11. Education for life

Whereas DAFNE is designed for people with type 1 diabetes, the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) programme provides structured self-management group education to individuals who are newly diagnosed with type 2 diabetes. The DESMOND programme was based on chronic disease management programmes in the USA and European models of care that included structured diabetes education. At the time of writing, the programme is being evaluated according to the Medical Research Council Framework for evaluating complex interventions (Campbell et al 2000). A randomised controlled trial, the largest of its kind in newly diagnosed adults with type 2 diabetes, is in progress and is due to report in 2007.

The programme can be offered as a 1-day 6-hour programme or in two half-day sessions or three 2-hour sessions. Groups consist of between five and ten individuals and are facilitated by two trained educators. Part of the programme involves personal goal setting and action planning to achieve goal outcomes. Goal setting and action planning increases self-efficacy and this has been shown to lead to improved biomedical and psychosocial outcomes (Bodenheimer et al 2002, see Chapter 3).

Meanwhile in the UK and, following NICE guidance mentioned above, the DESMOND programme is being rolled out to primary care services with the backing of the DH. It is considered to be the only widely available programme that currently fulfils the criteria for structured diabetes education for people with type 2 diabetes.

There are other examples of structured diabetes education programmes (Everett et al 2003, Sumner & Dyson 2004) and research in which structured diabetes education has been evaluated (Anderson et al 1995, Cooper et al 2003, Griffin et al 1998, Hampson et al 2001, Norris et al 2001, Trento et al 2002). All this work is contributing to an evidence base to guide this area of practice and in so doing is slowly making up for a long-recognised deficit in this aspect of care.

One programme that has been specifically applied to diabetes is the Dose Adjustment For Normal Eating (DAFNE) project. This programme, which is jointly funded by the DH and Diabetes UK, involves structured training in intensive insulin therapy and self-management. The main principles of the course are:

The programme is based on a well established and evaluated inpatient model pioneered in Düsseldorf (Muhlhauser et al 1987). The objective of the programme was to evaluate whether such a training programme could lead to improved glycaemic control and quality of life (DAFNE Study Group 2002). Further details can be obtained from www.dafne.uk.com.

Sue, (case Study 11.1) to complete the DAFNE programme would have participated in 5 days of outpatient training. The overall aim was to enable Sue to enhance her self-management abilities and gain confidence and, subsequently, independence from her diabetes team. She would have been in a group of six to eight people in which three main topics are covered: (1) nutrition, (2) dose adjustment of insulin and (3) preventing and managing hypoglycaemia and hyperglycaemia and managing special circumstances such as exercise. To be able to attend the DAFNE course, Sue would have needed to attend an approved hospital diabetes centre that met specific criteria. To be an approved site, the diabetes centre staff would have completed a DAFNE Educator Programme and be registered as DAFNE educators. It is preferable that at least four members of staff are trained and registered to deliver the DAFNE programme. Another criterion required for approval is that the whole diabetes team must be committed to the philosophy of DAFNE. This philosophy states that the culture of the diabetes centre must be supportive of autonomous, knowledgeable people with diabetes. It is essential that the whole team commits to this and not just the registered educators.

Hence, Sue would remain on her multiple injection regimen as this will maximise her opportunities for dose adjustment. Sue would learn how to use quick-acting insulin according to the amount of carbohydrate that she had eaten. During the DAFNE programme, she would have worked out how many units of quick-acting insulin she needed for each 10 g of carbohydrate that she ate. This ratio of insulin units : carbohydrates varies from person to person and sometimes at different times of the day. During the DAFNE programme, Sue had worked out that her insulin units : carbohydrate portion ratio was as follows:

As part of the DAFNE programme, blood glucose targets are agreed between the person with diabetes and the DAFNE team. Targets are agreed for fasting levels of blood glucose, pre-meal and bedtime. The actual ratio of insulin dose to carbohydrate portion is explained during the programme and individualised to each person. The above ratios are presented as an example only and will differ from person to person.

Materials used for education will include audiovisual and computer-based material, posters, leaflets, diagrams and practical equipment such as food models. Visual aids should encourage interaction between educator and the person with diabetes (Llahana et al 2001). Materials are very important to assist with the educational process and must be of the highest standards of accuracy as well as comprehensible, relevant and culturally specific.

Healthcare professionals using literature to support their education sessions should be aware of the problems of readability and literacy status of the material that they use. These problems are compounded where English is not a person’s first language. There is, therefore, a considerable need for educational materials which are culturally specific. Diabetes UK has made a determined effort to provide educational material suitable for a wide range of individuals, cultures and topics (see www.diabetes.org.uk).

At diagnosis, the person newly diagnosed with diabetes is usually anxious and although appearing keen to learn, is not necessarily in the most receptive frame of mind to acquire new knowledge. An education programme must therefore be planned and staged to take into account the person’s ability to assimilate information (Coates 1999).

The first stage of education commences at the time of diagnosis. The person will require emotional support and might want to ask questions regarding diagnosis, cause and implications of diabetes. This is a time when the educator will learn about the physical, psychological, spiritual and cultural needs of the individual and what is important to him or her. For example, the newly diagnosed individual might be terrified that the diagnosis will impact negatively on work or relationships, or on his or her abilities to be a parent or indeed to become a parent. A needs assessment will inform the educational content of immediate and ongoing education. The educational programme should be structured to provide the person with essential facts based on what questions he or she is asking and what he or she needs to know to be safe.

When commencing education with the individual concerned, it is important to determine first how much the individual already knows about diabetes and to discuss any misconceptions that he or she might have. It is common for people to be aware of the worst complications of diabetes, such as amputation or blindness, and many believe that these are inevitable.

The second stage requires a learning plan that has more detailed education on aspects of diabetes that address both the individual’s agenda and that of the educator (Box 11.3). Although the healthcare team has its own agenda for education, individuals determine which area they want to learn about next. Educational material must be presented in small, bite-sized chunks to enable the person assimilate it. Inviting questions, reiterating and encouraging the person to verbally reflect what has been said will assist the individual to make sense of his or her new knowledge and relate it to his or her own circumstances. Reinforcement with written material will help the individual to remember new facts but should not be a substitute for face-to-face collaborative education (Ellis et al 2004). It is good practice to review what the person understands of the content covered at a previous session prior to moving on to the next topic. This helps to secure the knowledge and skills acquired and give an opportunity to discuss how these have been implemented into the real world of living with diabetes. Collaborative goal setting will help the individual to ground his or her new-found knowledge into his or her unique circumstances.

For education to be effective, it must be reinforced and the person motivated in self-management. This is the third stage in education. A multitude of evidence demonstrates that educational interventions work for a limited period of time only. Stressful periods (see Chapter 3) get in the way of the hard work that optimal self-management requires. Hence, education becomes a lifelong process and includes facilitating individuals in problem solving to manage new situations.

For most people, the diagnosis and management of type 2 diabetes starts in general practice. At the first visit after diagnosis, the person might well be bewildered and hence not very receptive to education. However, some ‘first aid’ measures are appropriate until the next appointment. These would include a simple explanation of diabetes, simple adjustments to diet following the taking of a dietary history and, for some, the commencement of monitoring might be appropriate (Box 11.1). The person should be advised regarding contact numbers should there be a problem.

As far as possible, the family and friends of the individual should be included. Engaging social support has been shown to improve glycaemic and psychosocial outcomes in diabetes self-management (Van Dam et al 2005). At a further visit, the individual’s questions regarding diabetes would first be addressed.

Monitoring technique would be assessed and the results discussed. From the outset the person with diabetes should be encouraged to make sense of monitoring results with help from the clinician rather than have the clinician immediately offering explanations about reasons for results. As diet is the mainstay of management for the person with type 2 diabetes, more detailed and tailored dietary advice from the dietician would be appropriate (see Chapter 6).

If the person has already started oral hypoglycaemic therapy, it would be appropriate to advise that prescriptions can be obtained free in the UK by completing a FP92A form. This is not available to people who are treated by diet alone.

Education should take into account that people with type 2 diabetes have multiple risk factors contributing to premature cardiovascular disease. Subsequent visits would include education about the personal risk factors for the individual. The person with diabetes then has the knowledge to make decisions about what he or she would like to do to improve his or her risk factors. The individual can identify his or her own personal goals for self-management and an action plan to operationalise goal achievement is put into place. Goals might be to do with taking exercise, dietary changes or finding strategies to take medication regularly. Goals need to be realistic and achievable (see Chapter 3).

Diabetes education will include foot care, the clinic attendance that includes screening for complications and the associated cardiovascular risk factors and the need for exercise. The progressive nature of diabetes, the potential impact on employment, driving and insurance also need to be discussed. Thereafter, all visits are opportunities for revising education and educating people as their management alters or complications develop and progress.

The individual with newly diagnosed type 1 diabetes would be referred to secondary care services as assessment is required as to whether or not he or she is suffering from diabetic ketoacidosis, which would result in admission to hospital.

Subcutaneous insulin is commenced immediately if the person does not have diabetic ketoacidosis. This is usually done by the DSN in secondary care but as an outpatient or in the person’s own home. The individual is usually in a state of shock at the time of diagnosis. Many of the questions a newly diagnosed person has at this time are around how this could have happened and whether he or she has caused it. In terms of education, people usually respond well to undertaking practical procedures but will not necessarily retain much factual information. Hence, at the first visit, blood glucose monitoring and how to inject insulin will be taught (Box 11.2). When starting insulin therapy, the person will usually be seen at least daily for a few days and thereafter followed up as necessary with telephone contact being maintained by way of further support. Again, a staged approach is required, with more detailed explanations in response to the individual’s questions being introduced over a period of about 6 weeks. As people with type 1 diabetes tend to be seen more frequently, reinforcement of education is easier and individuals have greater opportunities to ask pertinent questions.

The person newly diagnosed with type 1 diabetes or type 2 diabetes will be informed that their blood glucose levels are high. All those with type 1 diabetes will be well aware of the symptoms that took them to see their doctor and these include thirst, polyuria, lethargy and probably a dramatic weight loss (Box 11.4). They might also have experienced Candida, cramps, painful peripheral neuritis and blurring of vision, which are all a consequence of hyperglycaemia (see Chapter 1). If the individual was acidotic then he or she might also have had nausea and/or vomiting and have been breathless. Those with type 2 diabetes might also have had all or some of these symptoms but possibly over a longer period of time and less intensely. Some people will have rationalised their symptoms and decided that they were tired because they were working too hard, or that they were thirsty because the weather had been hot. In helping to make sense of diabetes it is important to explain how the different symptoms relate to the physiology of diabetes and that if these symptoms return then it means that some aspect of treatment and/or self-management needs to be reviewed. Self-referral should be encouraged especially as it has been shown that type 2 diabetes requires progressively increasing treatment over time (UKPDS 1998).

Some people with type 2 diabetes might not have experience of hyperglycaemic symptoms if their diabetes had been diagnosed through a screening procedure at work or at a clinic. It can make the diagnosis more difficult to come to terms with if this is the case and blood glucose or urine monitoring can help to accept the reality of having diabetes.

Hyperglycaemia can be due to any one of several factors (Box 11.5). People with diabetes might be anxious about finding that their blood glucose levels are above target levels but can be reassured that they have time on their side to adjust their treatment or to seek advice. Left untreated, metabolic decompensation progresses to a hyperosmolar hyperglycaemic syndrome in the person with type 2 diabetes or diabetic ketoacidosis (DKA) in the person dependent on insulin (see Chapter 5).

Self management during an acute illness has always been an educational challenge because the elements of diabetes self-management during illness might have been taught early on but the individual with diabetes might not experience illness for many years and will have completely forgotten ‘the rules’. The most important advice to be given here is to seek help and to seek it quickly (Box 11.6). People who are unwell lose their appetite and tend to stop their drugs or insulin therapy because they fear hypoglycaemia; however, metabolic control can rapidly deteriorate under these circumstances. Food substitutes are presented in Box 11.6.

When a person is unwell, in most situations, the blood glucose will rise due to the hormones of stress even if the appetite has been suppressed (see Chapter 1). This means that the individual should not reduce his or her insulin or hypoglycaemic agents but in fact might need to increase the doses. Hence, people who are ill need to increase their monitoring to four times daily.

People with type 1 diabetes need to test their blood or urine for ketones and, if present, should self-refer to their GP, nurse or local accident and emergency centre for assessment. If all else is forgotten, people should be encouraged to remember the golden rule ‘Never stop taking insulin’. Vomiting might be a sign of diabetic ketoacidosis and the individual needs to seek urgent medical help, if not from the GP then again at his or her local accident and emergency centre.

People with type 2 diabetes who are unwell are also encouraged to increase self-monitoring as treatment might need to be started for those controlling their diabetes by diet alone, or treatment adjusted if already on oral hypoglycaemic agents or insulin. People taking metformin should continue with treatment if possible but as metformin needs to be taken with food this may be problematic. Alternative treatment might be required if the illness is prolonged.

Those people who are taking a sulphonylurea (e.g. gliclazide) and/or a thiazolidinedione (pioglitazone or rosiglitazone) need to continue with these but, again, adjustment of the sulphonylurea might be required in prolonged illness. Advice must be sought if there are any elevated blood glucose levels and ketonuria or evidence of raised blood ketones.

The exception to becoming hyperglycaemic during illness is if the person is suffering from a gastrointestinal illness causing diarrhoea but is not affected systemically. In this case, the person might become hypoglycaemic and, should this happen, he or she needs to seek advice. Oral hypoglycaemic medication might need to be stopped for the duration of the diarrhoea and insulin, in people with type 1 diabetes and type 2 diabetes, might need to be reduced. However, insulin in type 1 diabetes can never be stopped (see Box 11.6).

The reasons and significance of why ketones must be monitored if the blood glucose exceeds 10 mmol/L were discussed Even during illness the target blood glucose levels should remain in the 4.0–7.0 mmol/L range. The actual adjustment of insulin will vary according to individual needs.

It emerged that whereas Bill had always attended his clinic appointments he had never faced this situation before so he had never thought to check up on what to do when unwell. This is a common example of the importance of continuing education for people with diabetes.

Education about hypoglycaemia features prominently in caring for people with diabetes. Hypoglycaemia is the most common side effect of insulin therapy or sulphonylurea treatment. Individuals are frightened of hypoglycaemia and so may deliberately keep their blood glucose levels high. People must be taught how to achieve healthy glucose profiles and prevent, recognise and treat hypoglycaemia.

Every year, about 25–30% of insulin-treated people with diabetes suffer one or more severe hypoglycaemic episodes requiring the assistance of others (Williams & Pickup 2004). Symptoms such as hunger, pallor, tremors, palpitations, anxiety and confusion in association with a blood glucose level of less than 4 mmol/L is diagnostic of a hypoglycaemic episode.

The concern expressed by John is both common and well founded, given that hypoglycaemia can lead to both recurrent physical morbidity and to recurrent or persistent psychosocial morbidity and sometimes even death (Cryer 1997).

The issue of hypoglycaemia within type 2 diabetes has received more attention since the reporting of the UKPDS (1998), in which it was noted that 11.2% of people with type 2 diabetes using insulin experienced major hypoglycaemia for which hospital admission was required. More recent studies suggest that this might be an underestimate (Donnelly et al 2005, Leese et al 2003). It is therefore necessary to review the education John received when diagnosed with type 2 diabetes and when he started on insulin therapy. There might be clinical reasons why John has started to become hypoglycaemic and these must be considered. The possible causes of these hypoglycaemic episodes should be discussed (see Box 11.5).

Each of these issues should be discussed in a session with John. On reflection, he might thereafter understand what has caused his hypoglycaemia and also how to prevent it recurring. Sometimes, however, the cause is not obvious and clinical causes should be considered. These include:

In the event of no cause being found then insulin needs to be reduced and John is encouraged to learn and become confident in adjusting his insulin.

Treatment should be discussed with John and his family/friends as overcorrection can lead to rebound hyperglycaemia and undercorrection can lead to recurrence of the hypoglycaemic episode within a short space of time. Hypoglycaemia can be treated with:

John should be encouraged to carry fast-acting carbohydrate with him at all times. He should also have a card or equivalent that identifies him as having diabetes in case he should have a severe hypoglycaemic episode that requires external help.

Symptoms of hypoglycaemia vary from person to person and most people experience only one or two of a number of possible symptoms (M^cAuley et al 2001). John is already clear that his symptoms include tremor and profuse sweating and this wakes him up at night. However, it has been shown that people can sleep through overnight hypoglycaemia and wake up in the morning none the wiser (Diabetes Control and Complications Trial (DCCT) 1993). A history of headache or feeling ‘hungover’ might be a clue to overnight hypoglycaemia. A nocturnal hypoglycaemic episode is frightening for the individual and their bedfellow! People who require reassurance about this are advised to check their blood glucose level before going to bed at night and, if below 6 mmol/L, to consume extra carbohydrate before sleeping. It might be necessary to reduce the overnight basal insulin; however, the use of a short-acting insulin analogue with evening meal or within a fixed mixture of insulin has also been shown to reduce the incidence of night-time hypoglycaemia (Hermansen et al 2001).

Hypoglycaemic symptoms can be experienced at glucose levels greater than 4 mmol/L. If John’s blood glucose levels had been running consistently high for a period of time then, when the blood glucose falls, John might experience hypoglycaemic symptoms but not be at risk of impaired consciousness. The experience of hypoglycaemia is still very unpleasant and needs to be treated in the same way; however, as John improves his glycaemic control then his symptoms of hypoglycaemia would occur at a lower level.

John is right to be concerned about hypoglycaemia because there is a possibility if he continues to have episodes regularly his warning symptoms will become impaired or lost. If this happens then John would be asked to reduce his insulin doses and run his blood glucose levels at a higher level, completely avoiding all hypoglycaemia for a period of about 3 months. Thereafter, his insulin dose could be increased gradually to optimise glycaemic control and he should then find that his warning symptoms have returned. In a few people, warning symptoms do not return and specialist advice should be sought.

Hypoglycaemia is normally classified as mild (self-recognised and self-treated), moderate (usually conscious and able to self-treat or be treated with help from another person but without emergency intervention) and severe (requires the assistance of a third party and normally emergency intervention). Treatment of hypoglycaemia depends on the individual’s level of consciousness and should preferably be administered after confirmation of blood glucose. If the individual needs help from another (apart from medical help) then there are two treatments that can be administered by others.

Glucose in the form of a viscous gel (‘Hypostop’ now known as ‘Glucagel’) can be squeezed into the mouth if the person is uncooperative and is of particular value in children but should not be used if a person is unconscious.

Left untreated, the person would eventually lapse into a hypoglycaemic coma and would require assistance from someone for treatment. In this situation, relatives and friends can be taught how to administer glucagon 1 mg intramuscularly. Glucagon (known as ‘Glucagen’) is available in convenient packs containing 1 mg of the dried form of the agent and 1 mL diluting solution. The expiry date needs to be checked regularly and another prescription obtained before the current vial expires. Glucagon can be rapidly dissolved and injected subcutaneously or intramuscularly by another adult. A competent healthcare professional can give glucagon intravenously. The person should recover within 10 minutes then be encouraged to consume at least 20 g oral carbohydrate to replace glucose stores.

It is not unusual if a person is in a hypoglycaemic coma for emergency attention to be sought even though relatives or carers administer glucagon. Likewise, it should be sought calmly and quickly in the event of a person’s inability to swallow or loss of consciousness. While glucagon can bring a person out of a comatose state, it is not without its problems. One problem with glucagon is that it can cause nausea and vomiting, so although the person becomes more responsive, he or she may be resistant to eating or drinking. It is, however, necessary for the individual to eat in addition to receiving the glucagon injection to replenish liver glycogen stores and prevent secondary hypoglycaemia.

Glucagon is less effective when the person has been unconscious for a prolonged period of time (Cryer et al 2003). Under these circumstances, an intravenous injection of 50% dextrose is preferred and this is usually carried out in the hospital emergency care department. People can experience a severe headache for up to 24 hours after a prolonged episode of hypoglycaemia. Remember that although used in type 1 diabetes, glucagon is less useful in type 2 diabetes as hypoglycaemia, when induced by sulphonylureas, is often prolonged and a rise in glucose will stimulate a further rise in insulin secretion (Cryer et al 2003).

In the elderly, hypoglycaemia might simulate a transient ischaemic attack or a cerebral vascular accident. It is therefore important to check a blood glucose level in any elderly person who presents with neurological signs. Although these might appear to be of a minor nature, all such individuals should be admitted to hospital for a minimum of 24 hours for observation.

Exercise has many physical and psychological benefits especially for people with diabetes. A moderate to high level of exercise in people with type 2 diabetes has been shown to reduce the risk of cardiovascular mortality (Hu et al 2005). In another study, regular exercise was associated with reduced development of metabolic risk factors for cardiovascular disease, fewer exercise-induced cardiac abnormalities and reduced comorbidity (Petrella et al 2005). Exercise promotes a feeling of well-being and also improves the tissue sensitivity to insulin, thus decreasing insulin resistance. It is recommended that all people should be advised to maintain at least moderate levels of physical activity on a regular basis (SIGN 2001). The recommended form of exercise builds on what a person currently does rather than commence some new strenuous form of exercise. An example of this would be to increase the distance they walked each day for example, by walking to a further bus stop rather than using the closest one. When discussing exercise with people it is worth mentioning that physical activity such as gardening and housework can be regarded as a form of exercise, and not only those activities associated with recreational exercise. However, for those people with type 2 diabetes who wish to pursue a new form of exercise, a medical examination by their GP is advisable to ensure that there are no contraindications. Warm-up and cool-down exercises are recommended to avoid undue physical stresses to muscles and joints.

Everyone with diabetes is advised to carry some form of identification to inform others that they have diabetes. This may be a card, a Medical Alert bracelet or a similar locket. Most pharmaceutical companies produce identification cards and there are advertisements in the Balance magazine of Diabetes UK for these products.

The combination of smoking and diabetes has been shown to escalate coronary heart disease, arterial disease (UKPDS 1998) and renal disease (Biesenbach et al 1997). Hence, the person who smokes is at greater risk of having heart disease, a cerebrovascular accident or developing peripheral vascular disease. People might not be aware of the increased risks due to both conditions and every effort must be made to strongly encourage those who smoke to stop. Those people wishing to stop should be referred to the smoking cessation support in primary care or increasingly at local pharmacies. There are various methods recommended to help people stop smoking (SIGN 2001). These include the use of nicotine patches, group or individual counselling and hypnosis. A recent study showed that cigarette smokers with diabetes had poor awareness, knowledge and uptake of smoking cessation treatments and concluded that this is a neglected area of diabetes education (Gill et al 2005).

Stress, both physical and psychological, can have adverse effects on an individual’s blood glucose levels. This is important because suboptimal glycaemic control can be a symptom of stress and diabetes education would include assessment as to whether there were physical or emotional barriers to self-management. This holistic approach to care views the individual as a whole person and not just the sum of the parts (see Chapter 3).

Healthy drinking limits are the same for all whether or not they have diabetes. The recommended limits are 14 units of alcohol per week for women and 21 units of alcohol per week for men. People who are trying to lose weight should restrict their alcohol intake further (see Chapter 6). Alcohol taken with food seldom causes problems unless drunk to excess. When excessive alcohol is taken, hypoglycaemia can result. Others might wrongly assume that the person is drunk and not appreciate that the person needs glucose. People should be advised not to drink on an empty stomach but to consume food as well. Specific guidance is required for those who are trying to follow a calorie-restricted diet, and they should be referred to the dietician for this (see Chapter 6). It is difficult to manage diabetes if the person concerned has problems with excessive alcohol intake. People should be advised that there might be a greater lowering of their blood glucose if they undertake exercise after consuming alcohol (SIGN 2001). Both sulphonylureas and insulin can cause profound hypoglycaemia in the presence of excess alcohol. Under these circumstances, relaxing of glycaemic control is necessary if there is concern about excessive alcohol intake. The person should be encouraged to eat while drinking alcohol and to consume a carbohydrate-rich snack before going to bed.

A recent, large, multicentre study showed that people with type 1 diabetes were more likely to have driving mishaps due to hypoglycaemia than people with type 2 diabetes. However, it was found that half of those with type 1 diabetes and three-quarters of those with type 2 diabetes had never discussed hypoglycaemia and driving with their physicians (Cox et al 2003). This is clearly an important and neglected area of diabetes education.

In the UK, only those on oral hypoglycaemic agents or insulin therapy are required to inform the Driving and Vehicle Licensing Authority (DVLA). The responsibility for informing the DVLA lies with the individual. The primary healthcare team must ensure that the person is aware of this obligation. Once the DVLA has been informed then those on insulin therapy have a driving licence that is issued for 3 years and renewed at 3-yearly intervals thereafter, provided there is a satisfactory medical report. Those on oral hypoglycaemic agents will be given information and invited to inform the DVLA if there is any change in their treatment. They must also inform the DVLA if there is any other diabetes-related reason that might impair their ability to drive, i.e. diabetic eye disease. Once the person reaches 70 years of age the driving licence is renewed annually subject to a satisfactory medical report. This report is usually obtained from the GP or hospital specialist.

By contrast, in Northern Ireland the regulations state that every person with diabetes must inform the DVLA for Northern Ireland, regardless of their treatment. It is anticipated that this will change in the near future and will be brought into line with the DVLA in the rest of the UK. Those people who are controlled by diet or diet and tablets are issued with a licence for 10 years. Those individuals requiring insulin are issued with a licence for 1–3 years (Deegan 1995).

The great risk to the person and others is of hypoglycaemia while driving. For this reason, people who are taking a sulphonylurea or insulin are usually prohibited from driving any form of public service transport or heavy goods vehicle. Indeed, it is currently against the law for a Large Goods Vehicle licence or a Passenger Carrying Vehicle licence to be issued to a person requiring insulin therapy. As the UK becomes more involved in the European Union, this discretionary basis is likely to disappear. Helpful details can be downloaded from the Diabetes UK website (www.diabetes.org.uk).

Prevention of hypoglycaemia when driving is paramount. Any journey must be planned, especially a long journey. A blood glucose measurement must be taken before commencing any journey and carbohydrate consumed if below 5 mmol/L as driving becomes impaired when blood glucose is at 3.6 mmol/L (Cox et al 2003). Thereafter, blood glucose should be monitored at intervals on long journeys. A journey should not be undertaken when the person has injected insulin without having eaten. The person must allow for stops for food and to monitor blood glucose levels every 2 hours. Both rapidly absorbed carbohydrate and more substantial carbohydrate should be kept in a car in case of breakdown or delays in traffic, which could cause circumstances leading to hypoglycaemia.

Glucose must be kept in the car within easy access. If the person should feel hypoglycaemic, he or she should stop the car (using the hard shoulder on a motorway if needs be), switch off the engine, get out of the driver’s seat and take glucose to correct the hypoglycaemia. All this is required because the person could legally be charged with being in control of a vehicle while under the influence of drugs (Frier 1999). It is recommended that the journey is not resumed until 45 minutes after the hypoglycaemic episode so that cognitive function is fully resumed (Frier 1999).

All people with diabetes who are drivers should be advised to have their eyesight checked regularly and not to drive if their vision deteriorates suddenly or if their visual acuity with glasses is less than 6/12 in both eyes. Any eyesight changes must be notified to the DVLA.

It is illegal for employers to discriminate against people with diabetes except when there is substantial risk. Therefore people who are in employment are strongly advised to inform their employer of their diabetes. For those who have type 2 diabetes treated with diet and/or metformin there is not usually any problem with this. People who have type 1 diabetes or type 2 diabetes on sulphonylureas or insulin may find that certain aspects of their job are restricted because of the risk of hypoglycaemia.

There are, however, some forms of employment which are prohibited to any person who has type 1 diabetes (Box 11.7). Diabetes UK has lobbied hard to reduce the use of a ‘blanket ban’ on recruitment and is pressing hard for individual assessment (Diabetes UK 2005). Any employment where hypoglycaemia might not only endanger the life of the individual but also the lives of others is either prohibited or will require careful individual assessment. Those people who are currently employed in jobs that are classed as high risk and who then acquire type 1 diabetes might be allowed to continue in employment but in a less demanding post. Some forms of employment could be considered as inadvisable for a person with type 1 diabetes to pursue, again because of the risk of hypoglycaemia (Box 11.7).

While it is possible for people with type 1 diabetes to undertake shift work, they will need advice regarding insulin doses and the balancing of food intake to accommodate this. Where this is relevant, the person would be advised to visit his or her diabetes specialist nurse for detailed, personal advice.

Diabetes is a condition for which a person can register as disabled within the UK. However, people should be warned of the employment consequences of being thus labelled. They should also be advised that, once registered as disabled, they cannot request removal from the register at a later date. The Disability Discrimination Act (1995) introduced new laws to reduce discrimination against disabled people and this should help people with diabetes seeking some types of work from which they were previously excluded, such as in the emergency services. For further information see the Diabetes UK website (www.diabetes.org.uk).

As mentioned earlier, those people whose diabetes is controlled by the use of oral hypoglycaemic agents or insulin are eligible for prescription exemption within the UK. Previously, individuals controlled by diet were also exempt but this is no longer the case as the ‘diabetic diet’ is now regarded as healthy eating and not a ‘special diet’ (see Chapter 6). To apply for prescription exemption, the person must complete a FP92A form, which is available from the local social security office, some GP surgeries and local pharmacists. The person’s GP, who is required to complete part of the form, will then send it to the Family Health Services Authority (FHSA). The FHSA issues the exemption certificate and on its presentation, the person has exemption from paying for any items which are available on prescription. Prescription exemption can make a financial saving for those individuals who have multiple comorbidities requiring several different medications.

There are other benefits to which people with diabetes may be entitled within the UK. Further advice can be obtained by contacting the local Citizens’ Advice Bureau, the welfare rights adviser or social services department. Although several social security benefits are available, not everyone with diabetes is eligible for them. All people with diabetes are eligible for a free NHS eye test. However, only those on a low income are eligible for NHS vouchers for glasses. All these areas of policy are subject to change and if required the Citizens’ Advice Bureau webpage and advice guide can be consulted (www.citizensadvice.org.uk, www.adviceguide.org.uk).

People should be advised to inform all the insurance companies from which they have relevant policies once they are diagnosed as having diabetes. The responsibility for informing the various companies rests with the individual; this includes driving insurance. Failure to do so might jeopardise future claims. Some companies confer an additional premium for people with diabetes. The Disability Discrimination Act (1995) has not led to a reduced premium for life assurance or health-related policies as there is proof of higher risk for people with certain conditions, including diabetes. It is therefore important to shop around and receive quotations from several different companies. Diabetes UK has special arrangements with various insurance companies for people with diabetes. Advice can be given on motor insurance, life assurance and travel insurance. People should be encouraged to contact their regional Diabetes UK office for further information.

Diabetes UK, formerly known as the British Diabetic Association, is a charitable organisation, set up in 1934 by Dr R D Lawrence and the author H G Wells, both of whom had diabetes. Diabetes UK was the first patient organisation in the UK and promotes quality care for people with diabetes through campaigning, providing information, support and also funding research. It has an Advisory Council of people with diabetes and healthcare professionals to provide guidance on policy and care issues. Under the auspices of Diabetes UK, there are over 400 active local groups which are run entirely by volunteers. These groups offer support and companionship to people with diabetes and their carers. There are also a number of support events, such as adult and family weekends, children’s holidays and diabetes for life conferences throughout the UK. In addition, there is a network of regional offices to support and promote the work of Diabetes UK at a regional and national level across the UK. A careline (0845 1202 8960) is also available for professionals and people who wish to seek support and advice.

Those who join Diabetes UK receive a copy of Balance magazine bimonthly, updates on local or UK work and information on local Diabetes UK groups. The Balance magazine is for people with diabetes and is a welcome resource on current issues in diabetes management. Voluntary groups play an important part in caring for people with diabetes and people should be encouraged to link up with their local group.

For the healthcare professional, Diabetes UK is a valuable resource centre, which offers help and advice on a wide variety of topics. Healthcare professionals also have the opportunity to join Diabetes UK, which offers information and supplies professional journals.

Travel abroad is no longer an aspiration but a reality for many. Overseas travel can pose special problems but these can be minimised by taking a few simple steps prior to departure. Samantha will need a consultation with her diabetes care team to discuss insulin adjustment in relation to the times of her flights, meals taken and time change experienced. She should contact the travel agent or airline involved and request anticipated mealtimes and flight duration. This information, along with departure and arrival times, and time zone differences, should be made available to the diabetes team so that Samantha can be advised on insulin adjustment. Although not necessary in Samantha’s case, it must be remembered that all immunisations should be completed 1 month before travel to allow time to recover from side effects.

Before travelling, Samantha should be advised to pack extra insulin, two insulin pens and/or syringes, a blood glucose monitoring device, lancets and test strips and prescription medicines such as glucagon where needed. These should be packed in hand luggage. A travelling companion, in this instance her husband, should carry extra supplies in case hand luggage is lost. Samantha should also have supplies of both simple and complex carbohydrate sources, such as glucose tablets and biscuits in case of hypoglycaemia, identification such as an identity card, insurance papers and medication for diarrhoea (Chandran & Edelman 2003, Diabetes UK 2002). Before departure she should obtain a doctor’s letter containing a list of medication and any medical devices that she must carry. The letter should also include any allergies or medications to which Samantha is sensitive. As she is travelling by air, this letter should be presented to airline staff at check-in. All medication, especially insulin, should be carried in Samantha’s hand luggage and must not be stored within the cargo hold of the aircraft as this will be subject to temperature extremes and so the medication might be damaged. For up to date information on air travel contact the Diabetes UK website.

Special diabetic airline meals are available but tend to be low in carbohydrates. A standard airline meal, supplemented with extra bread, fresh fruit or beverages where necessary is recommended. Samantha should wait until she receives her meal on the plane before taking her insulin in case of delay in eating or low carbohydrate content of the meal. For those on oral agents, such as sulphonylureas, it might be easier to skip a dose and have slight hyperglycaemia for 6–8 hours than to take two doses too close together (Chandran & Edelman 2003).

Having arrived at her destination, Samantha will store her insulin in a thermal insulated bag or refrigerator, if available, as insulin vials maintain their potency at room temperature but not in temperatures that are either too warm or freezing. She should be advised that blood glucose meters generally perform best between 15 and 35°C, when outside these temperatures she should always check her meter with a control solution. If Samantha has problems with peripheral neuropathy or arteriopathy then she will need to be aware of foot-care guidelines, including avoiding going barefoot in case of foot injury. In the event of illness, injury or loss of medication, a list of English-speaking doctors practising abroad can be obtained from the International Association for Medical Assistance to Travellers at www.iamat.org. Samantha should be advised that insulin might be named differently in other countries and might come in different strengths, thus she should always double-check and ask about prescriptions when uncertain.

Travelling is an opportunity to revise what to do if unwell (Box 11.6). There is no reason why people with diabetes should avoid travel; early planning considering diabetes needs should ensure a happy and successful journey.