Ten things everyone living with diabetes should know

If you have diabetes, here are 10 things you need to know about the care you should be receiving and how to take control of your condition.

1. HbA1c

What is HbA1c?

This is the key blood test that tells us how well your diabetes is controlled. It stands for ‘glycosylated haemoglobin’ which is the concentration of your red blood cells that have sugar attached to them. This is different to your ‘blood sugar’ reading that you get when you prick your finger which tells us your sugar at that moment in time. Your HbA1c gives us an idea of how well your sugars have been controlled over the last 3 months.

What should my HbA1c be?

The general rule is that, if you are within the first 10 years of being diagnosed with Type 2 diabetes, your HbA1c should be around 48 mmol/mol. Good control early on means that you will be less likely to develop complications from diabetes in the future and your diabetes will be easier to control in the years ahead. Sometimes, if you have had diabetes for a long time, are on several medications or have lots of other medical conditions, your target HbA1c may be slightly higher. It is important to know what your HbA1c is now and what your personal target is. You should have a HbA1c check at least every 6-12 months.

2. Blood Pressure

Why is this important?

We always used to think about diabetes as being purely to do with blood sugars but now we describe it as a ‘cardio-renal-metabolic’ condition. This means we need to look after your heart, your kidneys and your sugars, as diabetes impacts all of these things. In diabetes, your blood pressure needs to be very well controlled to reduce your risk of heart attacks and strokes.

What should my blood pressure be?

It’s important to know what your target blood pressure is so you can monitor it and make sure it isn’t creeping up above this. For most people with diabetes, your blood pressure should be less than 140/90, but the lower the better. If you have kidney problems associated with diabetes, your blood pressure should be 130/80 at the most but if you are over 80 or quite frail, your target may be higher. You should have a blood pressure check at least every 6-12 months.

3. Cholesterol

Why is this important?

It is important to look after your heart in diabetes and reduce your risk of heart attacks and strokes. High cholesterol is a risk factor for heart attacks and strokes as it forms plaques in your blood vessels that can break off and block blood vessels upstream.

What should my cholesterol be?

In diabetes, your total cholesterol should ideally be less than 5mmol/L and your LDL (bad cholesterol) should be less than 3 mmol/L. You should have a cholesterol check at least every 6-12 months.

Should I be taking cholesterol medication?

If you are over 40 and have diabetes, it is a good idea to take a medication called a statin. As well as lowering your cholesterol, these medications have what we call ‘plaque-stabilising properties’ which reduce the risk of any bits of plaque (in your blood vessels) breaking off and blocking a blood vessel upstream, causing a heart attack or a stroke.

4. Kidney checks

We need to think about your heart, your sugars and your kidneys in diabetes. Having high sugars means that small blood vessels all over your body can be affected, including the small blood vessels that supply your kidneys. Our kidneys are important for many reasons including removing waste from the body, regulating our blood pressure and regulating the production of red blood cells. In diabetes, we measure kidney health in two ways:

eGFR ( estimated glomerular filtration rate)

This is a blood test to check your kidney function. Our kidneys act like a sieve - filtering through waste products without letting important particles, such as protein, leak through. The eGFR is the rate at which your kidneys filter things through - the faster the better. 60ml/minute and faster is a normal kidney function. If your kidneys are working at a slower rate than this (less than 60ml/min) it is important to monitor your kidneys and start certain medications to protect them. You should have a blood test to check your kidneys every 6-12 months.

Urine microalbumin (ACR)

Everyone with diabetes should have a urine test to check for microalbumin (tiny bits of protein) at least once a year. If protein is found in your urine, it means that your kidneys are allowing this to leak through the sieve. This means there is early damage to the small blood vessels supplying your kidneys, because of diabetes. It also means that it is likely that there is damage to the small blood vessels supplying your heart. The presence of protein in your urine means that we need to take measures to protect your kidneys and your heart - by controlling your blood pressure and cholesterol and starting certain medications that protect your heart and kidneys.

5. Eye checks

As well as affecting the blood vessels that supply your heart and kidneys, diabetes can affect the blood vessels that supply your eyes as well. Everyone with diabetes should have eye screening once a year. You should be automatically invited for this. When checking your eyes, they will look for any changes on your retina (the layer at the back of the eye that turns light into images) and the macula (the part of your eye that processes what you see directly in front of you). They will give you a score depending on the extent of any any damage to your retina and macula. A score of R0 M0 for example, means that both your retina and macula are completely healthy. If any changes are found in your eyes, you will be closely monitored and sometimes offered specific treatments.

6. Foot problems

Diabetes affects the small blood vessels in your feet as well. This can cause problems with blood supply to feet but also affects the nerves that supply your feet which can cause pain and numbness. A lack of feeling in the feet (numbness) is a real issue in diabetes. If you injure your foot and develop a wound, you may not have the same pain response that warns you that you need to protect the wound. Furthermore, a less good blood supply means wounds will be slower to heal and high sugars mean wounds are more likely to become infected.

You should have a foot check at least once a year with a healthcare professional but also, you should know the risk to your feet (low, medium, high) and know how to look after and check your feet. More information about looking after your feet.

7. Weight / BMI

A healthy body mass index ( weight / height 2 ) is anything between 18.5 to 24.9. However, weight and diabetes isn’t just about BMI. If you are overweight, even 1kg weight loss will, on average, reduce your HbA1c by 0.2mmol/mol. Whilst not everyone will be able to achieve a BMI in the “normal healthy” range, any weight loss will help your diabetes control and risk to your heart.

Where you carry your weight is important as well. People who tend to carry their weight around their middle have a greater risk of diabetes and heart problems. Therefore reducing weight in “central obesity” is even more important in diabetes.

There are many ways to help with weight. Speaking to an accredited dietician is a great way to start, along with increasing activity. Local Kent organisations such a One You Kent can help you to find a type of physical activity that suits you.

There is also a NHS-funded programme called the Type 2 Diabetes Pathway to Remission Programme. If you are aged 18-65 and within the first 6 years of diagnosis, you may be eligible. This is a strict programme of 3 months of soups and shakes, with a daily intake of about 800 calories a day, followed by a further 9 months of support. Almost half of the participants in the programme will put their diabetes into remission by reducing the fat stored in the liver and pancreas, improving the way their body regulates sugar. Find out more about the service.

8. Smoking

Smoking is even more problematic in diabetes (aside from cancer and respiratory risks). People with diabetes have a higher risk of heart attacks, strokes and foot disease and smoking increases this risk even further. Additionally, recent research has found that smoking increases blood sugars and makes diabetes more difficult to control. Stopping smoking is vitally important and more information can be found on the NHS Website

9. Increase your knowledge and feel empowered

When living with a chronic condition such as diabetes, it is important that you have as much knowledge as possible about what checks you should be having, why the checks are important, what your results mean and what you are aiming for. Everyone with diabetes should know:

• It’s important to have your 9 care processes completed every year (height, weight, HbA1c, Cholesterol, Blood pressure, Eye checks, Foot checks, Kidney checks (blood test and urine test). Smoking status).
• What their personal HbA1c, Blood Pressure and Cholesterol readings are and what their targets for these measurements are.
• How to check their feet and look after them properly and what their individual foot risk is.
• How to access information and education programmes about their diabetes. You can access diabetes education on the NHS. There is also a great diabetes education app funded by NHS Kent and Medway

10. Know your medications - their benefits and their risks.

Modern medications for diabetes are really effective, when combined with diet and lifestyle measures.

SGLT-2 inhibitors

There is a group of medications called the SGLT-2 inhibitors (dapagliflozin/forxiga, empagliflozin, canagliflozin). Not only do these reduce blood sugars but they also help with weight loss and lowering your risk of heart and kidney problems. There are some important things to know about them however. For example, if you are taking one of these medication and become unwell with a dehydrating illness (high fever, diarrhoea and vomiting) it is often sensible to stop them temporarily as they can increase your risk of a diabetes complication called DKA (diabetes ketoacidosis).

GLP-1 analogues

These are injections such as ozempic (semaglutide) and victoza (liraglutide). They are hugely useful in controlling blood sugars, reducing weight and protecting your heart and kidneys. Unfortunately there is currently a nationwide shortage of these medication due to their widespread use in weight loss as well. If you are prescribed one of these medications, it is important that you have had a conversation with your health care professional about the plan for your diabetes, should you not be able to get hold of your medication. These shortages are due to continue until the middle of next year.

Metformin

Is usually the first medication that you will be started on when you are diagnosed with diabetes. It works very well but can sometimes cause tummy upsets as a side effect. If this is the case, there is a modified release form that is gentler on the stomach so do speak to a GP if you are struggling with your metformin. The body gets rid of metformin through the kidneys, so if you have kidney problems or have a condition that affects your kidneys (either long term or temporarily) you will need to have a conversation with a GP about what to do with your metformin dose.

Gliclazide

Is a very good medication for reducing sugars quickly. It can sometimes contribute to weight gain however and can lead to episodes of hypoglycaemia (low sugars). If you are prescribed gliclazide you should know how to recognise a hypo, how to treat a hypo and have a blood glucose machine for checking your blood sugars. You can find out more about hypos here: https://www.diabetes.org.uk/guide-to-diabetes/complications/hypos.

Insulin

Many people with Type 2 Diabetes will eventually need insulin. Insulin is a very effective way of controlling blood glucose, especially when your pancreas has started to struggle to make enough of its own insulin after years of type 2 diabetes and insulin resistance. If you are taking insulin, you should be familiar with injection techniques, your dose and how to check your blood sugars regularly. If you are unwell, you should never just stop your insulin but you must make your healthcare professional aware as illness can make your sugars go too low or too high and your dose may need to be adjusted accordingly. You need to be aware of how to recognise and treat episodes of hypoglycaemia as well.