Screening for diabetes complications 23 December 2022 Diabetes complications are preventable, but complicated. Throw in the degree of progression of the condition and social, cultural and psychological determinants of health issues, including living in remote and rural regions, dealing with housing stress, and food insecurity, and the risk of diabetes complications significantly increases. Complications are fundamentally driven by sustained higher blood glucose levels, which can damage the blood vessels and nerves. However there are so many factors affecting a person’s abiltity to manage their blood glucose levels into their safe range, from health literacy, social and emotional wellbeing, to how the systems, including the health system, do or don’t work for them. This article aims to summarise some of the more common diabetes complication checks and balances, that are required for a person living with diabetes. However this summary is not exhaustive, as anywhere the blood flows through, and to, with sustained high glucose levels, can be damaged. The end, or the start of a year, can be a good time to remind and or support people living with diabetes to have, question and or plan their necessary checks and balances to prevent diabetes complications. These checks can be referred to as the Annual Cycle of Care (ACC) and include: Blood Glucose (HbA1c) check: Every 3 months – yearly Emotional wellbeing check-in: Every visit Kidney check: Yearly Blood fats check: Yearly Blood pressure check: 6 monthly Eye check: Every 2 years Foot check: 6 monthly Medication review: Yearly Dietary intake check: At least yearly Physical activity check: At least yearly Smoking status check: Every visit if applicable Blood Glucose (HbA1c) check – Every 3 months – yearly The HbA1c is an important blood glucose test that forms part of the ACC. Glycosylated Haemoglobin is abbreviated to HbA1c and is a check that usually involves taking blood from a vein in the arm. However a point-of-care test (POCT) can be performed using machines that analyse a drop of blood from a finger prick. The HbA1c reflects the average blood glucose level over the last 10-12 weeks and it is recommended that Aboriginal and Torres Strait islander people living with diabetes have this test every three months unless their GP suggests otherwise. At the very least is should be performed every 12 months as part of the diabetes ACC. The HbA1c develops when haemoglobin, a protein within red blood cells that carries oxygen throughout the body, joins with glucose in the blood, becoming ‘glycated’. For people living with diabetes this is important because the higher the HbA1c, the greater risk of developing diabetes-related complications. Red blood cells survive in the body for 8-12 weeks before they are renewed. This is the reason HbA1c tests are done at a minimum of three months apart. The results of an HbA1c test are shown in two ways on the pathology report. They are expressed as a percentage (%) or as a value in mmol/mol. Mmol/mol has been added to pathology results because it is the international way of measuring HbA1c. Goal for HbA1c for people living with diabetes is: 7% or 53 mmol/mol or less Emotional wellbeing – Every visit Emotional wellbeing is an important cornerstone of diabetes management. Diabetes distress, feelings of overwhelm, anxiety, trauma and depression can greatly impact the ability to manage diabetes, and engage in behaviours that help prevent complications. Emotional wellbeing check-ins should occur regularly throughout the year and referrals made to social and emotional wellbeing support workers, counsellors or psychologist where needed. Other supports can include caring peers or peer support groups such as the online Diabetes Australia – NSW&ACT ‘Diabetes Yarning Group’. Kidney check: Albumin to Creatinine Ratio (ACR) – Yearly Urine ACR is a urine test that forms part of the ACC which identifies early signs of chronic kidney disease, a complication of diabetes. If chronic kidney disease is detected early and managed, kidney function decline can be reduced and may even be reversed. Medicare funded point of care testing of ACR may also be available at Aboriginal and Torres Strait Islander Medical services. Blood fats check – 6 monthly Safe ranges of cholesterol and triglycerides in the blood will reduce a person’s risk of diabetes-related complications. Goals for blood fats for people living with diabetes are: Total cholesterol < (less than) 4mmol/L Triglycerides < 2mmol/L LDL < 2mmol/L HDL > (greater than) 1mmol/L Blood pressure check – 6 monthly Safe blood pressure ranges will reduce the risk of heart attack, stroke, eye and kidney disease. Goal: 130/80 – 140/90 mmHg or less. Eye check – Every 2 years These eye examinations (sometimes called diabetic retinopathy screenings) identify and prevent damage to the small blood vessels in the back of the eyes. This examination is usually performed by an Optometrist or Ophthalmologist, and can pick up eye damage due to high blood glucose levels and, if found early, can help prevent vision loss. Foot check – 6 monthly A foot check (sometimes called a diabetic foot assessment) is recommended to be performed twice a year to check the blood supply and sensation in both feet. Some people will require more regular checks by a Podiatrist. Aboriginal Health Practitioners, Diabetes Educators, Nurses and Doctors can also assist with foot checks. However everyday foot care at home is also really important to educate people living with diabetes on to help prevent foot complications. Medication review – yearly A referral from the Doctor (GP) to the Pharmacist (in store or home visit) for an annual medication review is really important. These checks ensure a person living with diabetes is on the correct type and dose of medication to help with their diabetes management but also other health conditions they may have, and helps prevent medication side-effects. Dietary intake check: At least yearly These help to identify what is and or isn’t doable in terms of making healthier food and drink choices and or to educate. Dietitians can provide intensive support in assessing and supporting nutritional health and wellbeing, and providing dietary guidance to help manage diabetes. A referral for the dietitian can be provided by the GP. Physical activity check: At least yearly These provide an opportunity to review and promote physical activity to optimise diabetes management and wellbeing. Physical activity is not limited to structured exercise, but can include housework, mowing lawns, gardening, fishing and walking on country, any movement that breaks up periods of sitting. The GP can assist with a referral to an Exercise Physiologist. Smoking status check: regularly Quitting smoking can help reduce a person’s risk of diabetes-related complications and improve overall health. Support can be found via the Quitline on 13 78 48. Who can perform the ACC checks? Many of the checks in the ACC can be performed without a GP present. For example, the pathology tests (blood and urine) can be performed by an Aboriginal Health Practitioner or Nurse. They, along with Diabetes Educators can perform the foot check and measure blood pressure. The GP will need to provide advice regarding the review of medications and checking all the items are complete. An Optometrist is qualified to provide a diabetes eye check recommended at least every two years as part the ACC. For most people living with diabetes it is also recommended they visit a Podiatrist once every 12 months for a foot check. 715 Health Assessment Aboriginal Health Workers can deliver a free 715 health assessment every 12 months, ~30-45 minutes. These assessments can help identify any health needs (including diabetes management needs) people in community may have and provide them with Allied Health etc referrals. For more information on diabetes for the health workforce and or people living with or at risk of diabetes, please head to the Diabetes Australia website here OR call the NDSS Helpline on 1800 637 700 to speak with a health professional.