Diabetes awareness in general practice

Many people with diabetes, particularly type 2 diabetes, remain undiagnosed (British Diabetic Association (BDA, 1997). Patients may have hyperglycaemia, hyperlipidaemia and hypertension for many years without symptoms, and can eventually present with advanced retinopathy, neuropathy or arterial disease.

The United Kingdom Prospective Diabetes Study (UKPDS) (BDA, 1998) found that up to 50% of people newly diagnosed with type 2 diabetes showed early signs of complications. There is thus a clear need for early detection of diabetes and screening for diabetes of those in high-risk groups.

In order to identify the undiagnosed diabetic population, public awareness of the symptoms of diabetes needs to be improved. Primary care, public health and health promotion sectors must work together to meet this need. This article  describes how this is being achieved within one general practice.

Primary care groups
The introduction of primary care groups (PCGs) has paved the way for contracts and services to be agreed at local level. The PCGs will be able to instigate clear lines of accountability to ensure that public funds are used effectively and appropriately.

It is intended that the varied knowledge and experience of health professionals working within PCGs will be used to improve the delivery and quality of local healthcare provision, and make more effective use of the limited financial and manpower resources of the NHS. It will enable doctors and nurses to define health needs and commission services, which will be achieved by good planning and monitoring of the allocated budget.

District diabetes register
Within my health authority we have an established district diabetes register, which involves 87% of general practices. This provides a means of assessing established contracts and services at local level through audit.

The register comprises a total of 8483 patients, of whom 7471 have given written consent for inclusion within the register.  The outstanding 1012 patients who have not yet been included in this total have declined to be part of the register or are in the process of returning their consent forms. The primary sector was encouraged to advertise the register through posters/ pamphlets located in local surgeries and  health centres, thereby providing an avenue for increasing awareness of diabetes for the whole population – not just the known diabetic population. 

The nurse’s varied role
Nurses based within the primary sector often have a varied role, which may include responsibility for organising and coordinating a flexible service. Practice nurses, in particular, also have, as part of their role, health promotion and prevention and management of disease – including diabetes. 

Diabetes mellitus is one of the most common chronic disorders in the UK, affecting people of all ages (BDA, 1997). The prevalence of diabetes increases with age. Over the age of 75 years the prevalence of diabetes is as much as 10% of the population.

Advertising diabetes
It is important that all health professionals are educators. The practice nurse has an invaluable role as an educator, with a professional duty to increase public awareness of the signs and symptoms of diabetes in order to identify the undiagnosed diabetic population.

The surgery or health centre is an excellent setting for providing indirect education, in the form of written materials. Patients sitting in the waiting area are a captive audience, thus this setting provides the ideal opportunity to display posters and leaflets relevant to diabetes all year round. Resources can be obtained from the BDA or from pharmaceutical companies, or one can design posters oneself (Figure 1).

Health promotion
Health promotion departments can be a useful resource to aid ‘lifestyle changes’ and can, in turn, promote ‘healthy lifestyles’.  Information related to smoking, alcohol, exercise and diet are all relevant to both the diagnosed and the undiagnosed diabetic population.

Displayed information
Patients regularly comment after their attention is drawn to displays in the waiting area of our surgery. Comments received frequently relate to the symptoms of diabetes. Examples include:

‘I didn’t realise that feeling tired was a symptom of diabetes’

‘I thought nothing of taking a jug of water to drink, when retiring to bed, each night – I’ve done that for years!’

‘I would like you to test my urine for sugar… both my parents were diabetic’ 

They are often surprised to learn that there are a number of  possible symptoms of diabetes. Other comments frequently relate to diet. Examples include:

‘It surprises me how normal the diet is for a diabetic patient – it’s just a healthy diet.’

‘The recipes in the British Diabetic Association cookery books look surprisingly delicious!’

‘I thought diabetic patients had to buy special foods.’

People appear unaware that patients with diabetes should consume a normal healthy diet, and assume that they should be on a very restricted or special diet. Unfortunately most of the British public do not eat a ‘normal healthy diet’, consuming foods high in fat, salt and refined carbohydrates. People newly diagnosed with diabetes may well feel isolated if they are unable to eat the foods they are used to consuming. This situation provides an ideal opportunity for the health professional to introduce and promote ‘healthy eating’ across the board, to include family and friends.

The BDA
Other resources such as videos, pamphlets, posters, stickers and promotional items aid education of the general public and in turn increase public awareness.

‘National Diabetes Week’, held in June, is a tremendous opportunity to raise funds for the BDA and provide the general public with information and education. Although health professionals may make a concerted effort to advertise diabetes during the first 2 weeks in June, it is important to maintain diabetes awareness in general practice all year round.

Last year, the BDA advertised the basic facts about diabetes at 2000 sites across the UK, including bus shelters and other public places. Advertising was also placed in national newspapers. 

Figure 2 highlights some of the resources available for improving diabetes awareness in general practice and the community.

Screening
The St Vincent Declaration (1989) set a 5-year target for raising awareness in the population and among health professionals of the current opportunities and future needs regarding prevention of diabetes and its complications.

Screening for diabetes is essential if we are to identify the 2% of the UK population who have undiagnosed diabetes. As Mackinnon (1995) pointed out, often diagnosis is not confirmed until the patient presents at the surgery with complications.

Rather than seeking general advice from the GP, patients may, on occasions, see the practice nurse. Consequently the practice nurse may be the first health professional to deal with the patient who is complaining, for example, of an ulcerated foot, recurrent thrush or increased thirst or urinary output. Both the nurse and the GP should therefore maintain a high index of suspicion at all times and be alert to the possibility of the diagnosis of diabetes.

Within my own work area, we have identified a further 19 patients with diabetes, increasing the number of known people with diabetes from 135 to 154, during the last 12 months (Figure 3).

These patients were detected through opportunistic screening when attending for a ‘well person check’ or a scheduled clinic, e.g. hypertension clinic, with the exception of one patient. This patient had recognised the association of symptoms when reading the surgery poster. This in turn had prompted him to make an appointment to have his urine and bloods checked, indicating that education in any form, whether direct or indirect, can be effective.

Diabetes screening and the practice nurse
Recommendations for screening should be formulated into each practice’s protocol. The BDA’s recommendations for diabetes screening are shown in Table 1.

As reported by the BDA (1997), the American Diabetes Association (ADA) has announced new guidelines for the diagnosis of diabetes mellitus, including the recommendation that the cut-off point for diagnosing diabetes using a fasting plasma glucose should be lowered from 7.8mmol/l to 7.0mmol/l.  

It is understood that the World Health Organisation endorsed the ADA guidelines, increasing the likelihood  that the guidelines will eventually be adopted in the UK, although it should be stressed that they have not been adopted at present. 

As a practice, we are aware of this recommendation, and await the formal guidelines. In preparation we keep patients within these levels under review by re-checking fasting blood glucose levels and promoting a healthy lifestyle, eating and exercise and reduction of cardiovascular risk factors. As a result this is likely to increase our diabetic population. 

Local diabetes services advisory groups (LDSAGs) around the country enable healthcare professionals, people with diabetes, and carers to liaise in order to evaluate the services and care provision for people with diabetes within the area. 

If the recommendation for wider screening of the population is to be adopted, resources within the primary sector will need to be increased.

Multidisciplinary care
It is essential that effective communication be maintained within the primary care team of optometrists, chiropodists or podiatrists, pharmacists, nursing staff and GPs. Patients identified by a member of the primary care team as having signs or symptoms of diabetes may require referral for investigation, via the GP, to confirm the diagnosis.

Professional training/updating
In order to provide effective patient-focused care, it is essential that healthcare professionals are properly trained.

All health professional have a responsibility to update their professional knowledge. The acquisition of knowledge and skills can improve quality of care, not just for today, but also in the long term. The UKCC (1992) specifies that ‘nurses should maintain and improve their knowledge and competence’.

Resources available from the BDA which enable health professionals to obtain up-to-date information on all aspects of diabetes, including pre-diagnosis, include:

• Education and Care Section – provides essential information on a multidisciplinary approach.
• Medical and Scientific Section – recently replaced by two separate sections, the Basic and Clinical Science Section and the Secondary (or Specialist) Care Section.
• Primary Care Diabetes UK – provides information and support to care in general practice, encouraging integrated diabetes care.

Additional information can be obtained by subscribing to specialist journals relating to diabetes (see below for information on the new Diabetes & Primary Care journal).

Conclusion
It is important that healthcare professionals working within the primary care sector  maintain a high index of suspicion for the signs and symptoms of diabetes when dealing with the general public.

Screening for diabetes is essential if we are to identify the potential 2% of the population within the UK who have undiagnosed diabetes. Because people are often unaware that they have diabetes or are unfamiliar with the symptoms, it is up to us all to be educators. 

This article is a good starting point. We are fortunate in having numerous resources available to us, and we should utilise them.

We have a duty to those known to have  diabetes, and to the general public, to explain what diabetes is, what the recognised symptoms are, and what care is available – we should all be striving to educate the community.

Acknowledgements
My grateful thanks go to the following people for their help and support with this article: Drs Dixon, Sher and White, who have given me the support to establish a successful diabetes service within our practice and the opportunity to improve my knowledge and skills in this specialised field of nursing; Mary MacKinnon, who encouraged and supported me while writing this article; Christine Wigley, South Staffs MAAG Dept, who provided me with up-to-date information about our district diabetes register; Mr Peter Shorrick, BDA, West Midlands, who provided me with information; and my family, for their patience and support.

Publisher’s note
Figures 2 and 3 are not available in the online version.