The Road Traffic Acts require that diabetics (irrespective of treatment) who are either applicants or driving licence holders must notify the DVLA of their condition and of any problems or diabetes complications that develop that may affect the safety of driving. Failure to inform the DVLA is now a criminal offence. For medico-legal reasons, health-care professionals should document in the medical records that they have advised the patient to notify the DVLA. GPs may be contacted by a medical officer from the DVLA with a request for further information (usually a DIAB3 form), such as details about glycaemic control (particularly the risk of hypoglycaemia), visual problems and any limb problems.

The medical standards for licence entitlement (more stringent for Group 1 than Group 2 licences) include:

1. Adequate visual acuity with or without correction, equivalent of Snellen chart 6/12

2. Minimum visual field of at least 120° on the horizontal, with no significant defect in the binocular field

3. Adequate awareness of hypoglycaemia. In addition, if frequent episodes impair driving, then driving “must cease” until adequate control is regained

4. If limb disability is present, driving is possible in both static and progressive or relapsing disorders, but vehicle modification may be needed and the DVLA notified

5. Absence of significant symptoms, e.g. sudden disabling attacks of giddiness or fainting or impaired psychomotor or cognitive function.

Group I (ordinary) licence holders and applicants on insulin are granted a licence up to 3 years. On renewal they are required to make a self-declaration that may lead to medical enquiries. Those treated with diet and tablets or diet alone are permitted to hold a licence valid to 70 years of age, subject to the conditions and the need to report any change to insulin treatment. For Group 1 (ordinary) licence holders and applicants, a questionnaire (Diabetic 1) needs to be completed (downloadable: http://www.dvla.gov.uk/drivers/dmed1_files/pdf/diab1.pdf).

Since 1991, diabetics on insulin have been banned from applying for and renewing thereafter a Group 2 (bus, coach and large goods vehicle driver) licence. Diabetics on diet alone or diet and tablet treatment are permitted to hold a Group 2 licence, subject to the absence of any relevant disability and to not being on insulin. Also, drivers with insulin-treated diabetes should not drive emergency vehicles, due to “… the difficulties for an individual, regardless of whether they may appear to have exemplary glycaemic control, in adhering to the monitoring processes required when responding to an emergency situation” (DVLA 2006).

Insulin is a drug within the meaning of the Road Traffic Act 1988, and a driver “in control of a motor vehicle” with symptoms of hypoglycaemia runs the risk of being charged with driving under the influence of drugs. To avoid this and to correctly manage a hypoglycaemic episode:

• The vehicle must be stopped (with ignition switched off) and in a safe place

• The driver not seated behind the steering wheel

• The low blood glucose level should be corrected (with either a suitable source of sugar or glucagon)

and

• The journey should not be resumed until recovery is complete. This may take 15 or more minutes and the blood glucose level should be checked first.

INSURANCE

If an insurance company asks about diabetes, then the applicant must inform the company if he is diabetic. Failure to do so and also to notify the DVLA can invalidate cover in the event of a claim.

Since the Disability Discrimination Act (1995) came into effect at the end of 1996, insurers can refuse or charge more for cover only with evidence of an increased risk of making a claim. However, because most evidence available about diabetic drivers indicates that they pose no higher risk than nondiabetic drivers, many insurance companies no longer ask about diabetes when cover is applied for.

Some companies, who base their risk assessment on their experience of drivers with diabetes, may still refuse cover or impose special terms or charge an increased premium if their statistics “show” a higher risk. When this happens, it is worth challenging the insurer, especially if the applicant’s diabetes is stable and well controlled. It is always worth shopping around for quotes from a number of insurers, as premiums can vary considerably.

MEDICAL PROBLEMS THAT MAY AFFECT DRIVING

Patients and professionals need to be aware of the following that can affect driving:

• Visual problems arise usually from either retinopathy or cataract. Incorrectable deterioration of visual acuity, loss of peripheral visual field through widespread ablative retinal photocoagulation, may also result in loss of fitness to drive.

• Hypoglycaemia (discussed above).

• Neurological and/or vascular deficit may result in severe damage to the feet (leading to ulcers, or even amputation), and so also results in loss of fitness to drive.

• Arterial disease may result in cardiovascular and/or cerebrovascular disability, which affects fitness to drive.

• Alcohol lowers blood glucose levels, increasing the risk of hypoglycaemia in those on insulin or certain oral medication. A hypo may look like drunkenness; if the breath smells of alcohol this could heighten suspicion. Hyperglycaemia, even in the presence of ketones, will not affect a breathalyser machine.

IMMUNISATIONS

QOF

DM18

Influenza and pneumonia are common, preventable infectious diseases associated with high mortality and morbidity in people with chronic diseases, such as diabetes. There are limited data on the morbidity and mortality of influenza and pneumococcal pneumonia specifically in diabetics. Safe and effective vaccines are available that can greatly reduce the risk of serious complications from these diseases. Unless contraindicated, the DoH recommends immunisation against influenza and pneumococcal pneumonia in all individuals with diabetes.

EMPLOYMENT

Diabetes UK has produced a useful booklet, Employment and diabetes.

FINDING A JOB

Diabetics on insulin are still not allowed to be in the following occupations:

• Driving either a heavy goods or public service or emergency vehicle

• Certain jobs in the Armed Forces, such as front-line troops and pilots

• Working offshore, such as on an oil rig or cruise ship

• Working at heights

• Being a jockey.

Since October 2004, blanket bans have been lifted for diabetics joining the police, fire and ambulance services, but applicants need to demonstrate that their diabetes is well controlled (with hypo-awareness), regularly monitored, and free of complications. The minimum levels of physical and mental fitness are still necessary for all applicants.

Any diabetic is entitled to be considered for any employment for which he is otherwise qualified. UK (via the Disability Discrimination Act) and European legislation offer protection against discrimination in employment against individuals with a medical condition such as diabetes. Due to a lack of up-to-date knowledge about diabetes, employers may fear that a diabetic poses a potential safety risk to the employer and/or the public. Most diabetics can manage their condition so that there is minimal risk of incapacitation from problems such as hypoglycaemia (ADA 2007). Employers need to consider whether the individual’s qualifications and medical circumstances (the condition, its treatment and any specific risks or problems) can be matched to the job specification. The Disability Rights Commission provides useful information for both employers and workers with long-term conditions such as diabetes.

Changing working hours

Working shifts can increase the risk of developing either metabolic syndrome or type 2 diabetes (Knutsson 2003). Altering working hours, such as changing shifts or working overtime, can disrupt eating and sleeping patterns in people with pre-existing diabetes, and may lead to a worsening of glycaemic control, particularly if the rotation pattern is rapid. Increased physical activity can affect blood glucose levels, and may require adjustments in calorific intake and treatment to maintain reasonable glycaemic control. Physically demanding work at unexpected times increases the risk of hypoglycaemia.

The following advice may be useful to diabetics working odd hours:

• Make sure meals or snacks are available

• Try to arrange meal breaks to be at set times

• Have a fast-acting carbohydrate snack readily available at all times in case of hypoglycaemia

• Monitor blood glucose levels more frequently

• Ensure that work colleagues are aware of diagnosis of diabetes, especially if working alone.

If on insulin, then it is sensible to use a newer prolonged-acting insulin (insulins glargine or detemir) as the basal insulin. These have the advantages of only being administered once daily and at the same time of day irrespective of the work pattern. Rapid-acting analogues (insulins lispro, aspart or glulisine) can then be administered to cover unpredictable and variable mealtimes. Where possible, patients should aim to time meals at 4 to 5 hour intervals, with snacks if required, and to keep to consistent quantities and types of food.

Adjustments to dosages, type and/or timing of insulin are usually necessary when working shifts, although administering insulin can usually be delayed 1 to 2 hours without significantly affecting diabetic control. This may be sufficient to cover an afternoon shift. If extra food is consumed later in the day, an appropriate increase in the later insulin dose may be needed. Major changes, such as moving to and from night shifts, require careful planning of food intake (more during the shift) and insulin administration, and patients may seek professional advice.

INTERCURRENT ILLNESS

The stress of illness can produce transient insulin resistance and worsen glycaemic control; even if there is little or no calorific intake. Patients treated with diet only or on oral medication may temporarily require insulin.

The following advice should be given to diabetics who become unwell:

• Keeping testing blood (or urinary) glucose regularly throughout the day

• Do not stop basal insulin, although the dose may need adjusting

• Try to drink plenty of fluids (water, sugary fluids or milk) and, if possible, eat soups, snacks or biscuits to maintain a calorific intake

• If unable to keep anything down or if urine test for ketones becomes positive or if having trouble controlling blood glucose, seek medical help. Hospital admission may be necessary more often in diabetics to treat infection and/or correct dehydration.

TRAVEL

Diabetics do and should be able to travel. They need to observe the same precautions as the rest of the population, but also to make their own arrangements to reduce the risk of diabetes complications and emergencies. Constant perfect glycaemic control is not an absolute necessity, but the extremes of hypoglycaemia and hyperglycaemia should be avoided.

Pre-travel planning is essential and involves obtaining essential information, ensuring current optimal diabetic management and having in place all the necessary arrangements. Health-care professionals and organisations, such as Diabetes UK and the NHS Scotland (on its website, www.fitfortravel.scot.nhs.uk), can provide useful information.

DOCUMENTATION

Patients should wear or carry some form of medical identification, such as a bracelet or necklace. In this period of heightened concerns about travel security, diabetic travellers should carry a practice- or hospital-headed letter from their practice that lists their medical problems, repeat medication and supplies, and confirms that their medication and devices (including needles and syringes) are required and appropriate for their personal therapeutic needs, and needs to be carried on the plane. This letter should be shown at check-in and at Customs. It may also be useful if seeking medical attention abroad.

INSURANCE

It is prudent to obtain adequate travel insurance and to carry the necessary sickness insurance forms in case of illness abroad. It is important to check that “pre-existing conditions” are not excluded.

Holders of the European Health Insurance Card (EHIC), which has replaced the old form E111, are entitled to reduced-cost or sometimes free essential medical treatment in all countries in the European Economic Area and Switzerland. Travellers with chronic conditions, including diabetes, may also be covered for treatment. This card should be obtained prior to departure, either online, via: http://www.dh.gov.uk/PolicyAndGuidance/HealthAdviceForTravellers/GettingTreatmentAroundTheWorld/fs/, or by telephoning 0845 606 2030, or from a Post Office.

It is advisable to also obtain travel insurance. Among the options available, Diabetes UK Insurance Services offers its own products, available online from May 2006 (see Diabetes UK website and follow links).

VACCINATIONS

Diabetics are advised to have the necessary vaccinations well in advance of departure, as these may cause a transient disturbance of glycaemic control.

PACKING

Diabetics should carry sufficient and suitably packed supplies of their medication (including either glucagon or glucose tablets to treat hypoglycaemia), supplies, testing equipment, and documentation for their trip. If possible, prescription medications should be kept in their original containers, and other items (such as syringes, alcohol swabs and test strips) should be packed in plastic bags with zipper-type seals. Any glass items should be wrapped carefully in socks or placed between soft clothing during transport.

If flying, then medication, supplies, fast- and slow-acting carbohydrates, and documentation should be packed in carry-on luggage, rather than stowed. Extra quantities should be taken in case of delays, mishaps or if further supplies are unlikely to be available at the destination.

Insulin must be kept out of direct sunlight and should always be kept cool, either in a cool bag or some form of cool storage, although open insulin vials retain their potency at temperate room temperatures for up to 1 month. Insulin should not be kept in car glove compartments (too hot) or in checked luggage (it will end up in the plane’s hold where it might freeze. After defrosting, it is likely to be less active).

MEDICATION

In a few countries insulin is not available in U100 strength, but in U40. If patients switch to U40 insulin abroad, to ensure the correct dose they should also use U40 syringes and so avoid any mixture with U100.

MODIFYING TREATMENT REGIMENS

In aiming to avoid hypoglycaemia or marked hyperglycaemia, diabetics are advised to run their blood sugars slightly higher than normal, particularly during long journeys.

OTHER PRECAUTIONS

Drinking only bottled water, avoiding salads and being careful about hygiene levels in restaurants are sensible precautions. Diabetics need to take on holiday comfortable, well-fitting shoes in case their feet swell in hot weather. They should avoid going barefoot, particularly on hot sand. As with nondiabetic travellers, appropriate emergency medication should be carried.

PREGNANCY AND GESTATIONAL DIABETES

NSF

Pregnancy in women with previously diagnosed type 2 diabetes is a different condition from gestational diabetes mellitus. However, many components of management are the same for both conditions.

PREGNANCY IN WOMEN WITH PREVIOUSLY DIAGNOSEDTYPE 2 DIABETES

Pregnancy is associated with increased risks in both type 1 and type 2 diabetes. Major congenital malformations remain the leading cause of mortality and serious morbidity in infants of mothers with type 2 diabetes (ADA 2007). The development of congenital malformations of major organs correlates with elevated HbA1c levels, both at conception and during the first 8 weeks of pregnancy.

With the increasing prevalence and earlier onset of type 2 diabetes, it is possible that primary care will encounter type 2 diabetics who conceive and become pregnant. However, the lead in the management of these women should be a specialist obstetric-endocrine clinic to achieve best outcomes.

MANAGEMENT

Monitoring should be undertaken for other known risks, and managed according to best practice.

Pre-conception

It is at this time that primary care can play a valuable role. There is evidence that foetal malformations can be reduced or prevented by careful management of diabetes before conception. However, many women with diabetes who conceive, have unplanned pregnancies, making it difficult to provide pre-conception care.

Type 2 diabetics are less likely to receive pre-conception counselling than those with type 1 diabetes. Care should aim to address the following areas:

• Weight management. Prior to conception, the woman should aim to achieve a BMI of less than 27 kg/m² weight loss may be indicated.

• Glycaemic control should be optimal at conception, aiming for a “reasonable” HbA1c (trying to avoid sustained hyperglycaemia). If on oral hypoglycaemic medication or if HbA1c is raised, then the patient should be started on insulin prior to conception.

• Diet should be low in fat, high in complex carbohydrates and high in dietary fibre.

• Increased physical activity can be encouraged.

• Certain drugs commonly prescribed to women with diabetes should be stopped prior to conception: statins, ACE or ARB, metformin (but see below) and acarbose.

Ante-natal care

Maintaining optimal glycaemic control is the key to achieving the best maternal and neonatal outcomes. The specialist obstetric-endocrine clinic team may include not just an obstetrician and diabetologist, but also a dietician and a diabetes specialist nurse. However, primary health-care professionals often play a supporting role.

For optimal glycaemic control during pregnancy, the suggested target capillary plasma glucose levels are:

• Before meals: 4.4–6.1 mmol/l

• 2 hours after meals: less than 8.6 mmol/l (DoH/Diabetes UK 2005).

Folic acid

As in GDM, pregnant diabetics are at increased risk of having babies with neural tube defects (NTDs). They should be prescribed (as this dose is prescription-only medicine) a daily supplement of 5 mg of folic acid before conceiving and during the first 12 weeks of pregnancy.

Diet

The timing of meals should be to ensure a regular and adequate caloric intake throughout the day; however, calorific intake needs to be monitored to prevent excessive weight gain (greater than 9 kg). Women are advised to avoid concentrated sweets. The diet should also contain adequate nutrients to meet the needs of pregnancy. Obese women should avoid daytime snacks and restrict their calorific intake.

Glycaemic medication

To achieve good glycaemic control and current practice is that insulin should replace oral medication, although no insulin is actually licensed for use during pregnancy (DoH/Diabetes UK 2005). The dosage, type and regimen should be tailored to the needs of the individual. If on an established insulin regimen, including analogue insulin, then change is not always necessary; however, there is no evidence for the safety of insulin glargine in pregnancy. It is likely that basal (intermediate- or prolonged-acting) insulin will be needed, in addition to prandial (rapid- or short-acting) insulin before meals.

However, it may be possible to use certain oral hypoglycaemic agents in pregnancy without increasing the risk of congenital malformations occurring. In a recent review, there was no difference found in outcomes between pregnant women treated with metformin and “controls” (Hughes & Rowan 2006). There is also evidence to suggest that the level of glycaemia at conception and subsequently correlates with the development of anomalies, and not the use of certain oral agents.

Hypoglycaemia

The risk of hypoglycaemia is greater in early pregnancy. Those close to the woman should be instructed in the recognition, management and treatment of hypoglycaemia. If a woman loses her hypoglycaemia awareness during pregnancy, she should be advised not to drive.

Physical activity

Although there is insufficient evidence to recommend, or advise against, diabetic pregnant women enrolling in exercise programmes (Ceysens et al 2006), moderate exercise after meals should be encouraged, but women need to be cautioned about hypoglycaemia.

Blood pressure

Women with type 2 diabetes are more at risk of developing hypertension during pregnancy.

Fundoscopy

Women with existing diabetic retinopathy are at increased risk of the retinopathy progressing during their pregnancy. Thus, more frequent eye screening may be necessary. Detailed retinal screening is advised in both the first and third trimesters (DoH/Diabetes UK 2005). If new vessel formation (and, occasionally, macular oedema) is found, then treatment must be started promptly.

Labour and delivery

If delivery occurs before 36 weeks’ gestation, then corticosteroids (betamethasone) should be administered to prevent neonatal respiratory distress syndrome. Additional insulin usually needs to be given to prevent severe maternal hyperglycaemia.

With good glycaemic control, and in the absence of significant diabetic or other complications, it may be possible to prolong pregnancy to 39 weeks to achieve a vaginal delivery, although this may vary according to local policy. The rate of delivery by caesarean section is higher than in women without diabetes. Women need to be assessed at 38 weeks’ gestation to plan for the delivery. Delivery takes place in a consultant-led unit, with neonatal intensive care available.

Postpartum

Immediately after delivery of the placenta, maternal insulin sensitivity improves. If on insulin prior to pregnancy, then the dose usually returns to that at pre-conception.

Breast feeding

Breast milk contains lactose: every time a woman feeds her baby, her blood glucose level will fall. To help prevent hypoglycaemic episodes, women who are breast feeding may need to reduce their insulin dose (by up to 30%) and/or increase their intake of starchy foods. This will vary between women.

GESTATIONAL DIABETES MELLITUS (GDM)

This is defined as diabetes mellitus with onset or first recognition during pregnancy. Pregnancy can act as a metabolic stress test for diabetes, resulting in gestational diabetes developing in those who “fail”. The condition should be regarded as heterogeneous, as women who develop it may be either obese, hyperinsulinaemic and insulin-resistant or thin and relatively insulin-deficient.

Much of the management of women with GDM should be the same as for pregnant women with diabetes previously diagnosed.

Diagnosis

Criteria

The diagnostic criteria for GDM are the same as for other diabetes. However, the ADA’s clinical practice recommendations do appear to have lower blood glucose thresholds for the diagnosis, following a 100 g (not 75 g) glucose load modified OGTT.

Screening

Pregnant women should be screened for diabetes. Diabetes UK recommends performing an OGTT, using a 75 g glucose load for the challenge, in women with “random” plasma glucose levels greater than 6.1 mmol/l fasting or 7.0 mmol/l within 2 hours of food. The diagnostic criteria for GDM, as defined by the World Health Organization (WHO), are levels of venous plasma glucose greater than 7.0 mmol/l fasting (same as normal diabetic criterion) or 7.8 mmol/l 2 hours post challenge (in the impaired glucose tolerance range of “standard” diabetes).

The ADA recommends performing an OGTT using a 100 g glucose load for the challenge, since using a 75 g load has not been “as well validated for detection of at-risk infants or mothers” (ADA 2007). The ADA diagnostic criteria for the 100 g glucose load OGTT are two or more plasma glucose values at or above:

• 5.3 mmol/l (fasting − 8–14 hours without calorific intake)

• 10 mmol/l (at 1 hour)

• 8.6 mmol/l (at 2 hours)

• 7.8 mmol/l (at 3 hours).

Management

Ante-natal

• Glycaemic control – basal insulin may not be required. However, small doses of short- or rapid-acting insulin need to be administered if the 2 hour post-prandial blood glucose level rises above 6.6 mmol/l. This level should be checked regularly, either by the patient or in clinic.

• Proteinuria and blood pressure – since women with GDM are at greater risk of developing hypertension, they should have urinalysis performed (checking for protein) and blood pressure recorded in clinic.

Women who have had GDM, but then return to normal glucose homeostasis, need to be advised of the increased risk of developing GDM in subsequent pregnancies and of type 1 or 2 diabetes in later life. However, this risk can be reduced by improving lifestyle: better diet, increased physical activity and optimising weight management.

CULTURAL ASPECTS OF DIABETES CARE

GENERAL POINTS

Many practices in the UK, particularly those in urban areas, look after ethnically, spiritually and culturally diverse populations. These factors can affect both the diagnosis (especially if using a bio-social model) and how health care is delivered.

Irrespective of culture, clear effective communication remains an essential part of the interaction between professional and patient. If English is not the patient’s first language, it must not be assumed that the patient has English proficiency. The professional should be prepared to invest extra time and care in eliciting the necessary information and in ensuring that any messages given are understood (avoid jargon, do not sound condescending and ask the patient to relate what has just been said).

In Afro-Asian culture, a greater emphasis is placed on physical symptoms than on psychological ones, and there may be a greater expectation upon the doctor to make a diagnosis without a full assessment, and to provide a prescription rather than advice. Many Asians may feel that the diagnosis of diabetes is a stigma and consider the disease to be contagious. Many Afro-Asian patients may be reluctant to answer questions about their life and family histories. Eye contact may be poor. If a family attends, the husband or senior male figure often speaks on the patient’s behalf. In contrast to the English sequence of “vision, hearing and touch” other cultures may prefer the sequence of “touch, hearing and vision”. Afro-Asian patients may prefer to be examined by a professional of the same gender.

Many Afro-Asian diabetics use various types of traditional and/or herbal medicines regularly, even if they are taking conventional therapeutic medicines. Karela or guard is a recognised insulin-like substance.

DELIVERY OF DIABETES CARE TO ETHNIC MINORITIES

OQF

Record 21

A collective term used for this group of individuals is black and minority ethnic (BME), although it is important to remember that this is not a homogeneous population. In the GMS contract, practices are now expected to record the ethnic origin of all newly registered patients.

Costs

The UK Asian Diabetes Study (UKADS) estimated the annual costs for South Asian patients to be £365 per patient in 2004 (O’Hare et al 2004), higher than the UKPDS estimate of £264 in 1998. This higher cost includes the extra input of additional diabetes specialist nurses for this population. Further research is needed to determine the cost-effectiveness of “culturally sensitive” initiatives.