Most people with type 1 diabetes attend GIH diabetes clinic; people with type 2 diabetes Must attend clinic diabetes clinics are able to provide all your routine diabetes care and annual review. So what happens at a diabetes clinic?
- Physical Examinations
Height and Weight: Your weight is often calculated as Body Mass Index (BMI) which expresses your adult weight in relation to your height. Your BMI should be between 20 and 25.
Blood pressure: should be taken at every diabetic clinic visit. You should aim for your blood pressure to be 140/85 or less.
Foot examination: This is done every year and checks the skin, the sensation and that the blood supply is satisfactory. Please wear shoes and socks that allow easy access to your feet.
Eye examination: This is done every year either at the diabetes clinic or at an opticians and involves :
- Looking at a reading chart to see if you have cataracts. You will need to bring your reading glasses with you for this.
- Having eye drops in to make your pupils bigger. The drops may sting at first and cause blurring of vision for up to 2 hours (it is best not to bring your car as your sight can be altered, making it unsafe to drive until they have worn off). The back of your eyes, the retina, will then be examined for any changes due to diabetes ( see section on retinopathy) – using an ophthalmoscope with a bright light in a darkened room.
Injection site examination if you are on insulin.
- Laboratory Tests And Investigations
1. Blood samples are taken and tested for:
Haemoglobin A1c (HbA1c): This is done at every visit and tells how well controlled your diabetes has been over the previous 3 months. The target to aim for is 7.0% or below; this is equivalent to keeping your blood glucose between 4 and 7 mmol/l before meals.
Creatinine: This is checked yearly and tells how well your kidneys are working.
Lipid profile: This is checked yearly or more often if you are on cholesterol- lowering tablets and tells how much ‘fat’ is in your blood. You may be asked to fast for this blood test. Lipids are made up of:
- “bad” cholesterol – “LDL”
- “good” cholesterol – “HDL”
A decision to use lipid lowering tablets will be made depending on your other medical conditions. However as a guideline a cholesterol level below 5mmol/L, with an LDL below 3mmol/l, and triglycerides below 2mmol/l is good.
Liver Function tests: these are checked periodically if you are on Metformin or one of the glitazones (see section on tablets) for blood sugar control, of if you are on a ‘statin’ tablet for high cholesterol, to make sure you can continue to take these tablets. 2. A ‘first-thing-in-the-morning’ urine sample. You will be asked to bring along a specimen of urine collected first thing in the morning. This may be tested for:
- Signs of infection
Microalbumin (small pieces of protein): increased levels of microalbumin in the urine are associated with a higher risk of developing some of the complications of diabetes and with high blood pressure that needs early treatment. These can both be helped with ‘ACE-inhibitor’ tablets.
- You May Then Also Need To See Other Members Of The Diabetes Team Including:
- Diabetes Specialist Nurse Review
- Dietitian review
- Podiatry review
- Lifestyle Issues
Every year you should have enough time to discuss in the diabetic clinic:
Your general well-being, including how you cope with your diabetes
Your current treatment
Your diabetes control, including home monitoring results and problems with hypo’s.
Any problems you may be having
Discussion should include where relevant issues such as smoking, alcohol consumption, sexual problems, stress and physical exercise. You should feel free to raise any or all of these issues with your diabetes care team. The diabetes clinic visit therefore involves many assessments and will take some time to complete in order to assess your diabetes properly. Please therefore allow yourself plenty of time for your diabetes clinic visit. e do and what do they show?
Blood sugar. Single blood sugar readings are of very limited value unless they are either extremely high or extremely low. It’s rather like a single air temperature reading – it doesn’t tell you much about the state of the weather. Of much more use is a series of readings taken over a period of time at different times of the day and to get this, unless the patient is in hospital, we rely on the patients own blood sugar checks. A pattern of high or low readings at certain times of the day will give a very good indication where changes need to be made to treatment or diet.
Haemoglobin A1c. This test relies on the affinity the red blood pigment haemoglobin has for glucose. Glucose sticks to the haemoglobin in proportion to the average amount in the blood over a period of time. As red cells last about six weeks then this is the period of time that the Haemoglobin A1c reflects. All the research into diabetic control has tended to focus on this reading. The target level for each diabetic patient may vary somewhat in relation to age and what is thought to be achievable but as a general rule 8% is quite acceptable whilst 10% and above may be more worrying though in the older diabetic where longterm complications are less of an issue and where hypoglycaemia could be dangerous we may accept, indeed feel happier with, the slightly higher figure.
Urinary protein and microalbumen. We check with a stick for protein in the urine. If this is positive then we check for a urine infection and if it is negative we send the urine to the lab. for the mich more sensitive microalbumen test. We are concerned about increased levels of the protein albumen because if it is persistent over several tests over a period of time it tends to predict future problems with kidney function. A 24 hour collection to measure the amount of albumen leaking out over a period of time will often be done after several positive random tests.
Kidney function tests (urea, electrolytes and creatinine). Along with microalbumen these tests tell us if your kidneys are suffering as a result of the diabetes. Again, what is valuable is a series of readings over a period of time.
Blood pressure. As with all patients we are concerned about blood pressure in order to avoid strokes and heart attacks but in diabetics we are also concerned to protect the kidneys. We strive to keep blood pressure very strictly controlled – especially if there is microalbumen or abnormal kidney function already.
Cholesterol. Heart disease is associated with diabetes and we monitor cholesterol closely in diabetics and we are much more likely to intervene with medication than in the non-diabetic. The ideal diabetic diet is also good for cholesterol with its emphasis on low fat, high complex carbohydrate and high fibre.
Circulation. Diabetes and smoking are the two main causes of blocked blood vessels in the legs. Diabetes goes for the smaller calibre blood vessels whilst smoking predisposes to blockage of the larger ones so the combination is a potential disaster. The chiropodist compares the blood pressure at the ankle compared to the arm using a special device called a Doppler ultrasound probe. She produces a figure which is a ratio and a number significantly less than one indicates trouble!
Autonomic nervous system. This part of the nervous system carries the body’s “autopilot” and controls things like blood pressure. Male sexual function requires an intact autonomic nervous system. Diabetes tends to damage this part of the nervous system – one test we do is to see if your blood pressure drops significantly on standing up (which normally it doesn’t do).
Sensory nerves. These nerves also get damaged – especially in the feet where good quality sensation is important to protect you. There are varous tests that can be done to test the sensory nerves – currently the chiropodist tests this for us with a special probe