DIABETIC CHECKS

Because of the risk of complications the following checks are recommended:

• Self-checks. These are most important and relate to both immediate complications (such as abnormally high or low sugars) and self-checks on feet, for example, to check for early signs of infections or ulcers. The diabetic needs to be aware of their health and ready to react quickly if s/he feels unwell - if need be seeing the doctor. Regular checks of blood or urine sugars need to be done - your doctor or nurse will say how often.
• GP Clinics. We run annual review checks and hold the clinic that carries them out on a monthly basis. Beforehand you will be asked to see the nurse for your comprehensive annual blood and urine test the results of which will be available when you come to the clinic. You will also be asked to go for an eye test to check for damage at the back of the eye so it can be treated before it has gone too far. When you attend the clinic itself you will normally see the nurse for a check on your blood pressure and she will complete the annual review screen on the computer. This gives the opportunity for the discussion of problems and to check that the test results are available. After seeing the nurse the chiropodist will check your feet and as well as looking for the early signs of ulcers etc. will check your circulation and the function of the nerves in the foot with some sophisticated equipment. Finally the doctor will review your overall management in the light of test reults including, especially, your own monitoring results.
• Dietitian. The dietitian is employed by the hospital. She runs clinics at the same time as the diabetic clinic but you do need to be referred and booked in with her in advance. Diet is central to the management of all diabetes and so we aim to give every diabetic the opportunity of a consultation soon after diagnosis and later if there are problems. You are welcome, indeed advised, to bring whoever plans and cooks the family meals with you if it isn't you yourself.
• Optician. Eye checks form a crucial part of the review of the well-being of diabetic patients. This should include a thorough check on the blood vessels at the back of the eye which are vulnerable to damage and which, by bleeding can cause loss of vision.

Additionally the following checks may be required in some cases:

• Surgery review. If during your annual review or at other times a problem is detected then you may be asked to come to see your own regular GP to look at ways to improve matters. Likely causes for recall are: unacceptable blood sugar or HbA1c levels, raised blood pressure or cholesterol, protein or microalbumin in the urine, other abnormal blood tests or the detection of complications.
• Hospital Diabetic Clinic. The hospital runs a clinic regularly and we tend use this where patients have complications or their diabetes seems difficult to control satisfactorily. The Diabetic Liaison Nurse is based at the hospital and is a valuable source of up-to-date information and can also monitor changes in therapy - especially where this involves insulin.
• Eye clinic. If the optician, GP or hospital clinic are concerned about your vision or the blood vessels at the back of your eye then you will be referred to the eye clinic. Laser therapy is used if there is a type of abnormality at the back of the eye called proliferative retinopathy.
• Nephrologist. If your kidney function is getting worse as judged by blood tests and/or your kidneys are leaking albumen into your urine, especially if your blood pressure is proving difficult to control, then you may be referred to the nephrologist (kidney specialist) who may wish to keep you under routine review. 

What tests do we do and what do they show?

• Blood sugar. Single blood sugar readings are of very limited value unless they are either extremely high or extremely low. It's rather like a single air temperature reading - it doesn't tell you much about the state of the weather. Of much more use is a series of readings taken over a period of time at different times of the day and to get this, unless the patient is in hospital, we rely on the patients own blood sugar checks. A pattern of high or low readings at certain times of the day will give a very good indication where changes need to be made to treatment or diet.
• Haemoglobin A1c. This test relies on the affinity the red blood pigment haemoglobin has for glucose. Glucose sticks to the haemoglobin in proportion to the average amount in the blood over a period of time. As red cells last about six weeks then this is the period of time that the Haemoglobin A1c reflects. All the research into diabetic control has tended to focus on this reading. The target level for each diabetic patient may vary somewhat in relation to age and what is thought to be achievable but as a general rule 8% is quite acceptable whilst 10% and above may be more worrying though in the older diabetic where longterm complications are less of an issue and where hypoglycaemia could be dangerous we may accept, indeed feel happier with, the slightly higher figure.
• Urinary protein and microalbumen. We check with a stick for protein in the urine. If this is positive then we check for a urine infection and if it is negative we send the urine to the lab. for the mich more sensitive microalbumen test. We are concerned about increased levels of the protein albumen because if it is persistent over several tests over a period of time it tends to predict future problems with kidney function. A 24 hour collection to measure the amount of albumen leaking out over a period of time will often be done after several positive random tests.
• Kidney function tests (urea, electrolytes and creatinine). Along with microalbumen these tests tell us if your kidneys are suffering as a result of the diabetes. Again, what is valuable is a series of readings over a period of time.
• Blood pressure. As with all patients we are concerned about blood pressure in order to avoid strokes and heart attacks but in diabetics we are also concerned to protect the kidneys. We strive to keep blood pressure very strictly controlled - especially if there is microalbumen or abnormal kidney function already.
• Cholesterol. Heart disease is associated with diabetes and we monitor cholesterol closely in diabetics and we are much more likely to intervene with medication than in the non-diabetic. The ideal diabetic diet is also good for cholesterol with its emphasis on low fat, high complex carbohydrate and high fibre.
• Circulation. Diabetes and smoking are the two main causes of blocked blood vessels in the legs. Diabetes goes for the smaller calibre blood vessels whilst smoking predisposes to blockage of the larger ones so the combination is a potential disaster. The chiropodist compares the blood pressure at the ankle compared to the arm using a special device called a Doppler ultrasound probe. She produces a figure which is a ratio and a number significantly less than one indicates trouble!
• Nervous system.
  • Autonomic nervous system. This part of the nervous system carries the body's "autopilot" and controls things like blood pressure. Male sexual function requires an intact autonomic nervous system. Diabetes tends to damage this part of the nervous system - one test we do is to see if your blood pressure drops significantly on standing up (which normally it doesn't do).
  • Sensory nerves. These nerves also get damaged - especially in the feet where good quality sensation is important to protect you. There are varous tests that can be done to test the sensory nerves - currently the chiropodist tests this for us with a special probe.

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