as logically labelled
separate files. If a figure or table has been published previously,
acknowledge the original source and submit written permission
from the copyright holder to reproduce the material.
References
In the text
Use the name and year (Harvard) system for references in the
text, as exemplified by the following:
● As Smith and Jones (2013) have shown …
● As already reported (Smith and Jones, 2013) …
For three or more authors, give the first author’s surname
followed by et al:
● As Robson et al (2015) have shown …
Simultaneous references should be ordered chronologically first,
and then alphabetically:
● (Smith and Jones, 2013; Young, 2013; Black, 2014).
Statements based on a personal communication should be
indicated as such, with the name of the person and the year.
In the reference list
The total number of references should not exceed 30 without prior
discussion with the Editor. Arrange references alphabetically first,
and then chronologically. Give the surnames and initials of all
authors for references with four or fewer authors; for five or more,
give the first three and add “et al”. Papers accepted but not yet
published may be included in the reference list as being “[In press]”.
Journal article example: Robson R, Seed J, Khan E et al (2015)
Diabetes in childhood. Diabetes Journal 9: 119–23
Whole book example: White F, Moore B (2014) Childhood
Diabetes. Academic Press, Melbourne
Book chapter example: Fisher M (2012) The role of age. In: Merson
A, Kriek U (eds). Diabetes in Children. 2nd edn. Academic Press,
Melbourne: 15–32
Document on website example: Department of Health (2009)
Australian type 2 diabetes risk assessment tool (AUSDRISK).
Australian Government, Canberra. Available at: http://www.
health.gov.au/preventionoftype2diabetes (accessed 22.07.15)
Article types
Articles may fall into the categories below. All articles should be
1700–2300 words in length and written with consideration of
the journal’s readership (general practitioners, practice nurses,
prescribing advisers and other healthcare professionals with an
interest in primary care diabetes).
Clinical reviews should present a balanced consideration of a
particular clinical area, covering the evidence that exists. The
relevance to practice should be highlighted where appropriate.
Original research articles should be presented with sections
for the background, aims, methods, results, discussion and
conclusion. The discussion should consider the implications
for practice.
Clinical guideline articles should appraise newly published
clinical guidelines and assess how they will sit alongside
existing guidelines and impact on the management of diabetes.
Organisational articles could provide information on newly
published organisational guidelines or explain how a particular
local service has been organised to benefit people with diabetes.
— Diabetes & Primary Care Australia —

Editorial
Diabetes and pregnancy
It is well known that diabetes is a systemic
condition and, if not managed efficiently,
can have a life-changing impact on the eyes,
feet and kidneys. In this issue, we consider
the impact of uncontrolled hyperglycaemia on
other body systems and functions – from skin
to bone, and from pregnancy to older age. On
page 75, Roy Rasalam and Lesley Weaving
discuss the practical aspects of maintaining
healthy skin in people with diabetes, and
Neil Gittoes and Vidhya Jahagirdar provide a
clinical review of the potential complications
to bone health as a result of diabetes (page 61).
There is a special section on diabetes and
pregnancy covering preconception care in
primary care and the resources available
for women with diabetes and health care
professionals (starting from page 47). Finally,
there is a paper by Anna Chapman and
Claudia Meyer on the increased risk of falls
in older people with diabetes and what can be
done to lower the risk (page 69). This topic is
especially pertinent with the growing ageing
population seen in Australia and globally.
Diabetes and pregnancy
One relatively new area of research in
diabetes and pregnancy that has caught my
eye is epigenetics – the effect of environment
on genetics. Questions are being raised
as to whether the maternal environment
(e.g. maternal obesity, poor nutrition and
hyperglycaemia) may “program” type 2
diabetes in offspring. There is some evidence
that suggests that shared genetic and
environmental risk, as well as developmental
programming, may lead to children born to
women with diabetes during pregnancy at
greater risk of developing type 2 diabetes in
later life (Berends and Ozanne, 2012). If the
female offspring then have their own children,
it is thought that an intergenerational
cycle of diabetes risk could be established
(Dabelea and Crume, 2011). The intricacies
of this are important to understand, as many
women with pre-existing type 2 diabetes
are often overweight or obese. They often
continue to gain weight with each additional
pregnancy and are sometimes reluctant to
engage with health services (Bandyopadhyay
et al, 2011). Women of South East Asian
origin are at particularly high risk of diabetes
during pregnancy, so by developing effective
strategies to specifically address these factors,
the risk of future diabetes to offspring may be
reduced (Greenhalgh et al, 2015).
What other considerations need to be
made to avoid the increased risk of adverse
pregnancy outcomes as a result of diabetes?
Pre-gestational diabetes (type 1 and
type 2 diabetes) is present in approximately
1% of pregnant women in Australia and the
prevalence is increasing not only here, but
around the world. Women with pre-existing
diabetes are at high risk of complications
during pregnancy, with up to four times
the rate of congenital malformations, and
up to a five-fold increased risk of stillbirth
and perinatal mortality compared to women
without diabetes. By safely optimising blood
glucose management, women can significantly
reduce their risk of complications, and
preconception care has been shown to reduce
these risks (Inkster et al, 2006).
Women of child-bearing age with diabetes
need to be informed of the availability and
importance of preconception care, which
can be provided by both primary and
specialised diabetes services; many women
with type 1 diabetes access diabetes specialist
services, while the majority of women with
type 2 diabetes are managed in primary care.
Included in preconception care is appropriate
contraception advice. Here, primary care
providers can make a real difference in
promoting and providing appropriate
contraception to women with diabetes to
prevent unplanned pregnancies.
In this pregnancy special, there are three
pieces related to pregnancy and diabetes. There
is a CPD module outlining the requirements
of preconception care for women with
Rajna Ogrin
Editor of Diabetes & Primary Care
Australia, and Senior Research
Fellow, RDNS Institute,
St Kilda, Vic.
Diabetes & Primary Care Australia Vol 2 No 2 2017 45

Editorial
“By considering the
health and wellbeing of
women with diabetes
prior to pregnancy,
we anticipate
that meaningful
improvements in
pregnancy outcomes
are possible.”
diabetes, including practical information for
health care providers, as well as case studies to
highlight the application of this information
in clinical practice (page 54). There is also
a wealth of resources for the clinician and
woman with diabetes to optimise healthy
pregnancy outcomes. Melinda Morrison from
the National Diabetes Services Scheme and
colleagues outline the resources available,
such as apps, booklets and online resources
(page 50). We also have the first “From
the other side of the desk” feature – a
new series to inform clinical care from the
perspectives of people with diabetes. In the
first of the series, Karen Barrett discusses her
journey with diabetes and how it affected her
pregnancies (page 47).
By considering the health and wellbeing
of women with diabetes prior to pregnancy,
and utilising the resources that have been
developed specifically to support this group
before, during and after pregnancy, we
anticipate that meaningful improvements in
pregnancy outcomes are possible. n
2017 NATIONAL CONFERENCE
Saturday 6th May 2017 – Melbourne Convention and Exhibition Centre, Victoria, Australia
The conference has been specifically designed for all primary care health
professionals working in diabetes care to:
Advance their education and learning in the field of diabetes health care
Promote best practice standards and clinically effective care in the management of diabetes
Facilitate collaboration between health professionals to improve the quality of diabetes
primary care across Australia
6TH MAY 2017 CONFERENCE PROGRAM
The 2017 PCDSA national conference program will combine cutting edge scientific content with
practical clinical sessions, basing the education on much more than just knowing the guidelines.
The distinguished panel of speakers will share their specialised experience in an environment
conducive to optimal learning. The Speaking faculty include, amongst others:
Associate Professor
Neale Cohen
Director Clinical Diabetes
Baker Heart and
Diabetes Institute
“Diabetes management
and research in primary
care – key components
to improving outcomes”
Doctor Christel
Hendrieckx
Senior Research Fellow
The Australian Centre
for Behavioural Research
in Diabetes
“The emotional health of
people living with diabetes”
For further information including the full 2017 program
and to register for the conference please visit:
www.eventful.com.au/pcdsa2017
If you have any questions regarding the conference,
please contact the Conference Secretariat;
Toll free telephone: 1800 898 499
Email: pcdsa@eventful.com.au
Ms Renza Scibilia
Manager - Type 1 Diabetes
and Consumer Voice
Diabetes Australia
“Engaging people with
diabetes, the diabetes
online community and
apps for diabetes”
Doctor Gautam
Vaddadi
Consultant Cardiologist
Alfred Health, Northern Health,
University of Melbourne
“The emerging importance
of cardiac failure diagnosis
and management in people
with type 2 diabetes”
pcdsa.com.au
Bandyopadhyay M, Small R, Davey MA et al (2011) Lived
experience of gestational diabetes mellitus among immigrant
South Asian women in Australia. Aust N Z J Obstet Gynaecol
51: 360–4
Berends LM, Ozanne SE (2012) Early determinants of type 2
diabetes. Best Pract Res Clin Endocrinol Metab 26: 569–80
Dabelea D, Crume T (2011) Maternal environment and the
transgenerational cycle of obesity and diabetes. Diabetes 60:
1849–55
Greenhalgh T, Clinch M, Afsar N et al (2015) Socio-cultural
influences on the behaviour of South Asian women with
diabetes in pregnancy: qualitative study using a multi-level
theoretical approach. BMC Med 13: 120
Inkster ME, Fahey TP, Donnan PT et al (2006) Poor glycated
haemoglobin control and adverse pregnancy outcomes in
type 1 and type 2 diabetes mellitus: Systematic review of
observational studies BMC Pregnancy Childbirth 6: 30
Diabetes & Primary Care Australia Vol 2 No 2 2017

From the other side of the desk
From the other side of the desk:
Patient perspective
Through diagnosis to pregnancy:
My journey with diabetes
Karen Barrett
I
was diagnosed with type 1 diabetes on Valentine’s
Day, 1983, a day meant for chocolates, roses
and sweets. What an irony it turned out to be.
Dressed in my school uniform and ready for school,
my Mum, being a nurse, had known for some time
that something wasn’t right. I had lost a substantial
amount of weight and the bathroom seemed to
be my best friend, as did my unquenchable thirst.
“Oh what a bombshell!” my Mum’s colleague said
that day after hearing my diagnosis. I never really
comprehended the significance of the diagnosis at
the time. I had felt fine.
In the early days after my diagnosis, to see my
diabetes specialist meant a day off school and a trip
to Canberra – that was the good part. The not-sogood
part became the endless questions from the
doctor – what was I putting in my mouth and at
exactly what time of the day – measurements on the
scales, numbers in books, pathology results and eye
tests. On and on it went. Would I pass or fail? Had
I been good or bad? I hated it.
There was never a time that I let my diabetes
stand in the way. I was quite sporty growing up
in a small country town, later trying triathlons
and endurance sports. But in my school life, I was
sometimes left out, missing the first school camp
because everyone was so very nervous to have a
person with diabetes at camp and friends’ parents
being reluctant to have me over, afraid of what or
what not to feed me.
As an adolescent, I was studious and quite fit and
healthy, with an obsessive personality. That was
until my late teens, when I seemed to burn out with
school, with life and with diabetes. Life became
tricky. I found solace in food and subsequently paid
the price, gaining weight.
My family, of course, was concerned, but the
constant questions about how many blood sugar
tests I was doing and whether I was looking after
myself was a continuous reminder of my diabetes,
something I wanted to forget. I ate in secret and lied
to keep them satisfied while continuing to silently
struggle. I was tired of all the rules, tired of all the
questions and tired of being different and feeling
restricted. As I entered adulthood, I thought I kept
my struggles well hidden from others for many
years. I went on to study nursing at university and
the big wide world gave me even more freedom
to hide from the reality of diabetes. Somehow,
I stayed on the tightrope of avoiding routine
doctor’s appointments while also avoiding more
serious hospital admissions. A visit to the doctor
would mean tests, which I knew I would fail, and
questions that I would be ashamed to answer – I
wasn’t up for the interrogations and judgements.
But, I didn’t feel like I was failing! I was eating what
I wanted, when I wanted, and being like the rest of
my friends and peers.
Time to get real
Then I found out I was pregnant…unplanned.
For me, I realised it was not fair to have a child,
with the high risk of complications to me and my
baby as a result of me not looking after myself.
A decision, that I feel to this day, even though I
agreed, had already been made for me. Time to get
real. If I was to ever create a family of my own, it
meant facing the issues I had so long avoided – the
medical world testing me on passing or failing at
diabetes.
Unable, and not allowing myself, to be anything
other than perfectly controlled, I became a
Citation: Barrett K (2017) Through
diagnosis to pregnancy: My journey
with diabetes. Diabetes & Primary
Care Australia 1: 47–8
About this series
The aim of the “From the other
side of the desk” series is to
provide a patient perspective on
a topic within diabetes, to reflect
on the doctor–patient relationship
and to inform clinical care.
Author
Karen Barrett, Registered Nurse
and Coordinator, Central Coast,
NSW.
Diabetes & Primary Care Australia Vol 2 No 2 2017 47

From the other side of the desk
“As a person with
diabetes, my advice
to the medical world
would be to consider
the person in front
of you without their
diabetes diagnosis.”
champion of the tests. It was an intense time but
my motivation to have healthy babies drove me
to that perfection, and I went on to have three
babies in 3 years. I told the medical team what they
wanted to hear, but this time I wasn’t lying.
It became my obsession to get the numbers
right. Averaging about 12–14 blood sugars daily
and the never-ending specialist appointments were
vital to achieving the desired outcome. I was lucky
that the care I received from my diabetes team
during my pregnancies was excellent and well
planned. I feel that it is vital to have a trusting
relationship with an endocrinologist before, during
and after pregnancies, and I was very fortunate
to have that. But pregnancy with diabetes is not
without its difficulties; the severe hypos during the
first trimesters became frequent and increasingly
exhausting, and with every pregnancy, I had
another toddler to care for. My first-born was
diagnosed with cerebral palsy (totally unrelated
to my diabetes), and as if that was not sufficiently
challenging, I became a single Mum when my
youngest was 11 months old. Juggling three
toddlers, a part-time job to survive financially and
my diabetes became routine. The all-or-nothing
personality has some advantages and in those
3 years, I was switched to “all”, determined to be
a good Mum.
However, as the years went by, I let those
numbers slip again. My three gorgeous children,
my world, were growing up fast, and at aged 6, 7
and 8 years, they kept me busy. I kept the medical
team at length – I knew I wasn’t going to “pass the
test”. My 7-year-old daughter, Presley, had spirit
(sometimes too much!) and when she came down
with a viral illness, as a mum with diabetes would,
I checked her blood sugar. My Mum had suggested
the “D” word as Presley kept sleeping through the
day, which was very much unlike her. I still recall
that moment, and I think I too knew something
wasn’t right. Weeks later, Presley mentioned to me
that she was waking through the night to go to the
bathroom. I knew. I waited.
My beautiful girl was dressed in her swimmers
ready to go swimming. I did her blood sugar and
there I was – the mother of a child with diabetes.
Now it was me answering the questions not as a
person with diabetes, but as a Mum. It was more
than my own tests – I had to pass all of Presley’s
tests as well.
I felt my skills as a parent were put under the
microscope. I believed it was all my fault if her
numbers weren’t right. What was she eating when
I wasn’t there? Was she exerting too much energy
during lunchtime at school? Could she recognise
a hypo? I felt like I had to live in her head, and
I became the “helicopter” Mum. Presley too
hated the medical world, clamming up at all the
questions and hating the scales and numbers. At
home, she dealt with the never-ending motherly
concerns and requests to check her blood sugar,
blaming every ailment or headache on diabetes,
whether or not it was.
Where I am now
Despite some complications of my own, at 44 years
of age, I now take care of myself and feel as well as
I can feel, given my past “bad behaviour”. I have
a good relationship with my team and appreciate
the rapport I have with them, which has taken
many years to establish and develop. I now take
charge of my appointments and we talk about the
concerns I have. The first questions asked are not
“shall we look at the numbers?” or “how many
highs/lows are you having?”; rather, “how are you,
and what’s going on in your world?”
I have had a lovely relationship with my
psychologist who somehow allows me to be proud
of who I am and what I have achieved. I am now
free of the judgement calls that I thought were
placed on me as a person with diabetes and then
as the mother of a child with diabetes. Mistakes
are human. Rough patches enable us all to make
better choices, and experience allows us to call the
shots. It’s OK not to be perfect. I truly hope that
if anything, I can pass this on to my children and
that they reach this point a whole lot sooner than
I did.
As a person with diabetes, my advice to the
medical world would be to consider the person
in front of you without their diabetes diagnosis.
Diabetes management is far more than looking
at the numbers. Consider their state of mind
and the unsaid pressures they may have put on
themselves. The bravest thing one can do is to ask
for help and say that we’re not OK, and creating
an environment where people with diabetes feel
comfortable and safe to do so is vital. n
48 Diabetes & Primary Care Australia Vol 2 No 2 2017

2017 NATIONAL CONFERENCE
Saturday 6th May 2017 – Melbourne Convention and Exhibition Centre, Victoria, Australia
The conference has been specifically designed for all primary care health
professionals working in diabetes care to:
Advance their education and learning in the field of diabetes health care
Promote best practice standards and clinically effective care in the management of diabetes
Facilitate collaboration between health professionals to improve the quality of diabetes
primary care across Australia
6TH MAY 2017 CONFERENCE PROGRAM
The 2017 PCDSA national conference program will combine cutting edge scientific content with
practical clinical sessions, basing the education on much more than just knowing the guidelines.
The distinguished panel of speakers will share their specialised experience in an environment
conducive to optimal learning. The Speaking faculty include, amongst others:
Associate Professor
Neale Cohen
Director Clinical Diabetes
Baker Heart and
Diabetes Institute
“Diabetes management
and research in primary
care – key components
to improving outcomes”
Doctor Christel
Hendrieckx
Senior Research Fellow
The Australian Centre
for Behavioural Research
in Diabetes
“The emotional health of
people living with diabetes”
Ms Renza Scibilia
Manager - Type 1 Diabetes
and Consumer Voice
Diabetes Australia
“Engaging people with
diabetes, the diabetes
online community and
apps for diabetes”
Doctor Gautam
Vaddadi
Consultant Cardiologist
Alfred Health, Northern Health,
University of Melbourne
“The emerging importance
of cardiac failure diagnosis
and management in people
with type 2 diabetes”
For further information including the full 2017 program
and to register for the conference please visit:
www.eventful.com.au/pcdsa2017
If you have any questions regarding the conference,
please contact the Conference Secretariat;
Toll free telephone: 1800 898 499
Email: pcdsa@eventful.com.au
pcdsa.com.au

Article
Resources to support preconception care
for women with diabetes
Citation: Morrison M, Audehm R,
Barry A et al (2017) Resources to
support preconception care for
women with diabetes. Diabetes &
Primary Care Australia 2: 50–3
Article points
1. Women with diabetes are
at increased risk of adverse
pregnancy outcomes. Early
intervention and planning
can reduce the risks.
2. Primary health care
professionals have a key role
in providing appropriate
contraception to women with
diabetes to prevent unplanned
pregnancies, as well as
encouraging optimal pregnancy
planning and preparation.
3. To address the gap in
information for women with
diabetes who are seeking
or already accessing prepregnancy
advice and
care, Diabetes Australia
has developed a suite of
resources with funding
through the National
Diabetes Services Scheme.
Key words
– Diabetes in pregnancy
– Education
– Preconception care
– Pregnancy
– Resources
– Type 1 diabetes
– Type 2 diabetes
Authors
See page 53 for details.
Melinda Morrison, Ralph Audehm, Alison Barry, Christel Hendrieckx,
Alison Nankervis, Cynthia Porter, Renza Scibilia, Glynis P Ross
Preconception care has been shown to reduce the rates of adverse pregnancy outcomes
in women with pre-existing type 1 or type 2 diabetes. With an increasing prevalence of
diabetes among women of child-bearing age, health professionals working in primary
care have an important role in encouraging women with diabetes to plan and prepare
for pregnancy. New resources, described here, are available for health professionals and
women with diabetes and provide up to date, evidence-based information on pregnancy
and diabetes.
Pre-existing diabetes (type 1 or
type 2 diabetes) is estimated to affect
approximately 1% of pregnant women
in Australia (Australian Institute of Health and
Welfare, 2016), and evidence suggests that the
prevalence is increasing (Abouzeid et al, 2014).
In particular, the prevalence of type 2 diabetes in
pregnant women is expected to increase as a result
of older maternal age, high rates of obesity and an
ethnically diverse population (Cheung et al, 2005;
Temple and Murphy, 2010).
Diabetes in pregnancy has many welldocumented
risks to both mother and baby
(Macintosh et al, 2006; Dunne et al, 2009;
Kitzmiller et al, 2010); however, these risks can
be mitigated by effective preconception and
pregnancy care, and most women with diabetes
will go on to have a healthy pregnancy and a
healthy baby (Ray et al, 2001; Wahabi et al, 2010;
Holmes et al, 2017).
While most women with type 1 diabetes access
specialist services, the majority of women with
type 2 diabetes are managed in primary care.
Health professionals in primary care are often the
first point of contact for women seeking pregnancy
information, and have a key role in promoting and
providing appropriate contraception to women
with pre-existing diabetes to prevent unplanned
pregnancies, and in specialist referral. They are
also critically important in encouraging diabetesspecific
preconception care in all women with
pre-existing diabetes to optimise maternal and
fetal outcomes (Temple and Murphy, 2010). In
the National Diabetes Services Scheme (NDSS)*
Contraception, Pregnancy & Women’s Health
Survey (2015) women with type 1 or type 2
diabetes (n=967) indicated that diabetes specialists
(endocrinologists and diabetes educators) and
general practitioners were the health professionals
with whom pregnancy and diabetes was most
frequently discussed. Interestingly, the majority
of women reported that they, rather than health
professionals, initiated the conversation about
pregnancy and diabetes.
Preconception care in the primary
health setting
Despite the documented benefits of preconception
care for women with pre-existing diabetes (Ray
et al, 2001; Wahabi et al, 2010), many women
with diabetes do not plan their pregnancies. Zhu
et al (2012) reported that 45% of pregnancies in
women with diabetes attending a tertiary obstetric
hospital in Western Australia during 2009–2010
*The National Diabetes Services Scheme (NDSS) is an
initiative of the Australian Government administered
with the assistance of Diabetes Australia.
50 Diabetes & Primary Care Australia Vol 2 No 2 2017

Resources to support preconception care for women with diabetes
were unplanned. While in an earlier Australian
multicentre study of pregnancies complicated
by diabetes, pre-pregnancy counselling was
documented in only 20% of women – 28% of
those with type 1 diabetes and 12% of those with
type 2 diabetes (McElduff et al, 2005).
Planning for pregnancy
The primary health care setting is where many
women with diabetes seek advice on reproductive
issues and access contraception. However, in the
NDSS Contraception, Pregnancy & Women’s
Health Survey (2015) only 49% of Australian
women with type 1 or type 2 diabetes could
recall being advised by a health professional to
use some form of contraception to prevent an
unplanned pregnancy, and 55% could recall being
advised by a health professional that they should
access diabetes-specific pre-pregnancy care before
becoming pregnant or planning a pregnancy.
These results differed by type of diabetes, with
those with type 2 diabetes being less likely to recall
receiving advice. These findings are consistent
with those reported in the TRIAD (Translating
Research into Action for Diabetes) preconception
study of US women aged 18–45 years enrolled
in managed care (Kim et al, 2005). Of these
women, 52% recalled discussions with a health
professional regarding glucose control before
conception, and 37% could recall receiving family
planning advice.
Due to the impact of an unplanned pregnancy
on both the developing fetus and mother, adequate
contraception should be maintained until
glycaemia and all aspects of care are optimised.
The longer-acting reversible contraceptives are an
excellent choice (e.g. intrauterine contraceptive
devices or implant) and are safe for women with
diabetes to use. When reviewing contraception in
women with diabetes, timing of pregnancy should
be discussed. Preconception planning for women
with diabetes should occur well before conception.
If available, involvement of a specialist diabetes in
pregnancy service is recommended.
New NDSS resources to support
preconception care
To address the gap in information for
women with diabetes who are seeking or
already accessing pre-pregnancy advice
and care, Diabetes Australia has developed
a suite of resources with funding through
the NDSS. These resources were developed
following extensive consumer and stakeholder
consultation, and provide up-to-date, evidencebased
pregnancy information for women living
with type 1 or type 2 diabetes. The NDSS
resources available include the following:
l www.pregnancyanddiabetes.com.au: A
website dedicated to pregnancy and diabetes
information.
l Pregnancy planning checklist: A checklist
to help women with diabetes prepare for a
healthy pregnancy. The checklist can be
completed as an online tool or downloaded
as a printable checklist (Figure 1).
l Having a Healthy Baby booklets: Booklets
providing comprehensive information on
planning and managing pregnancy. Separate
booklets are available for women with
type 1 or type 2 diabetes (Figure 2).
l NDSS pregnancy and diabetes factsheet:
Available for download in English, Arabic,
Chinese, Vietnamese, Korean, Turkish,
Urdu, Greek, Italian and Spanish.
l Plan for the best start e-newsletter: A
quarterly e-newsletter for women with
diabetes and health professionals. It
provides information on planning and
preparing for pregnancy, and there is access
to the latest NDSS resources and research
updates.
l Health professional continuing professional
development learning: E-learning modules
for primary health care providers on the
topic of preconception care for women
with type 1 or type 2 diabetes. The course
includes three modules with two nonassessed
case studies and can be accessed
from the NDSS pregnancy and diabetes
website. CPD points are available for
eligible health professionals.
These resources for patients and health
care professionals can be accessed at
www.pregnancyanddiabetes.com.au. Hard
copies of the booklets can be ordered online or
by phoning the NDSS Helpline (1300 136 588).
Page points
1. Due to the impact of an
unplanned pregnancy on
both the developing fetus and
mother, adequate contraception
should be maintained until
glycaemia and all aspects of
care are optimised.
2. Preconception planning for
women with diabetes should
occur well before conception.
3. Resources for patients and
health care professionals
can be accessed at www.
pregnancyanddiabetes.com.au.
Diabetes & Primary Care Australia Vol 2 No 2 2017 51

Resources to support preconception care for women with diabetes
Pregnancy Planning Checklist
Plan and prepare at least 3-6 months before you start
trying for a baby
What you need to do BEFORE you fall pregnant
Use contraception until you are ready to start trying for
a baby (ask your doctor if this is the most reliable
contraception suitable for you)
Talk to your doctor for general pregnancy planning advice
Make an appointment with health professionals who
specialise in pregnancy and diabetes
Aim for an HbA1c of less than 53mmol/mol (7%) if you
have type 1 diabetes or 42mmol/mol (6%) or less if
you have type 2 diabetes
Review your diabetes management with your diabetes
health professionals
Have all your medications checked to see if they are
safe to take during pregnancy
Start taking a high-dose (2.5mg-5mg) folic acid
supplement each day
Have a full diabetes complications screening and
your blood pressure checked
Aim for a healthy weight before you fall pregnant
For women
with type 1
or type 2
diabetes
Use this checklist as a guide to discuss with your health professionals
www.pregnancyanddiabetes.com.au
This checklist is intended as a guide only. It should not replace individual medical advice and if you have any
concerns about your health or further questions, you should contact your health professional.
The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered with the assistance of Diabetes Australia.
Figure 1. Pregnancy planning checklist, to help women with diabetes
prepare for a healthy pregnancy. Produced by the National Diabetes
Service Scheme.
Other resources
The Australasian Diabetes in Pregnancy
Society (ADIPS)-endorsed Pregnant
with Diabetes app has been developed
for pregnant women with diabetes, and
women with diabetes who intend to
become pregnant (Figure 3). It is written by
Prof. Elisabeth R Mathiesen and Prof. Peter
Damm and is based on the recommendations
of the Centre for Pregnant Women with
Diabetes at Rigshospitalet in Copenhagen,
Denmark. The Australian version has been
adapted by an Australian working party
to reflect the ADIPS guidelines. The app
can be downloaded from app stores free
of charge. The information covered in the
app is suitable for women with gestational,
type 1 and type 2 diabetes and covers
topics such as: how to plan for pregnancy,
Figure 2. Booklets for women with type 1 and type 2
diabetes. Produced by the National Diabetes Services
Scheme.
goal blood glucose levels, gestational weight
gain, diet and carbohydrate intake, physical
activity and insulin dosing.
52 Diabetes & Primary Care Australia Vol 2 No 2 2017

Resources to support preconception care for women with diabetes
National Development Program Expert
Reference Group (2013–16). We acknowledge
D. Charron-Prochownik for permission
to reproduce questions from the RHAB
questionnaire and V. Holmes for permission to
use reproductive health knowledge questions
in the NDSS Contraception, Pregnancy &
Women’s Health Survey.
Abouzeid M, Versace VL, Janus ED et al (2014) A population-based
observational study of diabetes during pregnancy in Victoria,
Australia, 1999–2008. BMJ Open 4: e005394
Australian Institute of Health and Welfare (2016) Australia’s
mothers and babies 2014-in brief. Perinatal statistics. AIHW,
Canberra, ACT. Available at: http://www.aihw.gov.au/
publication-detail/?id=60129557656 (accessed 14.03.17)
“Primary care health
professionals are
also ideally placed to
increase the awareness
of women with
diabetes about the
available resources
which are being
actively reviewed and
developed to meet
their needs.”
Cheung N, McElduff A, Ross G (2005) Type 2 diabetes in
pregnancy: a wolf in sheep’s clothing. Aust N Z J Obstet
Gynaecol 45: 479–83
Figure 3. The Australasian Diabetes in Pregnancy
Society (ADIPS)-endorsed Pregnant with Diabetes app.
Conclusion
Primary health care providers play an important
role in promoting effective contraception use
and encouraging women with pre-existing
type 1 or type 2 diabetes to plan and prepare
for pregnancy. They are also ideally placed to
increase the awareness of women with diabetes
about the available resources which are being
actively reviewed and developed to meet their
needs.
n
Acknowledgements
The authors are grateful to the women who took
part in the NDSS Contraception, Pregnancy
& Women’s Health Survey, to the Australasian
Diabetes in Pregnancy Society for approving the
use of the image of the Pregnant with Diabetes
app and to Effie Houvardas and Kaye Farrell,
for their contribution to Diabetes in Pregnancy
Dunne FP, Avalos G, Durkan M et al (2009) ATLANTIC DIP:
pregnancy outcome for women with pregestational diabetes
along the Irish Atlantic seaboard. Diabetes Care 32: 1205–6
Holmes VA, Hamill, LL, Alderdice FA et al (2017) Effect of
implementation of a preconception counselling resource for
women with diabetes: A population based study. Primary Care
Diabetes 11: 37–45
Kim C, Ferrara A, McEwan LN et al (2005) Preconception care in
managed care: the translating research into action for diabetes
study. Am J Obstet Gynecol 192: 227–32
Kitzmiller JL, Wallerstein R, Correa A, Kwan S (2010)
Preconception care for women with diabetes and prevention of
major congenital malformations. Birth Defects Res A Clin Mol
Teratol 88: 791–803
Macintosh MC, Fleming KM, Bailey JA et al (2006) Perinatal
mortality and congenital anomalies in babies of women with
type 1 or type 2 diabetes in England, Wales, and Northern
Ireland: population based study. BMJ 333: 177
McElduff A, Ross GP, Lagstrom JA et al (2005) Pregestational
diabetes and pregnancy: an Australian experience. Diabetes
Care 28: 1260–1
National Diabetes Services Scheme (2015) NDSS Diabetes
in Pregnancy National Development Program, Registrant
Consultation and Needs Assessment Report. NDSS, Canberra,
ACT
Ray JG, O’Brien TE, Chan WS (2001) Preconception care and the
risk of congenital anomalies in the offspring of women with
diabetes mellitus: a meta-analysis. QJM 94: 435–44
Temple RC, Murphy H (2010) Type 2 diabetes in pregnancy - an
increasing problem. Best Pract Res Clin Endocrinol Metab 24:
591–603
Wahabi HA, Alzeidan RA, Bawazeer GA et al (2010)
Preconception care for diabetic women for improving maternal
and fetal outcomes: a systematic review and meta-analysis.
BMC Pregnancy Childbirth 10: 63
Zhu H, Graham D, Teh RW, Hornbuckle J (2012) Utilisation of
preconception care in women with pregestational diabetes in
Western Australia. Aust N Z J Obstet Gynaecol 52: 593–6
Authors
Melinda Morrison, NDSS
Diabetes in Pregnancy Priority
Area Leader*, Diabetes, NSW,
Glebe, NSW; Ralph Audehm,
General Practitioner, Carlton
Family Medical and Department
of General Practice, University
of Melbourne, Vic; Alison Barry,
Credentialled Diabetes Educator
and Midwife, Mater Mothers’
Hospital, South Brisbane, Qld;
Christel Hendrieckx, Senior
Research Fellow, The Australian
Centre for Behavioural Research
in Diabetes, Deakin University,
Geelong, Vic; Alison Nankervis,
Senior Physician to the Diabetes
Service, The Royal Women’s
Hospital and Clinical Head,
Diabetes, Royal Melbourne
Hospital, Parkville, Vic; Cynthia
Porter, Advanced Accredited
Practising Dietitian/Credentialled
Diabetes Educator, Geraldton
Diabetes Clinic, Geraldton, WA;
Renza Scibilia, Manager Type 1
Diabetes and Consumer Voice,
Diabetes Australia, Melbourne,
Vic; Glynis P Ross, Visiting
Endocrinologist, Royal Prince
Alfred Hospital, Camperdown,
NSW, and Senior Endocrinologist,
Bankstown-Lidcombe Hospital,
Bankstown, NSW.
*Melinda Morrison is representing
Diabetes Australia/National
Diabetes Service Scheme.
Diabetes & Primary Care Australia Vol 2 No 2 2017 53

CPD module
Optimising pregnancy outcomes for
women with pre-gestational diabetes in
primary health care
Glynis P Ross
Citation: Ross GP (2017) Optimising
pregnancy outcomes for women
with pre-gestational diabetes in
primary health care. Diabetes &
Primary Care Australia 2: 54–9
Learning objectives
After reading this article, the
participant should be able to:
1. Identify the increased
risks of adverse pregnancy
outcomes to mother and
baby that are associated with
pre-gestational diabetes.
2. Describe the ideal
preconception care
consultation and the key
elements of care that a pregnant
woman with pre-existing
diabetes should receive.
3. Implement a checklist for
preconception care for
women with diabetes.
Key words
– Preconception care
– Pre-gestational diabetes
– Pregnancy
– Type 1 diabetes
– Type 2 diabetes
Author
Glynis P Ross, Visiting
Endocrinologist, Royal Prince
Alfred Hospital, Camperdown
NSW, and Senior Endocrinologist,
Bankstown-Lidcombe Hospital,
Bankstown, NSW.
Preconception care for women with pre-existing diabetes (type 1 or type 2) is critical to
optimise pregnancy outcomes and reduce the risk of adverse outcomes, including miscarriage,
congenital anomalies, hypertension, caesarean deliveries and perinatal mortality. Pregestational
diabetes is present in approximately 1% of pregnant women in Australia, and the
prevalence is increasing. Women with pre-gestational diabetes need to be informed on the
availability and importance of preconception care, which can be provided by both primary
care and specialised diabetes services. The key elements of preconception care for women
with diabetes are outlined in this article with two case examples to illustrate.
Women with pre-gestational type 1
or type 2 diabetes are at high risk
of complications during pregnancy
and of adverse outcomes including miscarriage,
congenital anomalies and perinatal mortality.
Despite advances in diabetes management, rates
of congenital anomalies are 2–4 times higher
than that of the background population and
there is a 3–5 fold increased risk of stillbirth
and perinatal mortality for births to women
with diabetes (Macintosh et al, 2006; Dunne et
al, 2009; Kitzmiller et al, 2010). Data from the
Australian Institute of Health and Welfare (2010)
show that in 2005–2007, more than half of all
Australian women with pre-gestational diabetes
underwent caesarean delivery (59%; 71% type 1
and 56% type 2 diabetes), compared to a third of
women without diabetes. Following birth, 58%
of infants born to women with diabetes were
admitted to a special care nursery or neonatal
intensive care unit, compared to 14% of babies
born to mothers without diabetes.
Glycaemic control in early pregnancy is strongly
associated with the risk of adverse pregnancy
outcomes (Nielsen et al, 2004; Guerin et al, 2007,
Jensen et al, 2009). Research shows that for every
10.93 mmol/mol (1%) increase in HbA 1c
above
53 mmol/mol (7%), there is a 5.5% increase in
risk of adverse outcomes (Nielsen et al, 2004). The
American Diabetes Association (2017) states that
the lowest rates of adverse pregnancy outcomes
are seen in association with an early gestation
HbA 1c
of 42–48 mmol/mol (6.0–6.5%).
Preconception care for women with existing
diabetes provides an opportunity to optimise
glycaemic control, as well as other aspects of
maternal health such as folic acid supplementation,
diabetes complications screening and
discontinuation of teratogenic medications prior
to conception (McElduff et al, 2005; Mahmud
and Mazza, 2010; Egan et al, 2015). Attendance
at diabetes-specific preconception care has
been associated with a reduction in congenital
anomalies (relative risk [RR], 0.25), perinatal
mortality (RR, 0.35) and reduced first trimester
HbA 1c
by an average of 26 mmol/mol (2.4%;
Wahabi et al, 2010).
Advice
Preconception planning and assessment is
recommended for all women considering
pregnancy, but it is particularly important for
women with diabetes or other medical disorders.
Primary health care providers are well placed to
complete most of the preconception screening
and risk assessment, and can facilitate many of
54 Diabetes & Primary Care Australia Vol 2 No 2 2017

Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care
the interventions and appropriate referrals that
may be required. A checklist, such as below,
may be useful when undertaking pre-pregnancy
counselling.
ADVICE AND CONSIDERATIONS
FOR ALL WOMEN CONSIDERING
PREGNANCY
o Appropriate contraception until
optimal situation for pregnancy.
o Review ALL current medications
and ensure they are safe and
appropriate for pregnancy.
o Check blood pressure.
o (For women not known to
have diabetes, assess risk,
and test appropriately for
abnormal glucose tolerance.)
o Promote a healthy lifestyle
with regard to diet, exercise
and optimal weight – this is
also advisable for partners!
o Encourage smoking cessation.
o Advise to cease alcohol intake.
o Advise to stop any
recreational drug use.
o Reduce caffeine intake.
o Dental check.
o Complete breast check
and pap smear.
o Assess immunity to rubella
and varicella zoster, and, if
necessary, organise vaccinations
with appropriate waiting
periods before conception.
o Consider vaccinations for
influenza and whooping cough.
o Commence folic acid 3 months
prior to pregnancy at 0.5 mg daily
(see below for dose adjustments
for women with known diabetes).
o Commence an iodine-containing
supplement (unless active
thyrotoxicosis is present).
o Consider checking thyroid
function, iron, B12 (especially if
vegetarian or taking metformin)
and vitamin D status (if at risk).
ADDITIONAL ADVICE AND
CONSIDERATIONS FOR WOMEN
WITH PRE-GESTATIONAL DIABETES
CONSIDERING PREGNANCY
o Refer to a diabetes specialist
or team if not already under
their care for assessment.
o Optimise glycaemic control
o In type 1 diabetes, pre-pregnancy
HbA 1c
should ideally be

Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care
Page points
1. Preconception care should be
individualised.
2. Women should be advised
to continue to use effective
contraception until the best
possible conditions for a
safe pregnancy and birth are
achieved.
3. Regular monitoring and
recording of blood glucose
levels during the preconception
stage and pregnancy can be
helpful in optimising pregnancy
outcomes.
Case studies
Outlined on the following two pages are two case
studies illustrating some of the considerations to
address during the preconception period. Given
the range of situations that may be encountered,
all care needs to be individualised. Ideally, most
women with diabetes should be assessed before
conception by a diabetes specialist or team with
expertise in diabetes and pregnancy. This is
particularly important when there are diabetes
complications or additional medical disorders.
For women in rural and remote areas, review
in a regional centre or via telehealth with a
specialist centre may be an appropriate option.
This is especially important for women with more
complex situations such as type 1 diabetes, type 2
diabetes requiring multiple medications, diabetes
vascular complications and/or other vascular risk
factors.
Case 1
Maria is a 41-year old woman and has come
to see you for a pap smear. You last saw her
4 months ago when she wanted a script for
the oral contraceptive pill (OCP). On routine
questioning when you are completing the
pathology request for cervical cytology she says
that she is considering having a break from the
pill as she and her husband are thinking about
having another baby.
History
Maria has two children aged 9 and 12 years.
The first pregnancy was uncomplicated and she
had spontaneous vaginal delivery at term. Her
daughter weighed 3450 g and was breastfed
for 12 months. Before her second pregnancy,
Maria had gained 8 kg in weight and her BMI
was 28 kg/m 2 . At 28 weeks during her second
pregnancy, Maria was diagnosed with gestational
diabetes. She was able to manage this with diet
modification alone and had spontaneous vaginal
delivery at 39 +3 weeks of a 3720 g son. He was
also breastfed for 12 months.
Three years ago (age 38 years), Maria’s
weight had risen and her BMI was 31 kg/m 2
(class 1 obesity range). Her fasting glucose was
7.2 mmol/L and her HbA 1c
was 49 mmol/mol
(6.6%) and a diagnosis of type 2 diabetes was
made. Initially she was treated with metformin
XR 2 g daily. Despite the metformin and Maria
trying to follow dietary guidelines, 4 months
ago her HbA 1c
was 62 mmol/mol (7.8%) and so
empagliflozin was added to her regimen. She
continued to struggle to find time to exercise.
Maria has a strong family history of
type 2 diabetes (both parents, her older brother
and all grandparents) and hypertension (father
and paternal grandmother). Her father had a
myocardial infarct at the age of 39 years with
subsequent stenting. For 7 years, Maria has also
been treated for hypertension with telmisartan,
and dyslipidaemia for which she is taking
atorvastatin and fenofibrate. She and her husband
smoke, but Maria has said she is trying to stop
so is only smoking in the evenings after dinner.
Discussion
Maria has several factors that increase her
risk of adverse pregnancy outcomes. She is of
advanced maternal age, is obese, a smoker, and
has type 2 diabetes, hypertension, dyslipidaemia
and a family history of early-onset ischaemic
heart disease.
Her glycaemic control is not satisfactory for
pregnancy, and although metformin can be
continued during pregnancy, empagliflozin
will need to be stopped and insulin therapy
commenced and titrated. She will need to increase
her blood glucose monitoring and recording of
results, preferably including dietary information.
Review with a dietitian, diabetes educator and
preferably an exercise physiologist is advisable.
She should be seen by a diabetes physician with
expertise in diabetes and pregnancy.
She has multiple vascular risk factors and is
at a higher risk of developing pre-eclampsia in
pregnancy. She should be appropriately counselled
regarding smoking cessation. The medication she
is on for hypertension needs to be changed and
the lipid management will need to be stopped
for pregnancy. As she has hypertension it would
be preferable that she is also seen by a renal or
obstetric medicine physician, especially if she
fails to achieve blood pressure targets or if she
has overt proteinuria. Given the multiple vascular
risk factors, she should have a pre-pregnancy
cardiac assessment.
56 Diabetes & Primary Care Australia Vol 2 No 2 2017

Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care
Advice
You advise Maria that she should stay on the
OCP for the time being and that preconception
planning is needed in view of her multiple medical
conditions and medications. If she still wishes to
become pregnant, she should commence highdose
folic acid and have routine pre-pregnancy
checks. If she conceives, her contraception choice
should be reviewed following the pregnancy as it
is not advisable for her to continue on the OCP
given her age and vascular risk status.
Case 2
Jennifer has come to see you for a referral letter to
her gynaecologist. She wants to have her intrauterine
contraceptive device (IUCD) removed as she is
keen to start a family. Jennifer is a 30-year-old
woman who has had type 1 diabetes for 21 years.
For the last 3 years, she has been using insulin
pump therapy. Jennifer’s most recent HbA 1c
of
70 mmol/mol (8.6%) was higher than usual after a
recent overseas holiday with her husband.
History
In her teens, Jennifer struggled with her diabetes
control but in the past 5 years has been managing
quite well. Her last episode of diabetic ketoacidosis
was 18 months ago when there was a problem with
insulin delivery through her pump. She has not
had severe hypoglycaemia (requiring the assistance
of another person) for 5 years and is using a
continuous glucose monitoring system (CGMS)
with predictive low-glucose suspend, as she knows
that she does not reliably sense hypoglycaemia.
Jennifer has diabetic retinopathy that has
previously required laser photocoagulation.
However, she has not had her eyes checked for
about 2 years as she missed an appointment and
did not find time to reschedule. She has overt
proteinuria (0.5 g per day) and is on ramipril for
nephroprotection. Her eGFR is 62 mL/min/1.73 m 2
and she has previously been assessed for other
causes of renal disease by a nephrologist. Her
blood pressure and lipids are normal. She has
a moderate degree of asymptomatic peripheral
neuropathy with loss of distal sensation to light
touch and vibration, as well as loss of ankle
reflexes. She senses a monofilament and has had
no diabetes-related foot complications.
Discussion
If conception is successful, this will be Jennifer’s
first pregnancy. As she is on insulin pump therapy
and uses a CGM device, she will already be under
a specialist diabetes team. Her glycaemic control
is sub-optimal and significantly increases her
risk of adverse pregnancy outcomes, including
miscarriage and congenital anomalies. Even
though the recommended HbA 1c
target for women
with type 1 diabetes in the preconception stage is
≤53 mmol/mol (7%), given her long duration
of type 1 diabetes and poor hypoglycaemic
awareness, it may not be safe to reduce her HbA 1c
below 58 mmol/mol (7.5%) due to the increasing
risk of severe hypoglycaemia at lower levels. She
needs specific specialist assessment and advice
regarding her HbA 1c
as well as review of all
aspects of her diabetes self-management (e.g. diet,
exercise, BGL testing and recording, insulin pump
settings review, pump management skills, driving
considerations, and hypoglycaemia and diabetic
ketoacidosis prevention and management).
Jennifer also needs an urgent diabetes eye
review. If there is active proliferative retinopathy or
macular oedema she will need to delay pregnancy
plans until the retinopathy has been treated and
is stable. As she has overt proteinuria, she should
be assessed pre-pregnancy by a renal or obstetric
medicine physician who will be able to continue
to manage her in pregnancy. Her risk of preeclampsia
and poor fetal outcomes, including
intrauterine growth restriction (IUGR), will be
increased. Although she is not known to have
autonomic neuropathy, she should be assessed for
this by her diabetes specialist.
Advice
You advise Jennifer to not have the IUCD
removed yet and that preconception planning is
needed in view of her complex diabetes situation
– especially her overall glycaemic control,
nephropathy and retinopathy. You also ask her
whether she has discussed pregnancy with her
endocrinologist and check the date of her next
scheduled appointment. Following diabetes
complications assessment and optimising
glycaemic management, Jennifer should
commence high-dose folic acid and have routine
pre-pregnancy checks.
”If a woman has
been diagnosed with
retinopathy, it is
important to ensure
it has been treated
and is stable prior to
pregnancy.”
Diabetes & Primary Care Australia Vol 2 No 2 2017 57

Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care
“Primary health
care providers have
critical roles to play
in the assessment
and management of
contraception,
pre-pregnancy
assessment
and care.”
Conclusion
Women of child-bearing age with pre-gestational
type 1 or type 2 diabetes need to be counselled
on the need for appropriate contraception at all
times unless trying for pregnancy in the best
possible circumstances to avoid adverse pregnancy
outcomes. Most women with pre-gestational
diabetes are able to have successful pregnancies.
However, they are at much higher risk of having
adverse pregnancy outcomes than women without
diabetes (Macintosh et al, 2006; Dunne et al,
2009). It has been shown that women who have
had optimal pre-pregnancy care and best practice
management of their diabetes, both before and
throughout pregnancy, will have a substantially
lower rate of adverse outcomes (Ray et al, 2001;
Wahabi et al, 2010).
Ideally, care should involve services that are
specialised in diabetes in pregnancy. However,
primary health care providers also have critical
roles to play in the assessment and management of
contraception, pre-pregnancy assessment and care,
coordination of specialist services and ongoing
support prior to, as well as throughout and
following, the pregnancy.
n
Acknowledgement
The author would like to acknowledge Melinda
Morrison for assistance with article editing and
referencing.
American Diabetes Association (2017) Standards of Medical Care in
Diabetes—2017. Diabetes Care 40(Suppl 1): S4–S5
Australian Institute of Health and Welfare (2010) Diabetes in
pregnancy: its impact on Australian women and their babies.
AIHW, Canberra, ACT
Dunne FP, Avalos G, Durkan M et al (2009) ATLANTIC DIP:
pregnancy outcome for women with pregestational diabetes
along the Irish Atlantic seaboard. Diabetes Care 32: 1205–6
Egan, AM, Murphy HR, Dunne FP (2015) The management of type 1
and type 2 diabetes in pregnancy. QJM: An International Journal
of Medicine 108: 923–7
Guerin A, Nisenbaum R, Ray JG (2007) Use of maternal GHb
concentration to estimate the risk of congenital anomalies in the
offspring of women with prepregnancy diabetes. Diabetes Care
30: 1920–5
Inkster ME, Fahey TP, Donnan PT et al (2006) Poor glycated
haemoglobin control and adverse pregnancy outcomes in type 1
and type 2 diabetes mellitus: Systematic review of observational
studies. BMC Pregnancy Childbirth 6: 30
Jensen DM, KorsholmL, Ovesen P et al (2009) Periconceptional A1C
and risk of serious adverse pregnancy outcome in 933 women
with type 1 diabetes. Diabetes Care 32: 1046–8
Kitzmiller JL, Wallerstein R, Correa A, Kwan S (2010) Preconception
care for women with diabetes and prevention of major congenital
malformations. Birth Defects Res A Clin Mol Teratol 88: 791–803
Macintosh MC, Fleming KM, Bailey JA et al (2006) Perinatal
mortality and congenital anomalies in babies of women with
type 1 or type 2 diabetes in England, Wales, and Northern
Ireland: population based study. BMJ 333: 177
Mahmud M, Mazza D (2010) Preconception care of women with
diabetes: a review of current guideline recommendations. BMC
Womens Health 10: 5
McElduff A, Cheung NW, McIntyre HD et al (2005) The Australasian
Diabetes in Pregnancy Society consensus guidelines for the
management of type 1 and type 2 diabetes in relation to
pregnancy. Med J Aust 183: 373–7
Nielsen LR, Ekbom P, Damm P et al (2004) HbA1c levels are
significantly lower in early and late pregnancy. Diabetes Care 27:
1200–1
Ray JG, O’Brien TE, Chan WS (2001) Preconception care and the risk
of congenital anomalies in the offspring of women with diabetes
mellitus: a meta-analysis. QJM 94: 435–44
Wahabi HA, Alzeidan RA, Bawazeer GA et al (2010), Preconception
care for diabetic women for improving maternal and fetal
outcomes: a systematic review and meta-analysis. BMC
Pregnancy Childbirth 10: 63
58 Diabetes & Primary Care Australia Vol 2 No 2 2017

Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care
Online CPD activity
Visit www.pcdsa.com.au/cpd to record your answers and gain a certificate of participation
Participants should read the preceding article before answering the multiple choice questions below. There is ONE correct answer to each question.
After submitting your answers online, you will be immediately notified of your score. A pass mark of 70% is required to obtain a certificate of
successful participation; however, it is possible to take the test a maximum of three times. A short explanation of the correct answer is provided.
Before accessing your certificate, you will be given the opportunity to evaluate the activity and reflect on the module, stating how you will use what
you have learnt in practice. The CPD centre keeps a record of your CPD activities and provides the option to add items to an action plan, which will
help you to collate evidence for your annual appraisal.
1. What percentage of pregnant women are
affected by pre-gestational diabetes?
Select ONE option only.
A. 0.1%
B. 1%
C. 2.5%
D. 5%
E. 10%
2. A woman with type 2 diabetes has an
HbA 1c
of 69 mmol/mol (8.5%) in early
pregnancy. Which ONE of the following
statements is NOT true?
A. She is at increased risk of miscarriage.
B. She is at increased risk of hypertension
in late pregnancy.
C. She is at increased risk of developing
retinopathy in pregnancy.
D. She will not have an increased risk of
pregnancy complications unless she is
obese.
E. It is safe for her to continue taking
metformin.
3. A 31-year-old woman with type 2 diabetes
has just found she is pregnant. She is
currently being treated with gliclazide and
metformin. Which of the following options
is most appropriate? Choose ONE option
only.
A. Stop gliclazide immediately
B. Continue gliclazide and metformin
initially
C. Check HbA 1c
D. Start self-monitoring of blood glucose
(finger-prick testing)
E. B, C and D
4. Attendance at diabetes-specific
preconception care has been associated
with which one of the following? Choose
ONE option only.
A. A reduction in congenital anomalies
B. A reduction in perinatal mortality
C. A reduction in first trimester HbA 1c
D. A, B and C
E. None of the above
5. Rachel has long-standing type 1
diabetes. Her most recent HbA 1c
is
70 mmol/mol (8.6%). She is keen to
conceive soon. Which of the following
statements is INCORRECT? Select ONE
option only.
A. She should avoid pregnancy until her
HbA 1c
is close to 53 mmol/mol (7%)
while still minimising hypoglycaemia
risk.
B. She should start taking folic acid 5 mg
daily at least 3 months before she starts
trying to conceive.
C. She should be referred to a specialist
diabetes and pregnancy unit to
optimise her diabetes management
prior to conceiving.
D. She should be advised to terminate the
pregnancy if she falls pregnant before
her HbA 1c
has improved as risk to her
and the fetus would be unacceptable.
E. She should delay pregnancy plans if
she has active retinopathy until it has
been treated.
6. A 43-year-old woman with type 2 diabetes
is currently 6 weeks pregnant. She has
a past medical history that includes
pernicious anaemia, hypertension
and hyperlipidaemia. Which of her
medications, if any, should she now STOP?
Choose ONE option only.
A. Metformin
B. Hydroxocobalamin 1 mg 3-monthly
C. Labetalol 200 mg twice daily
D. Simvastatin 20 mg daily
E. None of the above
7. Which of the following antidiabetes
agents, if any, are SAFE to prescribe for
a woman with type 2 diabetes planning
pregnancy? Choose ONE option only.
A. A sodium–glucose co-transporter 2
(SGLT2) inhibitor
B. A dipeptidyl peptidase-4 (DPP-4)
inhibitor
C. A glucagon-like peptide-1(GLP-1)
receptor agonist
D. Thiazolidinedione
E. Insulin
8. A 37-year-old woman with pre-gestational
type 2 diabetes is advised to monitor
her blood glucose levels as she has
recently commenced insulin to control
her diabetes. Which of the following
is the most appropriate to monitor her
glycaemia? Choose ONE option only.
A. HbA 1c
B. Self-monitoring of blood glucose
(finger-prick testing)
C. Fructosamine
D. Continuous blood glucose monitoring
E. A and B
9. Which of the following insulins does not
have regulatory approval for use during
pregnancy? Select ONE option only.
A. Insulin glulisine (Apidra ® )
B. Protaphane/Humulin NPH
C. Insulin detemir (Levemir ® )
D. Insulin aspart (Novorapid ® )
E. None of the above; they are all
approved for use in pregnancy
10. Ideally, what should the pre-pregnancy
HbA 1c
target for women with type 2
diabetes be? Choose ONE option only.
A.

2017 NATIONAL CONFERENCE
Saturday 6th May 2017 – Melbourne Convention and Exhibition Centre, Victoria, Australia
The conference has been specifically designed for all primary care health
professionals working in diabetes care to:
Advance their education and learning in the field of diabetes health care
Promote best practice standards and clinically effective care in the management of diabetes
Facilitate collaboration between health professionals to improve the quality of diabetes
primary care across Australia
6TH MAY 2017 CONFERENCE PROGRAM
The 2017 PCDSA national conference program will combine cutting edge scientific content with
practical clinical sessions, basing the education on much more than just knowing the guidelines.
The distinguished panel of speakers will share their specialised experience in an environment
conducive to optimal learning. The Speaking faculty include, amongst others:
Associate Professor
Neale Cohen
Director Clinical Diabetes
Baker Heart and
Diabetes Institute
“Diabetes management
and research in primary
care – key components
to improving outcomes”
Doctor Christel
Hendrieckx
Senior Research Fellow
The Australian Centre
for Behavioural Research
in Diabetes
“The emotional health of
people living with diabetes”
Ms Renza Scibilia
Manager - Type 1 Diabetes
and Consumer Voice
Diabetes Australia
“Engaging people with
diabetes, the diabetes
online community and
apps for diabetes”
Doctor Gautam
Vaddadi
Consultant Cardiologist
Alfred Health, Northern Health,
University of Melbourne
“The emerging importance
of cardiac failure diagnosis
and management in people
with type 2 diabetes”
For further information including the full 2017 program
and to register for the conference please visit:
www.eventful.com.au/pcdsa2017
If you have any questions regarding the conference,
please contact the Conference Secretariat;
Toll free telephone: 1800 898 499
Email: pcdsa@eventful.com.au
pcdsa.com.au

Article
Diabetes and bone health
Vidhya Jahagirdar, Neil J Gittoes
Diabetes and osteoporosis represent two major public health challenges. Osteoporosis
is characterised by decreased bone mineral density and micro-architectural changes of
the bone leading to increased risk of low trauma (fragility) fractures. Both diabetes and
osteoporosis are associated with significant morbidity, decreased quality of life and reduced
life expectancy. This article will explore the current literature on the inter-relationships
between diabetes and bone health, the impact on patients and the management strategies
that may be considered in primary care to minimise risk of diabetes-related bone disease
and improve outcomes.
Preface
Nick Forgione, General Practitioner, Trigg Health
Care Centre, Perth, WA
The connection between diabetes and
osteoporosis is often overlooked in the
busy management schedule of people
with diabetes. However, there is an accumulation
of evidence suggesting that type 2 diabetes may
be an independent risk factor for osteoporosis.
Despite the fact that bone mineral density
(BMD) is often higher in people with
type 2 diabetes compared to those without, it
is paradoxical that people with type 2 diabetes
have a higher risk of fracture. It is likely that the
explanation for this paradox is multifactorial,
including changes in trabecular bone,
microarchitectural changes in bone leading
to reduced bone strength and changes in the
material property of bone due to accumulation
of advanced glycation end products (AGEs).
Medications used in the management of diabetes
may also play a part.
Diabetes and osteoporosis represent
two major public health challenges.
Osteoporosis is characterised by
decreased bone mineral density (BMD) and
micro-architectural changes of the bone leading
to increased risk of low trauma or fragility
fractures that are sustained as a result of a fall
from standing height or less (Figure 1). Both
There is much that remains unclear about
people with diabetes-related osteoporosis.
Assessment of fracture risk must be approached
with caution as people with diabetes tend to
have a higher fracture risk for a given BMD
t-score compared to those without diabetes.
Also it is unclear whether antiresorptive agents
reduce fracture risk in type 2 diabetes to the
same extent as those without diabetes (Rubin et
al, 2013).
As the number of people with type 2 diabetes
increases and their life is extended through
improvements in management, ensuring early
detection and appropriate management of
osteoporosis in this population becomes another
priority for primary care management. Until
there is further clarification of whether or not
individuals with type 2 diabetes should be
screened and managed differently to the rest
of the population, it is important to at least
ensure that the current RACGP guidelines for
the detection and treatment of osteoporosis are
followed.
diabetes and osteoporosis are associated with
significant morbidity, decreased quality of life
and reduced life expectancy. In Australia, the
total number of adults with diabetes is projected
to rise to between 2 and 3 million by 2025
(Magliano et al, 2009). Osteoporosis is also
a condition that increases in prevalence with
ageing (Figure 2). Age-related bone loss and
Citation: Jahagirdar V, Gittoes NJ
(2016) Diabetes and bone health.
Diabetes & Primary Care Australia
2: 61–8
Article points
1. Diabetes and osteoporosis are
increasingly prevalent diseases.
2. Diabetes and its complications
influence important
determinants of bone strength
such as the material properties
of bone, bone density and
mineral content as well as
bone micro-architecture
and bone turnover.
3. Diabetes is an important
clinical risk factor for
osteoporosis and fracture,
and as clinicians it is
important to remember this
association when managing
people with diabetes.
Key words
– Bone
– Metabolic disorder
– Osteoporosis
Authors
Vidhya Jahagirdar is Specialty
Trainee Registrar in Diabetes,
Endocrinology and General
Internal Medicine; Neil Gittoes is
Consultant & Honorary Professor
of Endocrinology, Head, Centre
for Endocrinology, Diabetes and
Metabolism. Both are at the
Department of Endocrinology,
University Hospitals Birmingham
NHS Foundation Trust,
Birmingham, UK.
Diabetes & Primary Care Australia Vol 2 No 2 2017 61

Diabetes and bone health
Page points
1. The prevalence of osteoporosis
based on bone mass density
(BMD) is significantly lower in
type 2 diabetes compared to
age-matched controls.
2. Age, female gender,
glucocorticoid use and family
history are well-recognised risk
factors for osteoporosis and
osteoporotic fractures, but the
association between diabetes
and osteoporosis is tantalising,
but poorly understood.
3. As type 1 diabetes is usually
diagnosed in children, the early
and chronic alterations in bone
metabolism may result in lower
peak bone mass.
Figure 1. Osteoporosis is characterised by decreased
bone mineral density and micro-architectural changes
of the bone leading to increased risk of low trauma
fractures (Blausen Medical Communications, 2016).
post-menopausal physiological changes result in
an increased prevalence of osteoporosis from 2%
at 50 years to 25% at 80 years of age (NICE,
2012). One in two women and one in five men
sustain one or more osteoporotic fractures in their
lifetime. In 2012, there were 140 822 fractures
as a result of osteoporosis or osteopaenia in
Australians over the age of 55 years, with a total
cost of $2.75 billion. This is expected to increase to
around $3.84 billion by 2022 (Watts et al, 2013).
While age, female gender, glucocorticoid use
and family history are well-recognised risk factors
for osteoporosis and osteoporotic fractures, the
association between diabetes and osteoporosis
is tantalising, but poorly understood. Other
disease conditions associated with diabetes, such
as diabetic nephropathy, retinopathy, neuropathy
and obesity, as well as medication used in
the management of diabetes, may affect bone
health, increase risk of falls and predispose
patients to osteoporotic fractures. These factors
are confounders in attempting to delineate causal
links between diabetes and osteoporosis.
The aim of this article is to explore the current
literature on the inter-relationships between
diabetes and bone health, the impact on patients
and the management strategies that may be
considered in primary care to minimise risk
of diabetes-related bone disease and improve
outcomes.
Epidemiology of fractures in diabetes
The interaction between diabetes and osteoporosis
is poorly understood. Both type 1 and type 2
diabetes are associated with increased risk of
osteoporosis and fracture, and this risk is greater
in type 1 than type 2 (Vestergaard, 2007).
Various factors, such as type of diabetes, onset
and duration, metabolic control, BMI, BMD,
falls risk, diabetic complications and treatment,
may influence bone health in diabetes. There are
no well-designed randomised controlled trials
(RCTs) or carefully evaluated epidemiological
studies that have looked into all the above
factors as potential attributors to fracture risk in
diabetes.
Figure 2. Peak bone mass is reached at 30 years of age. Bone mass then decreases with age, more
so in women (Anatomy & Physiology, 2013).
Type 1 diabetes
BMD is lower in children and adolescents with
type 1 diabetes than children without diabetes.
As type 1 diabetes is usually diagnosed in
children, the early and chronic alterations in
bone metabolism may result in lower peak
bone mass. This may contribute to osteoporosis
and an increased risk of fracture in later life
(Bonjour and Chevalley, 2014).
According to a recent meta-analysis, type 1
diabetes is associated with three times increased
background risk of any fracture and the risk is
elevated in both men and women. In individuals
62 Diabetes & Primary Care Australia Vol 2 No 2 2017

Diabetes and bone health
Secondary causes
associated with diabetes
l Coeliac disease
l Graves thyrotoxicosis
l Hypothyroidism
l Hypogonadism
l Vitamin D deficiency
Anti-diabetes medication
l TZDs
l GLP-1 receptor agonists
l DPP-4 inhibitors
l SGLT2 inhibitors
Falls risk
l Diabetic retinopathy
l Diabetic neuropathy
l Obesity
l Hypoglycaemia
Decreased bone
turnover
CKD–MBD secondary to
diabetic nephropathy
Fracture risk
Abnormal bone architecture
Decreased bone mineral density
via collagen cross links
Decreased osteoblast differentiation
Osteoblast dysfunction
Increased osteoclast activity
Increased adipogenesis
Increased AGE
Increased PPAR-gamma
Decreased insulin/
IGF-1 secretion
Oxidative stress
Figure 3. The factors influencing bone health and fracture risk in diabetes. AGE=advanced glycation end-products; CKD–MBD=chronic kidney
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=
peroxisome proliferator-activated receptor-gamma; SGLT2=sodium–glucose cotransporter 2; TZD=thiazolidinedione.
with type 1 diabetes compared to people
without the condition, the relative risk (RR) for
hip fracture was 3.78 (95% confidence interval
[CI], 2.05–6.98; P

Diabetes and bone health
Page points
1. Insulin deficiency and reduced
insulin-like growth factor-1 have
been linked to the inhibition of
osteoblast differentiation and
osteopaenia in type 1 diabetes.
2. People with diabetes are at
increased risk of falls and this is
multifactorial due to advancing
age, diabetes complications,
hypoglycaemia and high BMI.
3. Cortical bone mass is reduced
in the feet and hands in severe
diabetic peripheral neuropathy
and may predispose to
metatarsal fracture and diabetic
Charcot’s osteoarthropathy.
Fracture risk has also been reported to be
independent of other usually reliable predictors
of fracture risk in type 2 diabetes, including age,
physical activity and BMI (RR 2.6 [95% CI],
1.5–4.5; Janghorbani et al, 2007).
How does diabetes affect bone?
Diabetes and its complications influence
important determinants of bone strength such
as the material properties of bone, bone density
and mineral content as well as bone microarchitecture
and bone turnover (Figure 3).
Oxidative stress
Diabetes is reported to affect bone metabolism
adversely through several mechanisms. Advanced
glycation end-products (AGE) are produced as
a result of oxidative stress in diabetes and are
important mediators of diabetic complications
such as diabetic retinopathy, nephropathy,
neuropathy and atherosclerosis (Goh and
Cooper, 2008). AGE accumulation in bones is
also detrimental and leads to abnormal structure
and alignment of collagen, contributing to bone
fragility (Katayama et al, 1996).
Insulin deficiency
Insulin has an anabolic effect on bone. Insulin
deficiency and reduced insulin-like growth
factor-1 (IGF-1) have been linked to inhibition
of osteoblast differentiation and osteopaenia
in type 1 diabetes (Kanazawa et al, 2011).
Treatment with insulin has been reported to
stabilise BMD (Hofbauer et al, 2007). Hence,
adequate optimisation of glycaemic control
with insulin in type 1 diabetes may prevent
osteopaenia and osteoporosis later in life.
Diabetic nephropathy and chronic kidney
disease (CKD)
Diabetic nephropathy often leads to CKD and
is the most common cause of end-stage renal
disease in Australia (Kidney Health Australia,
2015). The risk of developing moderate to severe
CKD (stages 3b, 4 and 5) is eight times greater
in women and twelve times greater in men with
type 1 diabetes than in people without diabetes
(Hippisley-Cox and Coupland, 2010). Similar to
diabetes and osteoporosis, the risk of developing
CKD increases with age.
Clinical expression of mineral and bone disorders
in CKD (CKD–MBD) is often asymptomatic
until late in its course. Abnormalities in
bone turnover and mineralisation can result
in osteitis fibrosa cystica (brown tumours;
Figure 4), adynamic bone disease, osteomalacia
and secondary hyperparathyroidism caused by
phosphate retention, decreased calcium and
1,25-dihydroxy(OH) vitamin D (calcitriol)
concentration, and uraemic osteodystrophy.
These conditions increase the risk of fractures due
to changes in bone quality. While abnormalities
in calcium and phosphate levels are detected
even at CKD stages 1 and 2, the clinical
significance of these abnormalities is unclear.
Hence, management is focussed on optimising
calcium and phosphate levels in CKD stages 3,
4 and 5.
Factors affecting falls risk
People with diabetes are at increased risk of falls
and this is multifactorial due to advancing age,
diabetes complications, hypoglycaemia and high
BMI (Figure 3).
Peripheral neuropathy
The ABC health study showed that individuals
with type 2 diabetes who develop fractures
are more likely to have peripheral neuropathy,
cerebrovascular disease and falls compared
with people with diabetes without fractures
(Strotmeyer et al, 2005). Cortical bone mass is
reduced in the feet and hands in severe diabetic
peripheral neuropathy and may predispose
to metatarsal fracture and diabetic Charcot’s
osteoarthropathy (Cundy et al, 1985), which can
cause foot deformity and gait disturbance, further
increasing fracture risk by increasing falls. People
with diabetic peripheral neuropathy are more
likely to fall when compared to age-matched
controls. While the underlying causative factors
are not entirely understood, reduced muscle
strength and stability (Handsaker et al, 2014)
and foot deformity are likely to be contributing
factors.
Retinopathy
The Blue Mountain Eye study showed that, in
64 Diabetes & Primary Care Australia Vol 2 No 2 2017

Diabetes and bone health
Page points
1. Individuals with diabetic
retinopathy or cataracts, or
both, with reduced visual acuity
are prone to falls.
2. Obesity is also associated with
decreased bioavailability of
vitamin D due to distribution in
the subcutaneous tissue leading
to vitamin D deficiency, another
risk factor for osteoporosis.
3. There is a high incidence of
fragility fracture in people who
experience hypoglycaemic
events.
Figure 4. Brown tumours of the hands in an individual with hyperparathyroidism (Gaillard, 2008).
people with diabetes, there was a significantly
increased risk of proximal humerus fracture
associated with diabetic retinopathy, cortical
cataract, longer diabetes duration (>10 years) and
insulin treatment (Ivers et al, 2001). Individuals
with diabetic retinopathy or cataracts, or both,
with reduced visual acuity are prone to falls. Thus,
the attendant increased risk of falls contributes to
greater risk of fracture.
Obesity
In total, 90% of people with type 2 diabetes are
overweight or obese. Obesity is commonly thought
to have a protective effect on bone as BMD tends
to increase with load bearing associated with
being overweight. In post-menopausal women,
obesity increased the risk of fractures at the
humerus and ankle while decreased the risk at
the hip, pelvis and wrist (Gonnelli et al, 2014).
Fewer data are available for men. The reasons for
site-specific fractures in obesity could be related
to fat padding protecting the hip and pelvis and
a tendency to fall backwards or sideways rather
than fall forward on outstretched arm leading
to wrist fracture. Obesity is also associated with
decreased bioavailability of vitamin D due to
distribution in the subcutaneous tissue leading
to vitamin D deficiency, another risk factor
for osteoporosis. Hence, in spite of increased
BMD, obesity is associated with increased risk
of fracture at particular sites, which is likely
to be due to the pattern of fall and vitamin D
deficiency.
Hypoglycaemia
There is a higher incidence of fragility fracture
in people who experience hypoglycaemic events
(Signorovitch et al, 2013). Intensive glycaemic
control (HbA 1c

Diabetes and bone health
Page points
1. Type 1 diabetes can be
associated with other
autoimmune conditions such as
coeliac disease, hypothyroidism
and Graves’ thyrotoxicosis,
which also increase this risk of
fracture and osteoporosis.
2. Hyperthyroidism and overtreated
hypothyroidism are
associated with lower bone
mineral density and increased
risk of fracture.
3. It is important to be aware
of the effect different antidiabetes
medication can have
on bone mineral density and
osteoporosis.
relationship between hypoglycaemia and
falls risk. It is intuitive, however, to speculate
that with frequent hypoglycaemic episodes
contributing to loss of consciousness, falls risk
would increase. Thus, hypoglycaemia-induced
falls with underlying low bone density in diabetes
would increase risk of fragility fracture.
Secondary causes for osteoporosis associated
with diabetes
Type 1 diabetes can be associated with other
autoimmune conditions such as coeliac disease,
hypothyroidism and Graves’ thyrotoxicosis.
About one-third of people with coeliac disease
have osteoporosis and may be at a higher risk of
fractures. Both hyperthyroidism and over-treated
hypothyroidism are associated with lower BMD
and increased risk of fracture (Mirza and Canalis,
2015). Hypogonadotrophic hypogonadism (low
gonadotropins and low testosterone) is found
in 25% of people with type 2 diabetes. Low
testosterone levels in men are associated with
low BMD and hypogonadism is a recognised
cause of osteoporosis, but there are no reliable
data available on fracture rates in people with
type 2 diabetes and hypogonadism (Dandona
and Dhindsa, 2011). Though epidemiological
observational studies have shown associations
between vitamin D deficiency and type 1 and
type 2 diabetes, the evidence is inconclusive
(Suzuki et al, 2006; Tahrani et al, 2010), as it
is for many associations between suboptimal
vitamin D and major health outcomes.
Anti-diabetes medication
Thiazolidinediones
Expression of peroxisome proliferator-activated
receptor-gamma (PPAR-gamma) is increased
in diabetes. This induces adipogenesis and
inhibits osteogenesis (Botolin and McCabe,
2006; Montagnani and Gonnelli, 2013).
Thiazolidinediones (pioglitazone and rosiglitazone)
are PPAR-gamma agonists. They improve insulin
sensitivity through their action on adipose tissue
and liver by increasing glucose utilisation and
decreasing glucose production. Thiazolidinediones,
through their action on PPAR-gamma, enhance
the effect of inhibiting osteoblast formation and
increase risk of fracture in type 2 diabetes.
Both pioglitazone and rosiglitazone are
associated with increased fractures in women
but not in men. A meta-analysis by Zhu et al
(2014) reported this risk as independent of age
and with no clear association with duration of
treatment. Thiazolidinedione use was associated
with significant changes in BMD and increased
fractures not only in the upper and lower limbs
but also at the lumbar spine and femoral neck
(Zhu et al, 2014). The benefit of improving
glycaemic control versus the risk of fracture
should be assessed carefully on an individual
case basis, especially in post-menopausal women,
before commencing treatment with pioglitazone
in type 2 diabetes.
Incretin-based medicines
Glucagon-like peptide 1 (GLP-1) agonists are
recommended in the management of obese people
with type 2 diabetes and their effect on the risk
of bone fractures is beginning to be established.
In a meta-analysis of RCTs, liraglutide was
associated with significantly reduced risk of
fracture and exenatide was associated with an
elevated risk of incident bone fractures (Su
et al, 2015). Protective effects of dipeptidyl
peptidase-4 (DPP-4) inhibitors on bone have
also been reported in a recent meta-analysis.
These data should be interpreted with caution as
the trials included in the meta-analysis were not
sufficiently long to assess fracture risk and the
effect on bone was not assessed as a primary endpoint
(Monami et al, 2011). The effects of DPP-4
inhibitors and GLP-1 agonists on bone health
need to be confirmed with well-designed RCTs.
Sodium–glucose cotransporter 2 (SGLT2)
inhibitors
In October 2015, the US Food and Drug
Administration (FDA; 2015) issued a warning
for the SGLT2 inhibitor canagliflozin relating to
increased risk of hip fractures and fractures of the
lower spine. More evidence is needed to ascertain
if this is a drug class effect.
Insulin
One large longitudinal study, using a German
database of over 100 000 people with type 2
diabetes in general practice found non-significant
66 Diabetes & Primary Care Australia Vol 2 No 2 2017

Diabetes and bone health
increase in risk of fracture in people on basal
insulin (glargine, insulin detemir and NPH
insulin) compared to oral hypoglycaemia agents
(Pscherer et al, 2016). This could possibly be
due to increased insulin-induced hypoglycaemiarelated
falls as discussed above, rather than direct
effect of insulin on the bone. In the absence of
RCT data at present, there is no clear evidence
to suggest that insulin increases the risk of
osteoporosis or fracture.
Management
There is no specific guideline for the management
of bone disorders in diabetes. Investigations and
treatment of osteoporosis should be based on
patients’ absolute risk of fracture taking into
consideration age, gender, menopausal status,
personal and family history of fractures, body
weight, falls risk, thiazolinediones use and
associated secondary causes of osteoporosis.
Fracture risk assessment based on FRAX,
Garvan or QFracture assessment tools can help
predict the risk of fracture. However, these may
under-estimate fracture risk in type 2 diabetes,
as paradoxically, BMD is often higher than in
those without diabetes, despite the increased risk
of fracture (Schwartz et al, 2011). Type 2 diabetes
is not an explicitly recognised risk factor included
in the risk assessment tool and BMD in type 2
diabetes can be normal or elevated in spite of
increased fracture risk. As BMD does not predict
fracture risk in renal osteodystrophy, it need not
be performed routinely in CKD stages 3–5 in
the presence of CKD-MBD (Kidney Disease:
Improving Global Outcomes [KDIGO] CKD-
MBD Work Group, 2009).
Bone mineral disorders in CKD can be identified
early by detecting decreasing serum calcium,
phosphate and vitamin D concentrations, and
increasing serum parathyroid hormone (PTH)
concentrations. The KDIGO clinical practice
guideline suggests monitoring for serum calcium,
phosphorus, 25-hydroxy vitamin D deficiency
and PTH routinely for CKD stages 3–5 with the
frequency of monitoring based on stage, rate of
progression and whether specific therapies have
been initiated (KDIGO CKD-MBD Work Group,
2009). PTH and bone alkaline phosphatase can
be used to evaluate CKD–MBD.
Anti-resorptive agents such as bisphosphonates
can be used as first-line agents to treat osteoporosis
and high fracture risk in diabetes and in CKD
stages 1, 2 and 3 (estimated glomerular filtration
rate [GFR] >30 mL/min/1.73 m 2 ) in the absence
of abnormal bone mineral markers. The effect of
drug treatment should be reviewed after 5 years
for alendronate and after 3 years for intravenous
zolendronic acid with a view to making a decision
regarding a drug holiday or continuing or switching
treatment. No studies have specifically looked at
optimal treatment for people with fractures where
thiazolidinediones have been implicated.
Screening for coeliac disease with tissue
transglutaminase antibodies (TTG) is
recommended at the time of diagnosis of type 1
diabetes and if a young adult with type 1 develops
intestinal or extra-intestinal symptoms consistent
with coeliac disease (NICE, 2009). Annual
screening for thyroid status is also recommended.
Screening for hypogonadism in people with type 2
diabetes and replacing with testosterone if found
deficient is also recommended (Dandona and
Dhindsa, 2011).
Good glycaemic control and blood pressure
control delays the progression of microvascular
complications, which are associated with increased
risk of falls and fracture. HbA 1c
targets should be
individualised and less stringent control (HbA 1c

Diabetes and bone health
“It is important,
where possible, to
ensure that messages
from different
clinicians pertaining
to lifestyle factors are
aligned and overlap as
much as possible.”
Conclusion
Diabetes and osteoporosis are increasingly
prevalent diseases. Diabetes is an important
clinical risk factor for osteoporosis and fracture,
and as clinicians it is important to remember this
association when managing people with diabetes.
Diabetes-related complications, hypoglycaemia
and obesity could increase the risk of falls
and fragility fracture. HbA 1c
targets should be
individualised taking into consideration age,
frailty, diabetes complications and falls risk.
While there is much to learn regarding the
associations between diabetes, osteoporosis
and fractures, it is important to recognise the
value of performing a multifactorial fracture
risk assessment, including falls risk. Tools are
available to conveniently assess this risk and
measurement of BMD by performing a DXA
scan may provide additional useful information
to help target those patients who are most
at risk of fracture with appropriate fracture
prevention drug therapies. The value of lifestyle
modification to address fracture and falls risk
cannot be underestimated. It is also convenient
that the lifestyle modifications required to
optimise bone health very much overlap with
the lifestyle guidance that is offered to optimise
the management of the underlying diabetes and
obesity. It is important, where possible, to ensure
that our messages to patients pertaining to
lifestyle factors are aligned and overlap as much
as possible, rather than conveying different sets
of instructions for different disease areas. This
is where diabetes and osteoporosis management
from a self-help perspective very much align. n
Acknowledgement
This article has been modified from one
previously published in Diabetes & Primary Care
(2016, 2: 68–74).
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68 Diabetes & Primary Care Australia Vol 2 No 2 2017

Article
Falls prevention in older adults
with diabetes: A clinical review of
screening, assessment and management
recommendations
Anna Chapman, Claudia Meyer
Older adults with diabetes have an increased rate of falls, recurrent falls and rate of
fracture following a fall. Falls can contribute to a heightened fear of further falling, social
isolation, avoidance of daily activities, and can increase the likelihood of premature
admission to residential aged-care facilities. The most common risk factors for falls within
this population group include peripheral neuropathy, foot complications, impaired postural
control, polypharmacy and insulin use, sub-optimal glycaemic control and hypoglycaemia,
as well as vision and cognitive impairment. Falls risk screening should be undertaken every
12 months for all older people with diabetes, followed by a more detailed falls assessment
for those deemed high risk to identify the contributory risk factors and management
strategies. Individualised strategies should be co-designed with individuals and where
appropriate, their carer(s), may involve referral to other health professionals, and should
be monitored and reviewed at regular intervals.
Falls are a complication of diabetes and
are being increasingly acknowledged
as impacting the overall health and
wellbeing of older adults (International Diabetes
Federation [IDF], 2013). Within the general
community-dwelling population of older adults,
approximately one in three people fall per
year (Moyer, 2012). The combination of age
(≥65 years) and diabetes increases the risk of
recurrent falls by 67% (Pijpers et al, 2012); and
older adults with diabetes are twice as likely to
have injurious falls (Roman de Mettelinge et al,
2013). At the individual level, falls can contribute
to a loss of confidence and reduced activity levels,
loss of lower-limb muscle and bone strength
(Karinkanta et al, 2010), and a heightened
fear of further falling (Zijlstra et al, 2007). For
the public health system, there are expanding
costs associated with falls-related hospitalisations
(Bradley, 2012).
Key to the prevention of falls is the identification
of at-risk individuals and the implementation of
appropriate interventions. Given the increased
prevalence and negative consequences associated
with falls among older adults with diabetes, falls
prevention should be considered an integral
component of diabetes care, and primary care
practitioners are well-placed to offer proactive,
comprehensive and individualised falls prevention
strategies. This article will assist primary care
practitioners in this role, providing an overview
of potential screening tools and outlining fallsrelated
risk factors pertinent to an older person
with diabetes. In addition, this paper will
consider the evidence and recommend actions
for older adults with diabetes, specifically for the
community-dwelling population (rather than the
hospital or residential aged-care setting).
Falls risk screening
Falls risk screening refers to the process of
identifying individuals who are at-risk of a fall,
to determine if a detailed falls assessment is
appropriate. To be effective, screening tools need
Citation: Chapman A, Meyer C
(2017) Falls prevention in older
adults with diabetes: A clinical
review of screening, assessment and
management recommendations.
Diabetes & Primary Care Australia
2: 69–74
Article points
1. Falls-related risk factors
for older people with
diabetes include peripheral
neuropathy, impaired postural
control, polypharmacy,
visual impairment,
cognitive impairment, foot
complications, and suboptimal
glycaemic control.
3. Valid and reliable risk screens
exist to identify individuals
at-risk of falls. As with all
older adults, individuals with
diabetes should be screened for
falls at least once every year.
4. Individuals at increased risk
of falls require a multifactorial
assessment that examines
the wide range of fallsrelated
risk factors.
5. Falls prevention interventions
should systematically address
the risk factors identified and
should be developed with the
older person with diabetes, and
where applicable their carer(s).
Key words
– Falls
– Older people
Authors
Author details are on page 74.
Diabetes & Primary Care Australia Vol 2 No 2 2017 69

Falls prevention in older adults with diabetes
Page points
1. Falls risk screening tools need
to be validated, quick and easy
to administer, cost-effective and
clinically relevant.
2. Falls risk screening should
be incorporated into routine
consultations, involving
assessment of an individual’s
falls history over the last
12 months together with
examination of balance and
mobility.
3. When classified as high risk,
individuals should undergo a
comprehensive falls assessment
in a timely manner to guide
appropriate and individualised
falls prevention strategies.
to be validated, quick and easy to administer,
cost-effective and clinically relevant. The
selection of a screening tool should complement
the setting (community, hospital or residential
aged-care) and the older adult being screened,
particularly with regard to age, ethnicity, as
well as cognitive and functional status.
The Global Guideline for Managing Older
People with Type 2 Diabetes recommends that
falls risk screening be performed during an
initial visit to a health care provider, reviewed
annually at a minimum and additionally
following a fall event (IDF, 2013). Falls
risk screening should be incorporated into
routine consultations, involving assessment
of an individual’s falls history over the last
12 months (frequency of falls, circumstances
surrounding each fall, and number of injurious
falls), together with examination of balance
and mobility. Table 1 provides a summary
of available tools and tests for use in the
primary care setting. As with any screening
procedure, all falls risk screening outcomes
should be documented and discussed with the
older person and their carer(s), and information
provided to individuals.
Falls risk assessment to identify fallsrisk
factors
Falls risk screening identifies individuals at
high risk of falls. When classified as such,
individuals should undergo a comprehensive
falls assessment in a timely manner to guide
appropriate and individualised falls prevention
strategies.
A recommended falls assessment tool can
be used to assess the overall risk of falls (as
summarised in Table 2). In addition, specific
assessment of individual factors known to
contribute to falls risk among older adults with
diabetes can be undertaken. It is important to
acknowledge, that although falls-related risk
factors are often referred to independently,
most falls occur as a result of the interaction
between intrinsic and extrinsic risk factors
(Tinetti et al, 1986). A description of the
specific risk factors that are primarily targeted
for further assessment with older adults with
diabetes are discussed below with assessment
and management recommendations provided
(Australian Commission on Safety and Quality
in Healthcare, 2009; American Geriatrics
Society and British Geriatrics Society, 2010).
Table 1. Summary of validated tools and tests recommended for screening of falls risk.
Falls risk screen Description Time to implement Scoring interpretation*
Balance and mobility tests
Timed Up and Go (TUG) test
(Podsiadlo and Richardson, 1991)
A measure of dynamic balance that assesses the time taken for an individual
to rise from a chair, walk 3 metres, turn around, walk back to the chair, and
sit down. Requires a stop-watch and a 43 cm-high straight-backed chair
with solid seat.
1–2 minutes
≥12 seconds is indicative of
an increased risk of falling.
Five Times Sit To Stand
(FTSTS) test
(Tiedemann et al, 2008)
A measure of lower-limb strength that assesses the time taken for an
individual to stand up and sit down as quickly as possible five times, with
their arms folded across their chest. Requires a stop-watch and a 43 cm-high
straight-backed chair with solid seat.
1–2 minutes
≥12 seconds is indicative of
an increased risk of falling.
Alternate Step Test (AST)
(Tiedemann et al, 2008)
A measure of lateral stability that involves weight shifting. An individual
is required to alternately place the right and left feet (no shoes) as fast as
possible on a step that is 18 cm high and 40 cm deep, for a total of eight
steps. A stop-watch is required.
1–2 minutes
≥10 seconds is indicative of
an increased risk of falling.
Multi-item screening tool
Falls Risk for Older People in the
Community (FROP-Com) Screen
(Russell et al, 2009)
A 3-item screening tool that addresses 12-month falls history, self-perceived
need for assistance to perform activities of daily living, and the objective
assessment of steadiness through the observation of an individual standing,
walking a few metres, turning and sitting.
Available at: http://bit.ly/2m6PXZX
1–2 minutes
Responses for each item are
scored from 0–3. A total
score between 0–3 indicates
low-risk. Scores between
4–9 indicate high-risk.
*Scoring criterion based on cut-off scores specified within best practice guidelines for falls prevention (Australian Commission on Safety and Quality in Healthcare, 2009).
Note: Above mentioned tools not specifically validated for older adults with diabetes.
70 Diabetes & Primary Care Australia Vol 2 No 2 2017

Falls prevention in older adults with diabetes
Table 2. Summary of recommended falls assessment tools.
Falls assessment tool Description Time to implement Scoring interpretation*
FallScreen © : Physiological
Profile Assessment
(Lord et al, 2003)
The short form is a validated five-item instrument that includes a single
assessment of vision, peripheral sensation, lower-limb strength, reaction
time and body sway. There is an associated cost for the purchase of the
tool.
Available at: http://bit.ly/2lYqPU7
15–20 minutes
≥1 is indicative of an
increased risk of falling.
FROP-Com
(Russell et al, 2008)
A detailed falls risk factor assessment tool that includes 26 items that
address 13 falls-related risk factors. The tool includes guidelines for
scoring, and evidence-based referrals and interventions. No equipment is
required and the tool is available at no cost.
Available at: http://bit.ly/2mFR8mD
10–15 minutes
Total score range is 0–60.
Scores >18 is indicative of
high risk.
QuickScreen ©
(Tiedemann et al, 2008)
A multifactorial falls assessment tool comprised of the following items:
previous falls, medication usage, vision, peripheral sensation, lower-limb
strength, balance and co-ordination. Minimal equipment is required. There
is an associated cost for the purchase of the tool.
Available at: http://bit.ly/2mlM7P5
10 minutes
≥4 is indicative of an
increased risk of falling.
*Scoring criterion based on cut-off scores specified within best practice guidelines for falls prevention (Australian Commission on Safety and Quality in Healthcare, 2009).
The above scores should be used for the purpose of assessment and re-assessment over time.
Note: Above mentioned tools not specifically validated for older adults with diabetes.
Peripheral neuropathy
The most common falls-related risk factor related
to diabetes is peripheral neuropathy, present
in approximately 50–70% of older adults with
diabetes (Kirkman et al, 2012). Peripheral
neuropathy results in changes to the motor
and/or sensory components of the foot and
ankle, potentially leading to postural instability,
foot complications, altered walking function
and muscle atrophy (Boulton, 2004; Palma et al,
2013; Brown et al, 2015). Clinical emphasis is
placed on the prevention of peripheral neuropathy
by means of optimal glycaemic control, as well as
the early recognition of the condition (Royal
Australian College of General Practitioners
[RACGP], 2016). Peripheral neuropathy should
be assessed annually using either the Diabetic
Neuropathy Symptom (DNS) score (Meijer
et al, 2002) and/or routine sensory tests (i.e.
a 10-g monofilament and palpating foot).
Postural instability
An increase in postural instability is a risk factor
for falls (Ganz et al, 2007; Drootin, 2011), which
is particularly important for people with diabetes
who experience a decrease in the functioning of
the neuromuscular and sensorimotor systems
(Crews et al, 2013). Control of balance to
maintain postural stability involves a complex
interplay of the sensory and motor systems and
integration of, and reaction to, this information
by the central nervous system.
In the primary care setting, the assessment
of postural stability can be easily performed
by balance and mobility tests (e.g. Table 1).
To address postural instability, falls prevention
exercise programs are encouraged (Australian
Commission on Safety and Quality in Healthcare,
2009; Gillespie et al, 2012). Exercise interventions
have recently been found to be effective for older
adults with diabetes with regard to lower-limb
strength, static balance and gait measures
(outcomes vital in the maintenance of postural
stability; Chapman et al, 2016). In particular,
individuals are likely to benefit from exercise
programs that incorporate a challenge to balance,
when delivered with sufficient frequency (e.g. total
of 50 hours, preferably at least 2 hours per week).
It should also be noted that walking programs,
although beneficial for metabolic control and
improvement of cardiovascular disease risk, have
been associated with an increased risk of falls
(Sherrington et al, 2011). Exercise programs
should be tailored to existing levels of fitness
and should consider an individual’s lifestyle
and any medical contraindications. Referral
to an appropriate health professional (e.g. a
physiotherapist or exercise physiologist) may be
Diabetes & Primary Care Australia Vol 2 No 2 2017 71

Falls prevention in older adults with diabetes
Page points
1. Foot complications, including
foot pain, foot ulceration and
consequent amputations, are
common among older adults
with diabetes and are significant
contributors to increased falls
risk.
2. Falls risk among adults with
diabetes has been found to
increase steadily at four or more
prescription medications.
3. It is important that primary care
practitioners comprehend the
overall medication burden as
it has the potential to lead to
medication-related problems
including non-adherence,
hypoglycaemia and increased
risk of falls.
warranted for a detailed assessment of balance,
and the design of challenging, yet safe exercise
programs (Australian Commission on Safety
and Quality in Healthcare, 2009).
Foot complications
Foot complications, including foot pain, foot
ulceration and consequent amputations, are
common among older adults with diabetes and
are significant contributors to increased falls
risk (Al-Rubeaan et al, 2015). In brief, foot-care
education should be provided to all people
with diabetes to assist in the prevention of foot
complications. Education should consist of basic
foot-care recommendations and, of particular
relevance to falls, advice regarding appropriate
footwear. Screening and risk stratification for
potential foot complications should also be
performed for all adults with diabetes, with the
intensity of monitoring and review dependent
on the associated level of risk. For individuals
classified as being at intermediate or high risk,
a podiatry assessment is an integral component
of a foot protection program (Menz et al, 2006;
R ACGP, 2016).
Diabetes-related foot ulcers deserve specific
mention when considering falls risk. Offloading
footwear is a common recommendation for
foot ulcers, yet it has a negative effect on
postural stability (van Deursen, 2008). In
particular, total contact casts and removable
or non-removable cast-walkers are problematic
for falls. Given their rigid nature, they do not
allow the foot to make its usual adjustments on
uneven terrain.
Sub-optimal glycaemic control
and hypoglycaemia
Hypoglycaemia, hypoglycaemic unawareness
and severe hyperglycaemia are well-established
risk factors for falls among older adults with
diabetes (Jafari and Britton, 2015; Sinclair et
al, 2015). Optimising an individual’s glycaemic
control can reduce short- and long-term
complications of diabetes, and can improve
quality of life, and functional and cognitive
ability. However, the potential harmful effects
of hypoglycaemia should be considered when
setting individual glycaemic targets. Targets
need be personalised and balanced against
factors such as an individual’s capabilities,
life expectancy, medical comorbidities, and
the potential risk of severe hypoglycaemia,
especially among frail, older adults with an
increased risk of falls (RACGP, 2016). For older
adults with diabetes who have a life expectancy
>10 years and are functionally independent and
fit, an HbA 1c
target of 53 mmol/mol (7.0%) is
often appropriate. However, less stringent HbA 1c
targets (i.e. 64 mmol/mol [8%]) are appropriate
for those with long-standing diabetes, a
history of severe hypoglycaemia, limited life
expectancy, advanced complications, and/or
extensive comorbid conditions (RACGP, 2016).
Medication and polypharmacy
Older adults with diabetes are often required
to take multiple medications in an effort to
control diabetes-related outcomes and other
comorbidities, and a significant proportion of
individuals take upwards of eight medications
(RACGP, 2016). Falls risk among adults with
diabetes has been found to increase steadily at
four or more prescription medications (Huang
et al, 2010). Falls risk can be heightened as a
result of medication interaction, medication
side effects (e.g. dizziness) and even the intended
effects of medications (e.g. glucose-lowering
leading to hypoglycaemia). Certain classes of
medication are more likely to increase the risk
of falls, and those commonly implicated in falls
related to older people with diabetes include
insulin, psychoactive medications (in particular
benzodiazepines), diuretics, antiarrhythmics
(class 1a), digoxin, and antidepressants (Berlie
and Garwood, 2010; Huang et al, 2010).
It is important that primary care practitioners
comprehend the overall medication burden
as it has the potential to lead to medicationrelated
problems including non-adherence,
hypoglycaemia and increased risk of falls.
Medication use (both conventional and
complementary), should be reviewed at least
once per year as part of the annual cycle of
care (RACGP, 2016). Referral for a Home
Medicines Review has the potential to identify
medications implicated in falls and consider the
ongoing need for these medications.
72 Diabetes & Primary Care Australia Vol 2 No 2 2017

Falls prevention in older adults with diabetes
Vision impairment
Vision impairment is an important risk factor
for falls in community-dwelling older adults,
with vision being a key sensory input for the
maintenance of balance and the avoidance of
obstacles. Diabetic retinopathy, occurring as
a result of microvascular disease of the retina,
causes visual impairment and blindness, and
affects more than 30% of adults with diabetes
(Dirani, 2013).
All older adults with diabetes should have a
visual acuity assessment at diagnosis, and at least
every 2 years (more frequently if vision noted to
have concerns). Primary care practitioners can
monitor individuals for retinopathy via retinal
photography or by examining the eyes through
dilated pupils. If practitioners are not confident
with fundoscopy and assessment of the retina,
referral to an eye specialist is recommended.
Older people may additionally benefit from an
assessment by an eye specialist for the provision
of appropriate spectacle correction (RACGP,
2016). The use of bifocal or multifocal lenses
by older people in the community is associated
with a doubled risk of falls as a result of
tripping. Individuals with an increased risk of
falls or established falls history are, therefore,
recommended to wear single-vision distance
spectacles when walking and negotiating steps
(Australian Commission on Safety and Quality
in Healthcare, 2009; Haran et al, 2010). Other
effective fall prevention strategies for vision
include maximising vision through cataract
surgery on the first eye (Lord et al, 2010).
Cognition
Cognitive impairment is a risk factor for falls,
with 50–80% of people with dementia falling
in a given year (Allan et al, 2009), and mild
cognitive impairment linked to greater risk of
injurious and multiple falls (Delbaere et al, 2012).
There appears to be a crucial link between the
decline of cognition and the use of executive
functioning for the purposes of balance, with this
decline evident in decreasing ability to control and
integrate cognitive abilities related to attention
and perception (Liu-Ambrose et al, 2008). People
with cognitive impairment may have difficulty
with planning and executing movements related
to balance and mobility, and may have difficulty
limiting sensory input which affects attention to a
task (e.g. walking while talking; Liu-Ambrose et
al, 2008). Medication use in people with cognitive
impairment also impacts falls risk, particularly
psychotropic medications that may magnify side
effects of other medications (Hill and Wee, 2012).
There is no specific literature relating falls,
diabetes and cognitive impairment. There
is, however, an emerging body of evidence for
effective falls prevention strategies for people with
dementia (Drootin, 2011), with studies showing
“traditional” falls prevention programs to be
unsuccessful with people with dementia (Shaw
et al, 2003). However, a different approach to
adoption of falls prevention strategies may be
beneficial with elements of health professional
involvement, inclusion of the caregiving dyad
and accommodation of individual needs and
preferences likely to be important (Meyer et al,
2013).
Built environment
Environmental hazards are considered a risk for
falls: clutter can be a tripping hazard; lighting
should be sufficient in order to prevent shadows;
flooring should be clear of rugs and provide a
contrast to furniture; and bathroom setup needs
to prevent slippage on wet surfaces, with grab
rails provided as needed. Home safety assessment
and modification interventions are effective in
decreasing falls risk and rates, especially for
people with severe visual impairment, which is of
relevance to the person with diabetes (Gillespie et
al, 2012).
Adaptation and modification of the environment
with an occupational therapist who is trained
to identify and maximise the benefits of the
person–environment fit is the crucial factor in
reducing risk (Clemson et al, 2014). Shared
decision-making processes with the person with
diabetes, and with their carer(s) if appropriate, will
most likely enhance the uptake of environmental
modifications.
Conclusion
Reducing the number of falls among older adults
with diabetes is dependent upon the identification
of at-risk individuals and the coordination of
Page points
1. Vision impairment is an
important risk factor for falls
in community-dwelling older
adults, with vision being a
key sensory input for the
maintenance of balance and the
avoidance of obstacles.
2. There appears to be a crucial
link between the decline
of cognition and the use of
executive functioning for the
purposes of balance.
3. Environmental hazards are
considered a risk for falls, and
efforts should be made to avoid
them where possible.
Diabetes & Primary Care Australia Vol 2 No 2 2017 73

Falls prevention in older adults with diabetes
“All primary care
practitioners should
have access to
education about
falls prevention, and
every attempt should
be made to provide
comprehensive
and individualised
education about falls
to older adults with
diabetes and where
appropriate, their
caregivers and family.”
Authors
Anna Chapman, Research Fellow,
School of Primary Health Care,
Monash University, Melbourne, Vic;
Claudia Meyer, Research Fellow,
Centre for Health Communication,
School of Public Health and Human
Biosciences, La Trobe University,
Melbourne, Vic. Both are at the
RDNS Institute, St Kilda, Vic.
appropriate preventive strategies. A diagnosis
of diabetes in an older adult should trigger to
primary care practitioners the potential for
increased falls risk. Systems need to be established
in the diabetes care pathway to enable falls
risk screening to be performed annually. All
primary care practitioners should have access
to education about falls prevention, and every
attempt should be made to provide comprehensive
and individualised education about falls to older
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74 Diabetes & Primary Care Australia Vol 2 No 2 2017

Article
The effect of diabetes on the skin
before and after ulceration
Lesley Weaving, Roy Rasalam
Diabetes affects the skin in many different ways at a microcirculatory level, making it
more prone to injury and ulceration. These changes not only have an impact on healing
but also on the resulting scar tissue, which is not as strong as the skin was prior to injury.
Eight-five percent of amputations are preceded by ulceration, with re-ulceration rates
reported to be as high as 70% after 5 years. This article looks at the changes that occur
in the skin of people with diabetes and the importance of skin care before and after
ulceration.
A
history of ulceration is considered
to be a significant risk factor for
re-ulceration, and as such, people
with diabetes are classed as high risk if they
have a history of foot ulceration (National
Institute for Health and Care Excellence,
2015). Australia’s amputation rate as a result
of diabetes appears to have increased in the
last decade and is a major contributor to the
national burden of condition (Lazzarini et al,
2012). Eighty-five per cent of amputations are
preceded by ulcers (International Diabetes
Federation, 2016); therefore, the prevention of
re-ulceration is an important consideration in
reducing amputation rates. Varying rates of reulceration
have been reported in the literature,
but the rate of re-ulceration is known to
increase over time from initial ulceration;
Miller et al (2014) reported 34% re-ulceration
at 1 year, 61% at 3 years and 70% at 5 years.
A critical triad of neuropathy, minor foot
trauma and foot deformity is present in >63%
of patients’ causal pathways to foot ulceration
(Reiber et al, 1999). There are many reasons
that determine whether people with diabetes
develop ulcers, including their vascular
status, nutritional status and compliance with
preventative therapies, such as custom-made
shoes or insoles (Miller et al, 2014). Despite
these interventions, one study has reported a
30% re-ulceration rate over a 2-year period,
during which individuals received regular
podiatric review (Westphal et al, 2011). With
this in mind, do we need to consider other
factors, such as the health of the skin? What is
the effect of ulceration on the skin during and
after healing, and does it play a role in the risk
of re-ulceration?
The skin
The skin is the largest organ of the body.
Its main functions are to act as a barrier
to substances entering the body and in the
prevention of moisture loss. It helps to regulate
temperature and provides sensory information
(e.g. pain, touch and temperature). It has
three layers: the epidermis, the dermis and a
fat (subcutaneous) layer (see Figure 1). The
epidermis is the thin outer layer, made of five
layers. The outermost layer is the stratum
corneum, which consists of dead cells and is the
major barrier to chemical and bacterial transfer
through the skin. The epidermis is thicker on
the plantar aspect of the foot and is relatively
waterproof. The second layer of the skin is the
dermis, which contains nerve endings, sweat
glands, oil (sebaceous) glands, hair follicles
and blood vessels. It consists of a thick layer
of fibrous and elastic tissue, giving the skin its
flexibility and strength. Below the dermis is a
Citation: Weaving L,
Rasalam R (2017) The effect
of diabetes on the skin before
and after ulceration. Diabetes &
Primary Care Australia 2: 75–9
Article points
1. People with diabetes
are more prone to skin
injury and ulceration.
2. Diabetes impairs the
skin’s ability to heal.
3. Scar tissue is not as strong as
the tissue was before injury.
4. Skin should be kept in the
best condition possible to
prevent re-ulceration.
Key words
– Healing
– Re-ulceration
– Scar tissue
– Skin
Authors
Lesley Weaving is diabetes
specialist podiatrist, Leicestershire
Partnership Trust, Coalville
Community Hospital, Coalville,
Leicestershire, UK; Roy Rasalam
is Director of Clinical Studies,
College of Medicine, James Cook
University, Qld, Australia.
Diabetes & Primary Care Australia Vol 2 No 2 2017 75

The effect of diabetes on the skin before and after ulceration
80% of the tensile strength of normal skin
(Ousey, 2009). Many factors play a role in
how closely the healed skin resembles the
original uninjured tissue, including the size,
depth and location of the wound, as well as
the nutritional status and overall health of the
individual (Teller and White, 2009).
Figure 1. Cross-section through the skin.
Page points
1. Skin conditions, such as
infection, xerosis and
psoriasis, are common in
people with diabetes.
2. Regular moisturising of dry skin
is recommended as part of a
routine foot care regimen.
3. Scar tissue is not as strong
as the original uninjured
tissue and so is at increased
risk of damage.
subcutaneous layer of fat that helps insulate the
body from heat and cold, provides protective
padding and serves as an energy store (Health
and Safety Executive, 2016).
The healing process
When the skin is damaged, a complex healing
process takes place that can be divided
into four phases (Box 1). The final stage
of healing, maturation, lasts from 21 days
to 2 years. During this process, epithelial
cells reduce the size of the wound. This is
followed by re-organisation of the collagen
by macrophages to form a scar (Brown, 2015).
In healthy individuals, the resulting scar
tissue formed after injury has approximately
Box 1. The wound healing process.
l Vascular response (haemostasis): injured
vessels constrict, a clot forms consisting
of a fibrin mesh that forms a scab, and
vasodilation of the vessels commences.
l Inflammation: occurs in acute wounds
3–5 days after injury and is prolonged in
chronic wounds.
l Proliferation: collagen fibres form to
replace lost tissue.
l Maturation: in healthy individuals, this
stage commences 21 days after injury.
Scarring develops, and the new tissue is
avascular and contains no hair, sebaceous
or sweat glands.
The effect of diabetes on skin healing
Diabetes can affect the skin in different
ways. Autonomic neuropathy is a common
complication of diabetes leading to dry
skin, loss of sweating and the subsequent
development of fissures and cracks that break
the skin barrier, allowing microorganisms to
enter (Vinik et al, 2003).
It is now understood that a complex
relationship exists between sensory
nerve function and vascular response in
type 2 diabetes. Dermal neurovascular
function is regulated by peripheral
C fibre neurons, which are damaged in
diabetic neuropathy. This results in an
imbalance between vasodilators (nitric
oxide, substance P, and calcitonin generelated
peptide) and vasoconstrictors
(angiotensin II and endothelin). This
dysregulation leads to decreased pain and
warm thermal perception, leaving skin
vulnerable to heat and tissue injury (Vinik et
al, 2001).
It has also been demonstrated that there is
a reduced oxygen supply within the tissue of
people with diabetes, which is accentuated
in the presence of neuropathy (Greenman
et al, 2005). Other skin conditions are also
commonly seen in people with diabetes,
the prevalences of which are reported to be
between 30% and 91.2% (Demirseren et al,
2014). The most frequently reported skin
condition in people with diabetes is cutaneous
infection (mainly fungal), followed by xerosis
(dry skin) and inflammatory skin diseases
such as psoriasis (Figure 2). These conditions
are more common in people with diabetes
who have nephropathy than in those without
nephropathy, and those who have an HbA 1c
of >64 mmol/mol (8%) are at the greatest risk
(Demirseren et al, 2014).
76 Diabetes & Primary Care Australia Vol 2 No 2 2017

The effect of diabetes on the skin before and after ulceration
Figure 2. Psoriasis is one of the most common skin
conditions experienced by people with diabetes.
Vascular endothelial cells line the entire
circulatory system, from the heart to
capillaries. These cells are important for
vascular biology and become impaired not only
with age but also as a result of hyperglycaemia,
which results in the impairment of blood flow
to the tissues (Petrofsky, 2011). When pressure
is applied to healthy skin, the affected tissue
can become hypoxic; once the pressure is
released there is reactive hyperaemia (increase
in blood flow) to oxygenate the tissue. Vascular
endothelial dysfunction can diminish this
response. It has also been demonstrated that
in a standing position, the average person still
has circulation in the skin but in people with
diabetes (even those with normal weight) there
is occlusion to the skin (McLellan et al, 2009).
This occlusion, together with reduced or no
post-occlusive hyperaemia, may be the reason
that feet are so susceptible to wounds and
skin injury, particularly in people with type 2
diabetes (Petrofsky, 2011).
Emollients
Regular moisturising of dry skin is
recommended as part of a routine foot care
regimen to reduce the risk of cracking and
ulceration. What is not always clear is which
emollient to use. There is little evidence
available as to the most effective emollient,
not only for the general population, but also
for people with diabetes. A moisturiser that
the patient is willing or happy to use that
is supported by the available evidence is
preferable. The clinician should also check
that the patient likes the smell, texture and
absorption of the cream before recommending
or prescribing one. There is some evidence
that high-concentration, urea-based emollients
are beneficial, and these have been shown to
improve dryness on the feet of people with
diabetes (Bristow, 2013).
For twice-a-day application, it is
recommended that an emollient is applied just
before getting into bed. Covering the foot with
a damp undersock and then a dry oversock may
enhance the effect of the emollient (Bristow,
2013). For once-a-day application, the cream
should form part of a patient’s daily regimen
of washing, drying and checking their feet
thoroughly. It is recommended that emollients
be used to lubricate the skin, but not between
the toes (International Working Group on
the Diabetic Foot, 2015). A pump dispenser
is considered by some clinicians a more userfriendly
way of delivering the right amount of
emollient than a tub and also decreases the risk
of contamination (Carr et al, 2008), although
tubes are also commonly used.
Silicones
Once skin has healed, silicone gel has been
proven to be effective in scar-tissue management
on non-weight-bearing areas; however there
is little evidence to support its use on weightbearing
areas (Westphal et al, 2011). Figure 3
and Figure 4 demonstrate that silicone gel may
be useful in protecting newly healed skin
during the maturation process. A person with
type 2 diabetes who suffered from psoriasis
had developed ulceration and subsequent
osteomyelitis at the base of the fifth metatarsal
Page points
1. Regular moisturising of dry
skin is recommended as
part of a routine foot-care
regimen to reduce the risk
of cracking and ulceration.
2. Once skin has healed,
silicone gel has been proven
to be effective in scar-tissue
management on non-weightbearing
areas; however there
is little evidence to support its
use on weight-bearing areas.
Diabetes & Primary Care Australia Vol 2 No 2 2017 77

The effect of diabetes on the skin before and after ulceration
Page points
1. There are many factors
affecting a person’s skin
when they have diabetes.
2. From available evidence, the
healing of a diabetic foot ulcer
should not be considered
the end result of a patient’s
journey, but the beginning of
a process to remain healed.
3. Further research is required
on the most-effective
way to care for the skin of
people with diabetes.
head, which had healed well with the use of
a removable cast device. However, once they
returned to wearing their bespoke shoes with
total contact insole, the skin re-ulcerated
(Figure 3). Silicone sheeting was used to protect
the area once epithelisation was achieved and for
8 weeks afterwards, and no further ulceration
occurred during this time (Figure 4). This
suggests that the silicone sheeting provided
some protection to the newly healed skin during
the early stages of the maturation process
(Weaving, 2014). However, a pilot study of
30 people with diabetes found that silicone gel
sheeting did not reduce the risk of ulceration
(Westphal, 2011).
Why it’s important to keep the
skin healthy
There are many factors affecting a person’s skin
when they have diabetes. These factors can lead
to ulceration and contribute to delayed healing.
Poor glycaemic control of diabetes has been
shown to affect the microcirculation, along
with poor oxygen supply, occlusion in the skin
during weight bearing, changes to the vascular
endothelial cells, dry skin and reduction in
elasticity all putting the skin at greater risk
of injury. This is further complicated by the
reduced strength of the scar tissue that forms
after the ulcer has healed.
Eighty per cent of ulcers are caused by some
form of trauma and are, therefore, considered
to be preventable (Healy et al, 2013). While
custom-made footwear is used to prevent
re-ulceration, it appears to be most effective for
those with foot deformity (Reiber et al, 2002).
Not every insole or shoe is a perfect fit to each
patient’s foot (Miller et al, 2014). It is therefore
important that the skin on the foot is kept in the
best condition it can be to cope with the stresses
placed upon it, whether it is from shoe wear or
simple day-to-day weight-bearing activities.
Conclusion
There is little evidence on how best to look
after the skin of people with diabetes. From
the available evidence, the healing of a diabetic
foot ulcer should not be considered the end
result of a patient’s journey, but the beginning
Figure 3. A patient with type 2 diabetes and psoriasis
experienced re-ulceration after changing from a
removable cast device back to their bespoke shoes.
Figure 4. The patient continued to use silicone sheeting
for 8 weeks after the ulcer had healed, which prevented
re-ulceration.
of a process to remain “healed”. We want
patients to be active and keep mobile to
help with their overall health and wellbeing;
however, the impact of diabetes on their skin
makes them vulnerable to skin breakdown,
particularly where there is scar tissue from
previous ulceration. Further research is
required on the most-effective way to care
for the skin of people with diabetes not just
when dry, but also post-healing during the
maturation process when the stresses and
strains of simple weight bearing could lead
to re-ulceration and, subsequently, potential
78 Diabetes & Primary Care Australia Vol 2 No 2 2017

The effect of diabetes on the skin before and after ulceration
loss of a limb. This is a worthwhile endeavour
when we consider that every 30 seconds a
lower limb is lost somewhere in the world as a
consequence of diabetes (Boulton et al, 2005).
n
Acknowledgement
This article has been modified from one
previously published in The Diabetic Foot Journal
(2016, 3: 142–8).
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Diabetes & Primary Care Australia Vol 2 No 2 2017 79

The PCDSA is a multidisciplinary society with the aim
of supporting primary health care professionals to deliver
high quality, clinically effective care in order to improve
the lives of people with diabetes.
The PCDSA will
Share best practice in delivering quality diabetes care.
Provide high-quality education tailored to health professional needs.
Promote and participate in high quality research in diabetes.
Disseminate up-to-date, evidence-based information to health
professionals.
Form partnerships and collaborate with other diabetes related,
high level professional organisations committed to the care of
people with diabetes.
Promote co-ordinated and timely interdisciplinary care.
Membership of the PCDSA is free and members get access to a quarterly
online journal and continuing professional development activities. Our first
annual conference will feature internationally and nationally regarded experts
in the field of diabetes.
To register, visit our website:
www.pcdsa.com.au