CPD: Preventing diabetes complications

GP Dr Roger Henderson provides an overview of the chronic complications of diabetes and the key preventive measures undertaken in primary care. Complete the full module on Nursing in Practice 365 today.

Diabetes can lead to a range of chronic complications if it is not well managed. These complications occur due to prolonged periods of high blood sugar levels. Prolonged poorly controlled blood glucose levels can damage the blood vessels, nerves and various organs. Understanding these risks and adopting preventive measures can help mitigate these potential long-term health issues. The NHS spends at least £10 billion a year on diabetes – around 10% of its entire budget – and almost 80% of this money is spent on treating the complications of diabetes.¹

This module discusses the common chronic complications linked to diabetes and how nurses are key to optimising care to reduce the risk of complications developing or progressing.

Learning objectives

By the end of this module, you will have a greater understanding of:

Some of the key chronic complications of diabetes and why they occur.
Diabetes preventive measures and how they work including lifestyle and dietary changes.
How nurses are important in promotion of education and self-care.
What diabetes monitoring is required and how regularly.
The role of nurses in diabetes reviews.

Diabetes mellitus is a medical condition characterized by the body’s inability to properly regulate blood glucose (sugar) levels. It occurs due to defects in insulin production, insulin action, or both. Insulin is a hormone produced by the pancreas that helps cells absorb glucose from the bloodstream to use as energy. There are a number of types of diabetes, the main ones being:²

Type 1 diabetes. This is an autoimmune condition where the immune system attacks and destroys insulin-producing beta cells in the pancreas. Typically diagnosed in childhood or adolescence, it can develop at any age and requires lifelong insulin therapy. About 10% of people with diabetes have the type 1 form.
Type 2 diabetes. This is the most common form of diabetes – affecting around 90% of people with the condition – and is characterized by insulin resistance (where the body’s cells don’t respond properly to insulin) along with an eventual decline in insulin production. Type 2 diabetes is typically associated with overweight and obesity, a sedentary lifestyle, and genetic predisposition. It is managed with lifestyle changes, oral medications, and sometimes insulin.
Gestational diabetes develops during pregnancy in women who have never had diabetes and is caused by hormonal changes that affect insulin action. This usually resolves following childbirth, but having gestational diabetes can increase the risk of developing type 2 diabetes later in life.

Rarer types of diabetes result from genetic mutations, pancreatic diseases, certain medications, or hormonal disorders.

What are the main chronic complications of diabetes?

Prolonged levels of high blood sugar in the body (hyperglycaemia) trigger various biochemical changes, including the release of advanced glycation end products (AGEs) that damage blood vessel walls, contributing to both microvascular and macrovascular complications.

Elevated glucose levels also increase oxidative stress, leading to endothelial dysfunction and vascular damage, and exacerbate chronic inflammation, promoting atherosclerosis.³

Other factors such as hypertension and hyperlipidaemia that tend to accompany type 2 diabetes also contribute to chronic complications including atherosclerosis.

Macrovascular complications involve large blood vessels and include cardiovascular disease, cerebrovascular disease and peripheral arterial disease.

Microvascular complications involve small blood vessels and include retinopathy, nephropathy and neuropathy.

These complications significantly contribute to morbidity and mortality in patients with diabetes.

Without proper management, diabetes can lead to:

Cardiovascular disease. Cardiovascular complications such as heart disease, stroke and peripheral arterial disease are now the primary causes of both morbidity and mortality related to diabetes. Over 75% of people aged over 40 with diabetes will die from cardiovascular disease, and they are more prone than those without diabetes to die from a first cardiovascular event.⁴
Kidney damage (nephropathy). People with diabetes are at increased risk of renal problems such as urinary tract infections, renal atherosclerosis, papillary necrosis and glomerular lesions due to nephropathy. It can progress to chronic kidney disease (CKD), indicated by a reduced estimated glomerular filtration rate (eGFR) of <60 mL/minute/1.73m². Earlier signs of kidney damage are indicated by the presence of microalbuminuria or albuminuria. CKD is the main complication in the working age group with type 1 diabetes,⁵ and is also becoming more common in people with type 2 diabetes. This is linked to the increasing prevalence of people with type 2 diabetes, improved survival of people with diabetes and cardiovascular disease and the trend towards younger onset of type 2 diabetes.⁶
Nerve damage (neuropathy). This is most commonly diabetic peripheral neuropathy, but can also include diabetic sensory neuropathy, diabetic autonomic neuropathy or diabetic motor neuropathy.

Distal symmetrical polyneuropathy (DSPN) is the most common diabetic peripheral neuropathy, affecting about 50% of patients with type 2 diabetes after 10 years and at least 20% of patients with type 1 diabetes after 20 years.⁷ DSPN may be present in approximately 20–25% of newly diagnosed patients with type 2 diabetes and painful diabetic neuropathy is estimated to affect between 16% and 26% of people with diabetes.⁸ It is also responsible for the majority of cases of foot ulcers in people with diabetes, often caused by accidental trauma to the foot which cannot be felt due to numbness caused by neuropathy.

Eye damage (retinopathy). Diabetic retinopathy is the most common cause of severe sight impairment in working-age people in England, Wales and Scotland.⁹ The exact mechanism causing diabetic retinopathy remains unclear but it is thought that occlusion of the microcirculation to the back of the eye causes ischaemia of the retina. Leakage from the retinal blood vessels also appears to cause haemorrhages in the retina and oedema. Progression of retinopathy is linked to the severity and duration of hyperglycaemia. If diabetes is diagnosed before the age of 30, the incidence of diabetic retinopathy after 10 years is 50%, rising to 90% after 30 years. There is no set glycaemic threshold that will predict the presence or otherwise of diabetic retinopathy.¹⁰
Foot ulcers and infections. Foot complications are common in people with diabetes due to high blood sugar levels causing damage over time to the nerves supplying the feet, as well as affecting the blood supply. It is estimated that 10% of people with diabetes will develop a diabetic foot ulcer at some point in their lives. As a consequence, diabetes is the most common cause of non-traumatic limb amputation, with diabetic foot ulcers preceding more than 80% of amputations in people with diabetes.¹¹

Other key complications of diabetes include:

Gum disease (periodontitis). The risk of periodontitis is increased 2-3 times in people with diabetes and this risk increases the worse the blood sugar levels are controlled.^12,13Diabetes increases the risk for periodontitis by contributing to increased inflammation in the gums.
Erectile dysfunction (ED). Over half of men with diabetes experience some degree of ED and the prevalence of ED is approximately 3.5-fold higher in men with diabetes than in those without.¹⁴ Diabetes related ED has many underlying causes including metabolic, neurologic, vascular, hormonal and psychological elements. ED should be regarded as the first sign of cardiovascular disease because it can be present before development of symptomatic coronary artery disease, as larger coronary vessels better tolerate the same amount of plaque compared to smaller penile arteries.¹⁵
Non-alcoholic fatty liver disease (NAFLD). Not only is the prevalence of NAFLD disease high among patients with diabetes, the liver disease is also more progressive. The prevalence of NAFLD among those with type 2 diabetes can be as high as 70%.¹⁶

Dr Roger Henderson is a GP in Scotland

To complete the full module worth 1.5 CPD points visit Nursing in Practice 365

References