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VOLUME 10 NUMBER 4 • NOVEMBER 2013
EDUCATOR’S FOCUS
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Factors that patients with diabetes should be encouraged to take re-
sponsibility for include dietary matters, smoking cessation,
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exercise,
ownership of their diabetes care, identifying their needs, misconcep-
tions, motivations and wants, and knowledge of their condition. Family
physicians and healthcare workers should ensure a good or satisfactory
patient relationship through a patient-centred approach by being non-
judgemental, establishing a good rapport with the patient and being open
and honest, attentive, and reflecting and praising achievements however
small, relinquishing some control to the patient, explaining the signifi-
cance of various findings, including their test results and risks of devel-
oping complications, identifying the patient’s agenda and jointly setting
goals, defining timelines and developing action plans.
Evidence shows that people with diabetes who do not receive appro-
priate education and knowledge have a four-fold risk of a major com-
plication. Education should therefore be a planned life-long process in
diabetes management as the condition evolves and life circumstances
change.
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PREVENTION AND EARLY DETECTION OF COMPLICATIONS
It should be remembered that 30 to 50% of people with type 2 diabe-
tes have complications at the time of diagnosis due to prolonged insulin
resistance (10 to 15 years) before hyperglycaemia is detected clinically.
The acute complications of diabetes include hypoglycaemia, which is
characterised by a low blood glucose level (< 2.7 mmol/l), diabetic keto-
acidosis (DKA) characterised by high blood glucose levels, ketosis and
acidosis and hyperosmolar non-ketotic coma (HONK) characterised by
high blood glucose levels. Other complications include blurred vision or
acute neuropathic symptoms and insulin oedema.
Understanding of the pathogenesis, causes and symptoms of the
above, and their early detection and effective management is vital to
avoid long-term complications. The importance of early detection of hy-
poglycaemia and its avoidance is very important as it is accompanied by
cardiovascular complications, especially acute myocardial infarction. This
is as a result of the stimulation of a number of inflammatory markers
including cytokines that are induced as a result of the hypoglycaemia.
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Chronic complications include both micro- and macrovascular complica-
tions. Microvascular complications include retinopathy, nephropathy, neu-
ropathy, dermopathy and cardiomyopathy. Risk factors for microvascular
disease include the duration of diabetes, poor glycaemic control, genetic
predisposition, hypertension, hyperlipidaemia and smoking. Some of these
will need timeous intervention from the treating health professional.
There is a continuous relationship between HbA
1c
level and micro-
vascular complication rate. Therefore, it is imperative that this is always
managed to the individual’s target as per the guidelines. In the young
diabetic, the HbA
1c
level should be < 6.5%. In the elderly and dependant
this should be between 7.5 and 8.5%.
Screening for these complications and their early detection, manage-
ment and referral is the hallmark of good diabetes practice. These will
include regular annual, or six monthly visits if indicated, to the ophthal-
mologist, cardiologist, nephrologist if urinary albumin or albuminuria is
present, neurologist if indicated for the early detection of various neu-
ropathies, podiatrist for the prevention and early detection of foot prob-
lems, and the dietician for medical nutritional management especially
in obese patients. Smoking cessation therapy must be instituted in all
patients. Aspirin should be used in all patients who have a greater than
10% risk assessment for cardiovascular disease.
Sexual dysfunction in the male is common and should alert one as a
marker for more widespread vascular disease. This should be evaluated,
especially for cardiovascular and other macro- and microvascular target-
organ involvement.
It must be remembered that the key to successful management and
prevention of the above complications lie in achieving early and on-going
glycaemic control, especially early morning and post-prandial glucose
control, blood pressure control according to the JNC7 guidelines, lipid
control according to the current 2012 guidelines, the total abstinence
from smoking, and lifestyle management of visceral abdominal adiposity
and obesity.
Macrovascular complications include coronary artery disease, athero-
sclerosis, cerebro-vascular disease and peripheral vascular disease. Early
screening, prevention and detection of these complications are essential
to avoid serious disability, morbidity and mortality. Diabetes is largely a
vasculopathic disease and a coronary artery risk equivalent. Once again,
the mainstay of prevention and the avoidance of complications are to
maintain long-term glycaemic control, satisfactory control of blood pres-
sure and lipid levels, anti-coagulation therapy according to the current
guidelines, and very importantly, smoking cessation.
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THE ABCS OF FOOT CARE IN DIABETES: ASSESSING
THE RISK FACTORS
Foot examination and management in the diabetic patient is discussed as
an example of risk-factor assessment for diabetes-related foot problems.
Healthcare workers should be familiar with the ABCss of diabetes care:
HBA
1c
level (glycosylated haemoglogin) (A), blood pressure control (B),
cholesterol (C), smoking cessation (s) and salicylates (s). These refer to
the risk factors for diabetes-related complications.
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The ABCS of foot care in patients with diabetes refer to the risk factors
for diabetes-related foot problems, as people with diabetes are prone to
peripheral neuropathy, peripheral vascular disease and often need spe-
cial care to avoid problems, especially as they are likely to have abnormal
foot structure.
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This can be summarised as follows:
A:
Anaesthesia (i.e. peripheral neuropathy)
B:
Blood supply (i.e. peripheral vascular disease)
