DPCA 1-2 full issue

Diabetes 

& Primary Care Australia 

Vol 1 No 2 2016 

The primary care diabetes journal for healthcare professionals in Australia 

The power of the 

multidisciplinary 

team approach 

How working in unison 

can improve clinical 

outcomes for people 

with diabetes 

IN THIS ISSUE 

Hard-to-reach groups 

A CPD module reviewing the 

latest research on engaging 

with hard-to-reach population 

groups. Page 43 

From the desktop 

Erin Jackson, dietitian, 

explains the benefits of using 

individualised care in the 

clinic. Page 51 

Periodontal disease 

Discussing the relationship 

between periodontal disease 

and diabetes. 

Page 59 

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Contents 

Diabetes 

& Primary Care Australia 

Volume 1 No 2 2016 

Website: www.pcdsa.com.au/journal 

Editorial 

The power of the multidisciplinary team: Changing clinical perspectives 40 

Gary Kilov introduces this issue, taking a close look at the impact the multidisciplinary team can have in approaching diabetes care. 

CPD module 

The challenges of managing diabetes in hard-to-reach groups 43 

Alia Gilani and John Furler review the latest evidence and recommendations in managing diabetes in hard-to-reach groups in Australia. 


Individualizing clients in dietary management 51 

Erin Jackson provides expert opinion and practical guidance on the importance of individualising care. 

Articles 

Evolution of health professional roles: GPs with a special interest in diabetes 52 

Jo-Anne Manski-Nankervis considers the role GPs with specialist interests could play in Australia. 

Blood glucose: To monitor or not in type 2 diabetes? The practical implications of the Choosing Wisely recommendation 55 

John Furler, Jessica Browne and Jane Speight disseminate how recommendations from the Choosing Wisely campaign fit with 

today’s clinical practice. 

Diabesity and periodontal disease: Relationship and management 59 

Rajesh Chauhan, Mark Kennedy and Werner Bischof investigate the possible relationship between periodontal disease and diabetes. 

The “NO TEARS” diabetes medication review 65 

Jane Diggle describes the NO TEARS tool used in the UK to assess individuals’ medicines and ensure effective treatment, and 

Cik Lin Yee and Rajna Ogrin describe the medicine reviews available in Australia and what could be learnt from NO TEARS. 

Editor-in-Chief 

Gary Kilov 

Practice Principal, The Seaport Practice, and Senior 

Lecturer, University of Tasmania, Launceston, Tas 

Associate Editor 

Roy Rasalam 

Head of Clinical Skills and Medical Director, 

James Cook University, and Clinical Researcher, 

Townsville Hospital, Townsville, Qld 

Editorial Board 

Ralph Audehm 

GP Director, Dianella Community Health, and 

Associate Professor, University of Melbourne, 

Melbourne, Vic 

Werner Bischof 

Periodontist, and Associate Professor, La Trobe 

University, Bendigo, Vic 

Nicholas Forgione 

Principal, Trigg Health Care Centre, Perth, WA 

John Furler 

Principal Research Fellow and Associate Professor, 

University of Melbourne, Vic 

Mark Kennedy 

Medical Director, Northern Bay Health, Geelong, 

and Honorary Clinical Associate Professor, 

University of Melbourne, Melbourne, Vic 

Peter Lazzarini 

Senior Research Fellow, Queensland University of 

Technology, Brisbane, Qld 

Rajna Ogrin 

Senior Research Fellow, RDNS Institute, 

St Kilda, Vic 

Suzane Ryan 

Practice Principal, Newcastle Family Practice, 

Newcastle, NSW 

Editor 

Olivia Tamburello 

Editorial Manager 

Richard Owen 

Publisher 

Simon Breed 

© SB Communications Group and the 

Primary Care Diabetes Society of Australia 

Published by SB Communications Group, 

1–2 Hatfields, London 

SE1 9PG, UK 

All rights reserved. No part of this journal 

may be reproduced or transmitted in 

any form, by any means, electronic or 

mechanic, including photocopying, 

recording or any information retrieval 

system, without the publisher’s 

permission. 

ISSN 2397-2254 

Diabetes & Primary Care Australia Vol 1 No 2 2016 39

Editorial 

The power of the multidisciplinary team: 

Changing clinical perspectives 

Gary Kilov 

Editor of Diabetes & Primary Care 

Australia, and Director at Seaport 

Diabetes, Launceston Area, Tas, 

and Senior Lecturer at University 

of Tasmania, Launceston, Tas 

Most of what I learned in medical 

school has long been forgotten 

or has been rendered obsolete 

by scientific advancement. Our improved 

understanding of pathological processes and 

concurrent technological advancements have 

resulted in the refinement of our disease 

management and provided welcome additions 

to our medical toolkits. But some clinical 

gems remain from my time at medical school, 

never to be forgotten or jettisoned. 

One such aphorism related to assessing and 

treating fractures: “Regard them as a soft 

tissue injury complicated by a broken bone” 

was the advice of a senior orthopaedic surgeon. 

Changing the perspective and altering the 

priorities when assessing the injury would 

hopefully result in a lower likelihood of 

missing a critical vascular, nerve or tendon 

injury. It is easy to be caught up in the glare 

of the X-ray, the bright white fragmented 

and distorted bone, and to be distracted 

from a potentially more disabling injury 

hidden in the amorphous soft tissue shadow. 

Having soft tissue injury at the forefront 

of the mind is a safety net. In a similar 

vein, managing diabetes and considering the 

priorities differently, may refocus attention 

on the complications and symptoms that may 

have more serious implications than initially 

recognised for our patients. 

Type 2 diabetes might be thought of as 

a generalised vasculopathy in the setting 

of dysglycaemia and other metabolic 

derangement. And since an unimpeded 

supply line is essential for the maintenance 

of health of all our organ systems, it 

follows that damage or compromise to the 

vasculature will result in end-organ damage. 

But it is not just the “big ticket items” 

such as the eyes and kidneys, caused by 

microvasculopathy, and the brain and heart, 

caused by macrovasculopathy, that are at risk 

during diabetes. Almost every part of the 

body is vulnerable. A multidisciplinary team 

is central to addressing the myriad challenges 

faced by those with diabetes, particularly if 

comorbidities and multi-morbidities increase 

the burden of disease. 

Roles of the healthcare professional 

in the multidisciplinary team 

In this issue, we address a wide range of topics, 

showcasing the usefulness of multidisciplinary 

input and expertise. Jo-Anne Manski- 

Nankervis disseminates the role of the GP 

with a specialist interest, a role established in 

UK and the Netherlands. Jo-Anne considers 

its position within the multidisciplinary team 

and whether this role would be beneficial in 

the Australian healthcare setting for diabetes 

management (on page 52). 

An excellent example of the multidisciplinary 

team already at work is an article exploring 

the implications of oral pathology, a marker 

of risk for cardiovascular disease. The product 

of collaboration by a GP, periodontist and 

dentist, the article examines the bidirectional 

relationship between oral health and diabetes 

(on page 59). 

Individualising care 

It is well understood that diabetes 

management is multifactorial, including 

pharmacotherapy and dietary and lifestyle 

advice. In this issue’s “From the desktop”, 

Erin Jackson, a dietitian based in Tasmania, 

shares her knowledge and clinical experience 

in providing dietetic advice to her clients with 

diabetes (on page 51). By individualising care 

and implementing medical nutrition therapy, 

favourable biochemistry and biometrics 

outcomes are achievable, without the need for 

escalating drug therapy. 

In cases where pharmacotherapy is 

unavoidable and indicated, it is often complex 

40 Diabetes & Primary Care Australia Vol 1 No 2 2016

Editorial 

and adherence in chronic diseases may be 

challenging. In an article describing the “NO 

TEARS” home medication review process, 

which is in use in the UK, a senior nurse and 

pharmacist team up to offer strategies to support 

appropriate polypharmacy and pharmacotherapy 

(on page 65). 

Self-monitoring of blood glucose (SMBG) 

is another part of diabetes management 

and is a standard part of type 1 diabetes 

management, but its role in type 2 diabetes 

is still under debate. Of course, SMBG must 

be individualised to the person with diabetes, 

taking into account age, manual dexterity, 

lifestyle and current medication. On page 55, 

primary care and psychology collaborate to 

provide a practical and rational approach to 

monitoring blood glucose in type 2 diabetes, 

taking into account the Choosing Wisely 

recommendations, a campaign with the aim 

of eliminating tests that are not supported by 

evidence, that duplicate other tests or procedures, 

that may cause harm and are not truly necessary. 

Beyond the biological considerations for 

individuals are complex social factors that 

predict diabetes-related outcomes. In this 

issue, we explore a significant proportion of 

the population that, for a variety of reasons 

is vulnerable and at risk. The article on 

page 43, again written across disciplines, 

addresses the challenges of engaging hardto-reach 

populations with some strategies to 

facilitate engagement. 

Final thoughts 

Each member of the multidisciplinary team 

brings a different perspective, nuance and 

priority to each individual with diabetes. 

The result is a broad, holistic approach, 

which enables us to maintain the “big 

picture” and ensures comprehensive diabetes 

management in primary care. Facilitating the 

collaboration between health professionals to 

improve the quality of diabetes primary care 

across Australia is one of the key aims of the 

inaugural PCDSA conference to be held on 

30 April 2016 at the University of Melbourne, 

Parkville, Victoria. The conference aims to 

support primary care health professionals 

to deliver high-quality clinically effective 

care, in order to improve the lives of people 

living with diabetes by advancing education 

and promoting best practice standards and 

clinically effective care. We hope you will be 

able to attend and look forward to welcoming 

you to the conference. 

n 

“A multidisciplinary 

team can result is 

a broad, holistic 

approach enabling us 

to maintain the ‘big 

picture’ and ensuring 

comprehensive 

diabetes management 

in primary care.” 

For more information and to register your attendance at the 

inaugural PCDSA conference, please go to 

http://www.eventful.com.au/pcdsa 

Date: Saturday 30 April 2016 

Location: University of Melbourne, Parkville, Victoria 

Confirmed speakers: Prof Peter Coleman, Prof John Dixon and 

Prof Trisha Dunning 


INAUGURAL 

NATIONAL 

CONFERENCE 

30th April 2016 

University of Melbourne, 

Parkville Victoria, Australia 

The conference has been specifically designed for all 

primary care health professionals working in diabetes care to: 

 

 

 

Advance their education and learning in the field 

of diabetes health care 

Promote best practice standards and clinically 

effective care in the management of diabetes 

Facilitate collaboration between health professionals 

to improve the quality of diabetes primary care across Australia 

PROGRAM 

The 2016 PCDSA national conference program will combine cutting 

edge scientific content with practical clinical sessions, basing the 

education on much more than just knowing the guidelines. 

The distinguished panel of speakers will share their specialised 

experience in an environment conducive to optimal learning. The 

Speaking faculty include, amongst others: Professor Peter Colman, 

Professor John Dixon, Professor Trisha Dunning, Professor Jane 

Speight, and Sir Michael Hirst, former President 

of the International Diabetes Federation (IDF). 

For further information and to register for the conference please visit: 

www.eventful.com.au/pcdsa 

If you have any questions regarding the conference, 

please contact the Conference Secretariat; 

Toll free telephone: 1800 898 499 

Email: pcdsa@eventful.com.au 

pcdsa.com.au

CPD module 

The challenges of managing 

diabetes in hard-to-reach groups 

Alia Gilani and John Furler 

We are in the midst of a global diabetes epidemic that is multi-faceted in its impact. 

This includes effects on population health, the economy and healthcare services. The 

management of diabetes is becoming increasingly challenging. The numbers of people 

to treat is rising and there are many pressures in primary care to achieve targets, not 

least because annual reviews are expected to be delivered in the same format for all. 

Population trends indicate that diversity is increasing, and this may mean that there will 

be widening gaps in the health needs for different groups, leading to further challenges 

for healthcare providers. Meeting the challenges of managing diabetes in hard-to-reach 

groups is a significant part of this, and this article explores a range of groups, highlighting 

the difficulties in engagement and the different needs that exist in each. 

Hard-to-reach groups can be defined 

as those who are underserved, service 

resistant or “slipping through the net” 

(Doherty et al, 2004). Marginalised groups 

tend to experience more significant inequalities 

than the general population, and it is thus of 

great importance for the healthcare system and 

Government to have strategies to tackle this. 

Often, such groups receive the least healthcare. 

This was eloquently described by Julian Tudor 

Hart as the inverse care law: “The availability of 

good medical care tends to vary inversely with 

the need for the population served.” Targeting 

inequalities may require the adoption of novel 

ways of working and thinking “outside the box”. 

Engagement with hard-to-reach groups is 

essential, as one of the determinants of population 

health is access to healthcare (Levesque et al, 

2013). Examples of hard-to-reach groups include 

Aboriginal and Torres Strait Islander populations, 

people from culturally and linguistically diverse 

(CALD) backgrounds (including refugees), 

those with mental illness, and people from 

socio-economically disadvantaged backgrounds 

(including those experiencing homelessness). It 

is difficult to get an accurate estimation of the 

number of individuals who are in these hardto-reach 

groups, not least because of reduced 

engagement with services and incomplete data 

collection. 

Diabetes in Aboriginal and Torres Strait 

Islander people 

The Australian Institute of Health and Welfare 

(AIHW) provides a comprehensive summary of 

the current prevalence of diabetes, its risk factors 

and associated conditions in the Aboriginal 

and Torres Strait Islander population (AIHW, 

2015). Aboriginal and Torres Strait Islander 

people experience a much higher burden of 

cardiovascular disease (CVD), diabetes and 

chronic kidney disease (CKD) than the non- 

Indigenous population. 

l Indigenous people are 3.5 times as likely as 

non-Indigenous adults to have diabetes (18% 

compared with 5%); the rate was 4 times as 

high in Indigenous adults aged 35–44 years 

(11% compared with 3%). 

Citation: Gilani A, Furler J (2016) 

The challenges of managing diabetes 

in hard-to-reach groups. Diabetes 

& Primary Care Australia 1: 43–9 

Learning objectives 

After reading this article, the 

participant should be able to: 

1. Give examples of a range 

of hard-to-reach groups, 

in which diabetes care 

may be sub-optimal. 

2. Describe barriers to 

healthcare faced by different 

hard-to-reach groups. 

3. Explain potential links 

between the inequalities faced 

and diabetes outcomes. 

Key words 

– Hard-to-reach groups 

– Inequalities 

– Quality of care 

Authors 

Alia Gilani is a Health Inequalities 

Pharmacist, Glasgow, UK; John 

Furler is Principal Research 

Fellow and Associate Professor, 

University of Melbourne, Vic. 


www.pcdsa.com.au/cpd – The challenges of managing diabetes in hard-to-reach groups 

Page points 

1. From 2011–2013, hospitalisation 

and death rates were greater 

in the Indigenous population, 

particularly among those under 

the age of 55, than the non- 

Indigenous population. 

2. Increasing geographical 

remoteness also increases the 

prevalence of disease. 

3. Refugees are a particularly 

vulnerable group, and over 

20 000 refugees arrive in 

Australia each year. 

l Indigenous people are twice as likely as non- 

Indigenous adults to have signs of CKD (22% 

compared with 10%); the rate was 4 times as 

high in Indigenous adults aged 45–54 years 

(25% compared with 6%). 


non-Indigenous adults to smoke daily (42% 

compared with 16%). 


non-Indigenous adults to be overweight or 

obese (72% compared with 63%). 


non-Indigenous adults to have high blood 

pressure (25% compared with 21%). 

In the same report, hospitalisation and death 

rates were also found to be greater in the 

Indigenous population, particularly among those 

under the age of 55, than the non-Indigenous 

population. Indigenous people were 4 times 

as likely as non-Indigenous people to have 

diabetes and 3 times as likely to have CKD as 

underlying or associated causes of death. The 

death rates for both conditions were 10 times 

higher for Indigenous people compared with 

non-Indigenous people between the ages of 55 

and 64 years. 

The prevalence of disease also rises with 

increasing remoteness. In remote areas, 

Indigenous people are 6 times as likely to have 

diabetes – and 5 times as likely to have CKD – 

as non-Indigenous people. CVD was 1.4 times as 

common in Indigenous people living in remote 

areas compared with Indigenous people living in 

non-remote areas. Diabetes and CKD were twice 

as common in this comparison. 

Barriers to Aboriginal Australians accessing 

mainstream general practice include their 

history of dispossession and ongoing experience 

of racism and discrimination. Acknowledging 

this is important when building respect and 

trust. Addressing issues such as transport, 

offering flexibility in clinic arrangements 

and appointments, and providing outreach 

and collaborative styles of consulting are 

important to improving access to care for 

Aboriginal and Torres Strait Islander people. 

Cultural respect is a key element of quality 

care (Liaw et al, 2015). The Royal Australian 

College of General Practitioners’ National 

Faculty website contains excellent resources 

to help GPs provide accessible and culturally 

appropriate high-quality care to people of 

Aboriginal and Torres Strait Islander background 

(www.racgp.org.au/yourracgp/faculties/aboriginal 

[accessed 23.02.16]). 

CALD communities in Australia 

Hanif and Karamat (2009) describe culture as 

“a complex interaction of multitudes of factors 

that give people an ethnic belonging” that “has 

an impact on their lifestyle and predisposition to 

chronic disease.” They describe factors that are 

influenced by culture and that in turn impact 

on the management of diabetes. Culture can 

have a significant influence on chronic disease 

management, including through perception 

of disease, reduced access to services, lifestyle 

choices, concordance with medication, and 

language barrier and thus communication with 

healthcare professionals. 

Using national survey data from 1999–2000, 

the AIHW published a report concluding the 

prevalence of diabetes was higher in Australian 

men who were born in the Middle East and 

North Africa, and South-East and Southern 

Asia than in their Australian-born counterparts 

(AIHW, 2003). Men born in the Middle East 

and North Africa were 3.6 times more likely to 

self-report diabetes, while those born in South- 

East and Southern Asia were 1.9 times more 

likely. Men born in UK and Ireland and North- 

West Europe also had higher rates of self-reported 

diabetes, although not as pronounced. Women 

born overseas showed a similar pattern in the 

prevalence of diabetes, apart from women from 

the UK and Ireland and North-West Europe, 

who had lower diabetes prevalence rates than 

Australian-born women. Overall for both sexes, 

the people from the Middle East and North 

Africa had the highest standardised prevalence 

ratios followed by South-East Asia and Southern 

Asia (AIHW, 2003). 

Refugees 

Refugees are a particularly vulnerable group, and 

over 20 000 refugees arrive in Australia each year. 

Research led by a team at Monash University, 


The challenges of managing diabetes in hard-to-reach groups – www.pcdsa.com.au/cpd 

Box 1. Care example. 

Narrative 

Mrs L is a sixty-year-old refugee from Vietnam. Soon after her arrival in Australia, she was found 

to have type 2 diabetes. Prior to arriving in Australia, Mrs L lived in a troubled and oppressed 

community, under constant threat of violence and aggression against her large family. The family 

lived on minimal income from a small shop in a village, where they also had a small holding. They 

were very poor and had little beyond primary education. They had access to emergency medical 

care only via mission-run clinics. 

It became clear fairly soon after her arrival that she had had poorly controlled diabetes for many 

years, with evidence of retinopathy and kidney damage. Mrs L certainly had no experience 

of regular medical care and, in any case, was faced with other more pressing priorities. Her 

family was granted temporary visas but no long-term security. They had to rely on friends and 

the extended community for financial support and access to housing, and initially relied on the 

Red Cross to underwrite the cost of medical care, as they had no right to Medicare-funded care. 

Nevertheless, Mrs L managed to see a GP in a community health centre regularly for care of her 

diabetes, initially managed with oral medication and diet, with input from a diabetes educator. 

Yet achieving glycaemic targets was difficult for her and the GP. Together, they would review her 

medicines and how to take them. She seemed to understand the concern, but there was much 

more going on in her life than simply managing her diabetes. Her retinopathy and kidney damage 

progressed. With help from the local hospital diabetes outpatient clinic she commenced insulin, 

a difficult task for a non-English-speaking person who was nearly blind and with little experience 

of medical care. Nevertheless, she had managed to move closer to her glycaemic target, which 

seemed a great achievement to her and the GP. 

Eventually a letter, containing an element of frustration, from her hospital diabetes specialist arrived 

at the general practice: 

“I reviewed Mrs L today…She describes herself as stable however she has not been recording any 

blood glucoses…she hasn’t followed my advice to increase her morning insulin…her HbA 1c 

is similar 

to before at 72 mmol/mol (8.7%)…she doesn’t seem willing to accept my advice…I very much 

doubt she will improve beyond this point.” 

“GPs could play a 

key role in providing 

enhanced care for 

refugees by leading 

the provision of 

continuing health 

care.” 

Discussion 

General practice and primary care teams can play a key role in helping individuals to manage their 

diabetes and achieve targets. Accessible care without financial barriers, with the use of interpreters 

and facilitating access to local members of the multidisciplinary diabetes team are all important. 

Using materials at an appropriate level of health literacy is also critical. Above all, the GP can play 

a key role by providing continuity of care and avoiding stereotyping and lowering expectations of 

patients who come from socio-economically disadvantaged backgrounds. Research suggests that 

patients from disadvantaged backgrounds are keen to engage actively in making decisions about 

their medical care and self-management. The GP can play a critical role in helping them to do so. 

Melbourne, Vic (Russell et al, 2013) identified that: 

“refugees in Australia face profound and complex 

health and social problems, and there are 

inadequacies in the health care system, particularly: 

refugees struggle to access primary health care that 

matches their needs; Health professionals often find 

themselves unable to communicate effectively with 

refugees; Health services focused on providing care 

to refugees are not well coordinated with each other 

or with mainstream health services. Refugees are 

likely to fall through the gaps between services.” 

The study suggested GPs could play a key role 

in providing enhanced care for this group by 

leading the provision of continuing health care for 

refugees (see Box 1), using health case managers 

and qualified interpreters, and addressing financial 

barriers to care. 



Page points 

1. Engagement with individuals 

who have a mental condition 

and diabetes can be 

challenging, and this may 

be made more difficult if 

the mental condition is 

undiagnosed. 

2. In Australia, the attributable 

excess mortality burden from 

all causes due to socioeconomic 

status is estimated 

at 19% for men and 12% for 

women. 

3. Individuals from socioeconomically 

disadvantaged 

areas, for example, were less 

likely to have their BMI, blood 

pressure and smoking status 

recorded, were less likely to be 

tested for HbA 1c 

and had more 

poorly controlled HbA 1c 

. 

Mental health 

Even historically, people have drawn 

connections between diabetes and depression. 

In the 17 th century, the physician Thomas Willis 

proposed that diabetes was caused by “long 

sorrow and other depression” (Balhara, 2011). 

There remains some truth to this hypothesis in 

modern healthcare. In a review of the evidence, 

the odds of depression across 20 controlled 

studies in people with diabetes was found to be 

double that of the control group without diabetes 

(Anderson et al, 2001). In Australia, the 2012 

AusDiab Study (Tanamas et al, 2013) found 

the prevalence of depression was 65% higher in 

those with diabetes compared to those without 

diabetes (16.2% vs 9.8%, respectively). 

The strong relationship between diabetes and 

mental illness is in fact a bidirectional one, and 

the link between the two can manifest in many 

ways (Balhara [2011] explores this in detail): 

l The two conditions can develop independently 

of one another. 

l During the course of diabetes, the condition 

can have a role in the pathogenesis of 

psychiatric disorders. 

l Conversely, psychiatric disorders are 

independent risk factors for diabetes, and 

medications used to treat mental illness 

can have side effects resulting in diabetes or 

impaired glucose tolerance, particularly with 

antipsychotic polypharmacy (Gallego et al, 

2012). 

l It is also important to note that there may be 

an overlap between the clinical presentation of 

hypoglycaemia and psychiatric disorders. 

Engagement with individuals who have a 

mental condition and diabetes can be challenging, 

and this may be made more difficult if the mental 

condition is undiagnosed. Indeed, there may be 

up to 45% of individuals with diabetes in whom 

such a condition remains undiagnosed (Li et al, 

2010). Other potential implications for healthcare 

beyond engagement in a clinical setting are poor 

treatment adherence (Gonzalez et al, 2007), poor 

glycaemic control (Lustman et al, 2000) and an 

increased risk of hospitalisation (Das-Munshi 

et al, 2007). Overall, there is strong evidence of 

poor self-care behaviour in people with diabetes 

and a mental condition (Gonzalez et al, 2007). 

In terms of accessing healthcare, there is 

evidence of increased healthcare use and 

associated costs in people with diabetes who 

have depression compared with those who do not 

(Egede et al, 2002). But this does not necessarily 

lead to better outcomes; rather, the evidence 

shows worse outcomes, in part owing to the 

difficulties in communicating with clinicians 

(Piette et al, 2004). GPs may tend to prioritise 

managing the mental health issues over diabetes 

care. Models of care may have to be adapted 

to improve engagement and enhance diabetes 

outcomes (Kahn et al, 2009). 

Socio-economic disadvantage, 

health literacy and homelessness 

Socio-economic disadvantage 

In Australia, the attributable excess mortality 

burden from all causes due to socio-economic 

status (SES) is estimated at 19% for men and 

12% for women. This is greater than the fraction 

attributed to all behavioural risk factors in total, 

such as smoking, diet and reduced physical 

activity (Mathers et al, 1999). Diabetes is not 

exempt from the effects of SES. A number of 

studies have found that adults variously defined as 

low SES, on the basis of educational achievement, 

occupation or residential area, have higher 

prevalence of diabetes (1.5–3 times higher than 

the least disadvantaged communities), higher 

mortality from diabetes and higher prevalence 

of associated biological risk factors for diabetes. 

An Australian study (Overland et al, 2002) 

identified that socio-economically disadvantaged 

people with diabetes had a low prevalence of GP 

care and noticed that disadvantaged people were 

less likely to be referred or to have particular 

further investigations. Studies in the UK have 

also demonstrated significant social variations in 

diabetes care processes. Individuals from socioeconomically 

disadvantaged areas, for example, 

were less likely to have their BMI, blood pressure 

and smoking status recorded, were less likely 

to be tested for HbA 1c 

and had more poorly 

controlled HbA 1c 

(Hippisley-Cox et al, 2004). 

Health literacy 

Addressing the barriers to access care are clearly 



important (Levesque et al, 2013). From an 

individual GP perspective, health literacy may be 

an important factor in providing quality diabetes 

care and supporting self-management. For 

example, low health literacy has been associated 

with hypoglycaemia (Sarkar et al, 2010) and 

fewer recordings of glucose levels (Mbaezue et 

al, 2010). Using low literacy materials (Howard- 

Pitney et al, 1997), using strategies such as “teach 

and teach back”, and involving family members 

can be an important strategy to overcome such 

barriers (Martire et al, 2004). 

Homelessness 

Homelessness is a particular and often extreme 

case of social disadvantage. In Australia, there are 

currently over 100 000 people (56% male) who 

are homeless, which accounts for 0.5% of the 

population (Homelessness Australia, 2012). The 

Australian Bureau of Statistics states that when 

a person does not have suitable accommodation 

alternatives, they are considered homeless if 

their current living arrangement: 

l Is in a dwelling that is inadequate. 

l Has no tenure, or if their initial tenure is 

short and not extendable. 

l Does not allow them to have control of, 

and access to space for social relations 

(Homelessness Australia, 2012). 

In the recent past, the face of homelessness 

has changed to include a wider demographic. 

From predominantly single alcoholic adult 

men, homelessness now affects adolescents, 

single mothers, the unemployed, elderly people 

and recent immigrants (Turnbull et al, 2007). 

The homeless population is more prone to 

chronic medical conditions and more prone 

to experience barriers accessing healthcare 

(Hwang and Bugeja, 2000). Of particular 

relevance, there is evidence of poor glycaemic 

control and difficulties in managing diabetes 

(Hwang and Bugeja, 2000). In addition to 

this, there is evidence of poor nutritional status 

and mental health problems (Langnäse and 

Müller, 2001). The prevalence of diabetes in 

the homeless population in some studies was 

found to be higher too (Arnaud et al, 2010). 

The increased risks associated with diabetes 

that are experienced by the homeless population 

include hypoglycaemia, foot problems, nonadherence 

and insulin misuse. These may seem 

like obvious risks, and similar to those in a nonhomeless 

person with diabetes, but a lack of easy 

access to healthcare services is liable to augment 

each of them. 

While average healthcare costs can be higher 

in the homeless population, it is important 

to be aware that often the care that these 

individuals receive is in emergency departments 

(Padgett et al, 1990; Salit et al, 1998). Indeed, 

a homeless individual is up to 5 times more 

likely to be admitted to hospital than someone 

in the general population (Martell et al, 1992). 

Effective management of a long-term condition 

may not be at the top of the individual’s, or the 

healthcare provider’s, list of priorities. Rather, it 

may be that an acute condition takes priority. 

Finally, as homeless individuals may not 

have stability in their lives and their lifestyle 

behaviours may be sporadic, it can be very 

challenging for healthcare professionals to 

engage with this population. 

Conclusion 

It can be easy for us as healthcare professionals 

to get so caught up in the management of 

diabetes in the general population (which often 

is the majority of the population we serve) 

that we become tempted to apply a standard 

template of healthcare provision for all. 

Disadvantaged groups are often hard to reach 

and experience greater inequities, compared 

with the general population, and can often get 

neglected. Successful approaches in diabetes 

management for the hard-to-reach population 

should be championed, and learnings should 

be disseminated widely to promote replication 

in other areas with other groups. Although 

this module has focused on certain groups, it 

has applicability to other hard-to-reach groups, 

including people with learning disabilities 

and children and young people with diabetes. 

Overall, there is no one solution to improving 

diabetes care in groups where there are 

inequities. Recognising the inequities is the 

first step, which then allows us to confront the 

challenge of taking effective action. n 

Page points 

1. Using low literacy materials, 

strategies such as “teach and 

teach back” and involving 

family members can be an 

important strategy to overcome 

the barrier of low health 

literacy. 

2. In Australia, there are currently 

over 100 000 people who are 

homeless, which accounts for 

0.5% of the population. 

3. While average healthcare costs 

can be higher in the homeless 

population, it is important to be 

aware that often the care that 

these individuals receive is in 

emergency departments. 



“Recognising the 

inequities among 

certain populations is 

the first step, which 

then allows us to 

confront the challenge 

of taking effective 

action.” 

Acknowledgement 

This article has been modified from one 

previously published in Diabetes & Primary Care 

(2014, 16: 206–11). 

AIHW (2003) A picture of diabetes in overseas-born Australians. 

Bulletin no 9, AUS 38. AIHW, Canberra, ACT 

AIHW (2015) Cardiovascular disease, diabetes and chronic kidney 

disease. Australian facts: Aboriginal and Torres Strait Islander 

people. AIHW, Canberra, ACT. Available at http://bit.ly/24nsSn7 

(accessed 23.02.16) 

Anderson RJ, Freedland KE, Clouse RE, Lustman PJ et al (2001) The 

prevalence of comorbid depression in adults with diabetes: a 

meta-analysis. Diabetes Care 24: 1069–78 

Langnäse K, Müller MJ (2001) Nutrition and health in an adult 

urban homeless population in Germany. Public Health Nutr 4: 

805–11 

Levesque J-F, Harris MF, Russell G (2013) Patient-centred access 

to health care: conceptualising access at the interface of health 

systems and populations. International J Equity Health 12: 18 

Li C, Ford ES, Zhao G et al (2010) Undertreatment of mental 

health problems in adults with diagnosed diabetes and serious 

psychological distress: the behavioral risk factor surveillance 

system, 2007. Diabetes Care 33: 1061–4 

Liaw ST, Hasan I, Wade V et al (2015) Improving cultural respect to 

improve Aboriginal health in general practice: a multi-methods 

and multi-perspective pragmatic study. Aust Fam Phys 44: 387– 

92 

Arnaud A, Fagot-Campagna A, Reach G et al (2010) Prevalence 

and characteristics of diabetes among homeless people 

attending shelters in Paris, France, 2006. Eur J Public Health 20: 

601–3 

Balhara YP (2011) Diabetes and psychiatric disorders. Indian J 

Endocrinol Metab 15: 274–83 

Lustman PJ, Anderson RJ, Freedland KE et al (2000) Depression and 

poor glycemic control: a meta-analytic review of the literature. 

Diabetes Care 23: 934–42 

Martell JV, Seitz RS, Harada JK et al (1992) Hospitalization in an 

urban homeless population: the Honolulu Urban Homeless 

Project. Ann Intern Med 116: 299–303 

Das-Munshi J, Stewart R, Ismail K et al (2007) Diabetes, common 

mental disorders, and disability: findings from the UK National 

Psychiatric Morbidity Survey. Psychosom Med 69: 543–50 

Doherty P et al (2004) Delivering services to hard to reach 

families in On Track areas: definition, consultation and needs 

assessment. Development and Practice Report 15. Home Office, 

London, UK. Available at: http://bit.ly/1qZs8CM (accessed 

10.07.14) 

Egede L, Zheng D, Simpson K (2002) Comorbid depression is 

associated with increased health care use and expenditures in 

individuals with diabetes. Diabetes Care 25: 464–70 

Gallego JA, Nielsen J, De Hert M et al (2012) Safety and tolerability 

of antipsychotic polypharmacy. Expert Opin Drug Saf 11: 527– 

42 

Gonzalez JS, Safren SA, Cagliero E et al (2007) Depression, 

self-care, and medication adherence in type 2 diabetes: 

relationships across the full range of symptom severity. Diabetes 

Care 30: 2222–7 

Hanif W, Karamat MA (2009) Cultural aspects. In: Khunti K et 

al (eds). Diabetes UK and South Asian Health Foundation 

recommendations on diabetes research priorities for British 

South Asians (first edition). Diabetes UK, London, 27–35 

Hippisley-Cox J, O’Hanlon S, Coupland C (2004) Association 

of deprivation, ethnicity, and sex with quality indicators for 

diabetes: population based survey of 53,000 patients in primary 

care. BMJ 329: 1267–9 

Homelessness Australia (2012) Homelessness statistics. 

Homlessness Australia, Lyneham, ACT. Available at: 

http://bit.ly/1n8icRQ (accessed 23.03.16) 

Howard-Pitney B, Winkleby MA, Albright CL et al (1997) The 

Stanford Nutrition Action Program: a dietary fat intervention for 

low-literacy adults. Am J Public Health 87: 1971–6 

Hwang SW, Bugeja AL (2000) Barriers to appropriate diabetes 

management among homeless people in Toronto. CMAJ 163: 

161–5 

Kahn LS, Fox CH, Carrington J et al (2009) Telephonic nurse case 

management for patients with diabetes and mental illnesses: a 

qualitative perspective. Chronic Illn 5: 257–67 

Martire LM, Lustig AP, Schulz R et al (2004) Is it beneficial to 

involve a family member? A meta-analysis of psychosocial 

interventions for chronic illness. Health Psychol 23: 599–611 

Mathers C, Vos T, Stevenson C (1999) The burden of disease and 

injury in Australia. AIHW, Canberra, ACT 

Mbaezue N, Mayberry R, Gazmararian J et al (2010) The impact of 

health literacy on self-monitoring of blood glucose in patients 

with diabetes receiving care in an inner-city hospital. J National 

Med Assoc 102: 5–9 

Overland J, Hayes L, Yue DK (2002) Social disadvantage: its impact 

on the use of Medicare services related to diabetes in NSW. 

Aust N Z J Public Health 26: 262–5 

Padgett D, Struening EL, Andrews H (1990) Factors affecting the 

use of medical, mental health, alcohol, and drug treatment 

services by homeless adults. Med Care 28: 805–21 

Piette J, Richardson C, Valenstein M (2004) Addressing the needs 

of patients with multiple chronic illnesses: the case of diabetes 

and depression. Am J Manag Care 10: 152–62 

Russell G, Harris M, Cheng I-H et al (2013) Coordinated Primary 

Health Care for Refugees: A Best Practice Framework for 

Australia. Australian Primary Health Care Research Institute, 

Southern Academic Primary Care Research Unit, Dandenong, 

Vic 

Salit SA, Kuhn EM, Hartz AJ et al (1998) Hospitalization costs 

associated with homelessness in New York City. N Engl J Med 

338: 1734–40 

Sarkar U, Karter AJ, Liu JY et al (2010) Hypoglycemia is more 

common among m diabetes patients with limited health literacy: 

the Diabetes Study of Northern California (DISTANCE). J Gen 

Internal Med 25: 962–8 

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Australian Diabetes, Obesity and Lifestyle study. Baker IDI Heart 

and Diabetes Institute, Baker IDI Heart and Diabetes Institute, 

Melbourne, Vic 

Turnbull J, Muckle W, Masters C (2007) Homelessness and health. 

CMAJ 177: 1065–6 



Online CPD activity 

Visit www.pcdsa.com.au/cpd to record your answers and gain a certificate of participation 

Participants should read the preceding article before answering the multiple choice questions below. There is ONE correct answer to each question. 

After submitting your answers online, you will be immediately notified of your score. A pass mark of 70% is required to obtain a certificate of 

successful participation; however, it is possible to take the test a maximum of three times. A short explanation of the correct answer is provided. 

Before accessing your certificate, you will be given the opportunity to evaluate the activity and reflect on the module, stating how you will use what 

you have learnt in practice. The CPD centre keeps a record of your CPD activities and provides the option to add items to an action plan, which will 

help you to collate evidence for your annual appraisal. 

1. Which of the following is the MOST 

appropriate statement concerning the 

availability of good healthcare? Select 

ONE option only. 

A. Good access to care tends to be 

available equally across different 

population groups 

B. Good access to care tends to be 

available in inverse proportion to 

local population needs 

C. Good access to care tends to be 

available in proportion to local 

population needs 

D. There is no statistically significant 

evidence concerning the availability 

of good access to care in different 

population groups 

2. What is the approximate INCREASED 

prevalence of diabetes, if any, in 

Aboriginal and Torres Strait Islander 

people compared with the overall 

Australian population? Select ONE 

option only. 

A. Twice as high 

B. 3–4 times as high 

C. 10 times as high 

D. 20 times as high 

E. No difference 

3. Which of the following culturally 

diverse background groups in Australia 

is MOST likely to have the HIGHEST 

prevalence of type 2 diabetes? Select 


A. Southern and Eastern Europe, and 

Central Asia 

B. South-East Asia and South Asia 

C. Middle East and North Africa 

D. North-West Europe 

E. UK and Ireland 

4. What are important strategies for 

providing high-quality general practice 

care to refugee populations? Select ONE 

option only. 

A. Use care coordinators or case 

managers if necessary 

B. Provide the same quality of care as you 

would to other patients in the practice 

C. Use interpreters where appropriate 

D. Reduce financial barriers to care 

if possible 

E. All of the above 

5. Which is the MOST appropriate 

statement about the effect of the 

increased use of healthcare by people 

with depression compared with people 

without depression? Choose ONE 

option only. 

A. Better clinical outcomes 

B. No difference in clinical outcomes 

C. No evidence regarding differing 

outcomes 

D. Worse clinical outcomes 

6. What proportion of people with 

diabetes are likely to have depression 

compared to people without diabetes? 

Select ONE option only. 

A. About 50% more likely 

B. 1.5–2 times as likely 

C. 4 times as likely 

D. 4–5 times as likely 

E. 10 times as likely 

7. Which is the LEAST appropriate 

statement about the link between 

diabetes and depression? Choose ONE 

option only. 

A. Depression can develop 

independently of diabetes 

B. Depression can cause diabetes 

C. Diabetes can develop independently 

of depression 

D. Diabetes can cause depression 

E. Diabetes control can be worse in 

people with depression 

8. Approximately how many people are 

homeless in Australia currently? Select 


A. 10000 

B. 25000 

C. 75000 

D. 100000 

E. 200000 

9. What are key factors in improving 

access to care for Aboriginal and Torres 

Strait Islander people. Choose ONE 

option only. 

A. Acknowledging a history of 

dispossession and ongoing 

experiences of racism in the 

community 

B. Providing culturally respectful care 

C. Providing flexible appointment 

arrangements where possible 

D. All of the above 

10. In relation to the link between socioeconomic 

disadvantage and diabetes, 

which of the statements below is 

correct? Choose ONE option only. 

A. Diabetes is up to 3 times as common 

B. A higher prevalence of risk factors 

is part of the explanation for the 

association 

C. People with diabetes from socioeconomically 

disadvantaged 

backgrounds are less likely to be 

referred for further investigations 

D. All of the above 


Call for papers 

Would you like to write an article 

for Diabetes & Primary Care Australia? 

The new journal from the Primary Care Diabetes Society of Australia 

To submit an article or if you have any queries, please contact: gary.kilov@pcdsa.com.au. 

Title page 

Please include the article title, the full names of the authors 

and their institutional affiliations, as well as full details of 

each author’s current appointment. This page should also have 

the name, address and contact telephone number(s) of the 

corresponding author. 

Article points and key words 

Four or five sentences of 15–20 words that summarise the major 

themes of the article. Please also provide four or five key words 

that highlight the content of the article. 

Abstract 

Approximately 150 words briefly introducing your article, 

outlining the discussion points and main conclusions. 

Introduction 

In 60–120 words, this should aim to draw the reader into the 

article as well as broadly stating what the article is about. 

Main body 

Use sub-headings liberally and apply formatting to differentiate 

between heading levels (you may have up to three heading levels). 

The article must have a conclusion, which should be succinct and 

logically ordered, ideally identifying gaps in present knowledge and 

implications for practice, as well as suggesting future initiatives. 

Tables and illustrations 

Tables and figures – particularly photographs – are encouraged 

wherever appropriate. Figures and tables should be numbered 

consecutively in the order of their first citation in the text. Present 

tables at the end of the articles; supply figures as logically labelled 

separate files. If a figure or table has been published previously, 

acknowledge the original source and submit written permission 

from the copyright holder to reproduce the material. 

References 

In the text 

Use the name and year (Harvard) system for references in the 

text, as exemplified by the following: 

● As Smith and Jones (2013) have shown … 

● As already reported (Smith and Jones, 2013) … 

For three or more authors, give the first author’s surname 

followed by et al: 

● As Robson et al (2015) have shown … 

Simultaneous references should be ordered chronologically first, 

and then alphabetically: 

● (Smith and Jones, 2013; Young, 2013; Black, 2014). 

Statements based on a personal communication should be 

indicated as such, with the name of the person and the year. 

In the reference list 

The total number of references should not exceed 30 without prior 

discussion with the Editor. Arrange references alphabetically first, 

and then chronologically. Give the surnames and initials of all 

authors for references with four or fewer authors; for five or more, 

give the first three and add “et al”. Papers accepted but not yet 

published may be included in the reference list as being “[In press]”. 

Journal article example: Robson R, Seed J, Khan E et al (2015) 

Diabetes in childhood. Diabetes Journal 9: 119–23 

Whole book example: White F, Moore B (2014) Childhood 

Diabetes. Academic Press, Melbourne 

Book chapter example: Fisher M (2012) The role of age. In: Merson 

A, Kriek U (eds). Diabetes in Children. 2nd edn. Academic Press, 

Melbourne: 15–32 

Document on website example: Department of Health (2009) 

Australian type 2 diabetes risk assessment tool (AUSDRISK). 

Australian Government, Canberra. Available at: http://www. 

health.gov.au/preventionoftype2diabetes (accessed 22.07.15) 

Article types 

Articles may fall into the categories below. All articles should be 

1700–2300 words in length and written with consideration of 

the journal’s readership (general practitioners, practice nurses, 

prescribing advisers and other healthcare professionals with an 

interest in primary care diabetes). 

Clinical reviews should present a balanced consideration of a 

particular clinical area, covering the evidence that exists. The 

relevance to practice should be highlighted where appropriate. 

Original research articles should be presented with sections 

for the background, aims, methods, results, discussion and 

conclusion. The discussion should consider the implications 

for practice. 

Clinical guideline articles should appraise newly published 

clinical guidelines and assess how they will sit alongside 

existing guidelines and impact on the management of diabetes. 

Organisational articles could provide information on newly 

published organisational guidelines or explain how a particular 

local service has been organised to benefit people with diabetes. 

— Diabetes & Primary Care Australia —



Individualising clients in dietary management 

Erin Jackson 

have your way. I have my way. As 

for the right way, the correct way, 

“You 

and the only way, it does not exist.” 

Philosopher Friedrich Nietzsche wrote this in the 

late 19 th Century, articulating the diversity among 

individuals; however, it took me a while to fully 

realise what he meant. 

As a freshly graduated dietitian with a brain 

full of nutrition facts and a head size to match, it 

became clear there was something amiss when I 

began working in the clinic. The outcomes that 

the literature promised were few and far between, 

and the client return statistics were dismal. But 

how? I was following the guidelines; all the client 

needed to do was comply with these very precise 

dietary principles every day for the rest of their 

life. 

Luckily, after a little more practice in the 

game and with some hard-to-take reflection, it 

became clear that no two clients required the 

same diet even when they had the same condition. 

The importance of what they were eating and 

the reasons why was more of an influence than 

the dietary advice I was giving. Take your diet 

yesterday, for example. What influenced the foods 

you ate? Was it taste, time, convenience, cost, 

environment, availability, culture or tradition? 

Despite both of us knowing it is not the healthiest 

option, the reason why you had toast and jam for 

breakfast might be very different from the reason 

why I had had toast and jam, and if these reasons 

are different then the solutions to change are also 

likely to differ. 

So returning to Nietzsche, once I had come to 

terms with “the only way does not exist” and had 

individualised the dietary approach to my clients, 

the outcomes we were after finally followed. We 

developed suitable options that clients were able to 

contemplate slotting into their daily lives because, 

in the end, it is the client who decides whether or 

not to implement the advice. We’ve found that if 

advice is impractical or too dissimilar to what they 

are used to doing, then the sustainability of any 

change will be compromised. 

Implementing the individual-based approach 

becomes even more pertinent when considering 

the presenting condition of the clients. For 

example, as we all know in diabetes, one client 

may have very good glycaemic control whilst 

another may not. Therefore despite both of these 

clients having diabetes, the approach to their 

dietary management will differ significantly. This 

is perhaps why, when we were approached to 

trial lowering carbohydrate intake as a means of 

improving glycaemic control in some clients, I was 

open to the idea. As a result, my practice incurred 

the biggest and most inspiring change yet. Once 

an advocate for encouraging carbohydrate intake 

in diabetes management (as long as it was low 

glycaemic index!), I was now lowering carbohydrate 

altogether and seeing significantly better client 

outcomes across all key parameters including 

weight, glycaemic control and even lipids. Again, 

the amount of restriction was individualised to 

the client based on what they could sustain and 

their glycaemic profile. Surprisingly, clients were 

finding the change much more achievable and 

sustainable than previous dietary advice and were 

inevitably eating a much healthier, unprocessed 

and well-rounded diet. 

As a dietitian, I am so fortunate to have the 

time to sit with a client and determine and 

understand the details of why they eat what they 

eat. When they return to the clinic (and yes, they 

do now return!), they know that if a strategy 

hasn’t worked, we will find an alternative. They 

won’t be chastised or made to feel uncomfortable; 

they will be supported and encouraged, because 

the right way, the correct way and the only way 

– it does not exist. n 

Citation: Jackson E (2016) 

Individualising clients in dietary 

management. Diabetes & Primary 

Care Australia 1: 51 

About this series 

The aim of the “From the 

desktop” series is to provide 

practical expert opinion and 

comment from the clinic. In this 

issue, Erin Jackson champions 

individualised care after seeing 

the results for herself in clinic. 

Author 

Erin Jackson is an Accredited 

Practising Dietitian and Accredited 

Nutritionist, Member of the 

Dietitians Association of Australia, 

and Lecturer at the University of 

Tasmania, Tasmania, Tas. 


Article 

Evolution of health professional roles: 

GPs with a special interest in diabetes 

Jo-Anne Manski-Nankervis 

Citation: Manski-Nankervis JA (2016) 

Evolution of health professional 

roles: GPs with a special interest in 

diabetes. Diabetes & Primary Care 

Australia 1: 52–4 

Article points 

1. In the UK, a GP who has 

received additional training 

and experience in a particular 

area can become an accredited 

GP with a specialist interest 

(GPwSI). No such framework 

currently exists in Australia. 

2. There are many potential 

advantages to the role, 

including improved access to 

specialist care and reduced 

costs, but there are also 

potential disadvantages, such as 

fragmentation of primary care. 

3. There are programs in Australia 

that are trialling whether 

specialist GPs are an effective 

way to improve access to care. 

Key words 

– Advanced skills 

– Education 

– GPwSI 

Author 

Jo-Anne Manski-Nankervis is a 

GP in Essendon, Melbourne, Vic, 

and Lecturer at the Department of 

General Practice at the University 

of Melbourne, Vic. 

The prevalence of diabetes is increasing in Australia, necessitating health professionals 

to work together effectively and consider new ways to ensure that optimal care can 

be provided to all. One way in which this may take shape is in the evolution of health 

professional roles. A GP with a special interest (GPwSI) can provide a level of care and 

knowledge above what is provided in routine general practice. The author explains the 

GPwSI framework currently in use in the UK and considers whether it would be beneficial 

to develop something similar in Australia. 

In the UK, a GP with a special interest 

(GPwSI) has received additional training 

and experience in a specific clinical area and 

takes referrals for patients who may previously 

have been referred directly to a consultant. It 

is possible to be accredited in a range of health 

specialities, such as cardiology, mental health, 

older people and diabetes. 

GPwSI in diabetes 

In the case of diabetes care, there has been a long 

history of GPs in the United Kingdom working 

in diabetes clinics with shared care arrangements 

with specialists and running diabetes clinics 

within general practice. The increasing burden 

on specialist diabetes clinics, together with 

a government move to shift chronic care 

management from secondary to primary care, 

led to the development of the GPwSI in diabetes 

(Association of British Clinical Diabetologists, 

2002). Whilst the role of the GPwSI in diabetes 

varies according to local requirements in the UK, 

there are three common features: 

● Clinical service (i.e. provide assessment, 

advice, information and treatment to primary 

care colleagues for patients whose care does not 

require a specialist diabetes service). 

● Education and liaison. 

● Leadership. 

The development of the GPwSI role in the 

UK has standardised guidance that should be 

adhered to (Goenka et al, 2011; Royal College of 

General Practitioners and Department of Health, 

2003). In order to be able to attain recognition as 

a GPwSI, GPs in the UK need to have generalist 

qualifications as well as experience working under 

direct supervision with a consultant physician 

who has a special interest in diabetes in a hospital 

or community setting, or a personal development 

portfolio. This is in addition to demonstrating 

ongoing professional development. It is a basic 

requirement that a GPwSI must have clinical and 

governance support from consultant specialist 

colleagues, and it is recommended that a GPwSI 

should spend a minimum of one session a week in 

general practice in addition to time spent in the 

area of special interest. 

A GPwSI may form part of multidisciplinary 

care, working alongside specialist physicians, 

diabetes educators, dietitians, podiatrists and 

psychologists. There are also guidelines on the 

patient groups where it would be appropriate for 

primary care to refer directly to secondary care 

specialists rather than GPwSIs (see Box 1 for a 

quick guide): 

● Children and adolescents with diabetes. 

● Pregnant women with diabetes. 

● Individuals with very unstable type 1 diabetes 

or those requiring admission for severe 

hypoglycaemia and hyperglycaemia leading to 

diabetic ketoacidosis. 

● People requiring new or complex treatments, 

such as insulin pumps. 

● People with complications (e.g. retinopathy, 

nephropathy and foot problems requiring 


Evolution of health professional roles 

Table 1. Potential advantages and disadvantages of the GP with a special interest (GPwSI) role. 

Advantages 

Provides an alternate avenue for referral and access to 

specialist investigations 

Increased job satisfaction and reduced burnout for GPs 

Can link in-depth knowledge of primary care to specialist 

knowledge, allowing psychological and social issues to be 

accounted for 

Reduced waiting time and improved access compared to 

specialist services 

Present in the local community, which is more convenient 

to the patient 

May be associated with reduced costs 

multi-specialist management and intensive 

control of risk factors in keeping with any 

national or local guidelines and protocols). 

● Individuals requiring specialist psychological 

support for complications of diabetes (e.g. 

depression or erectile dysfunction). 

● Individuals with rare or unusual types of 

diabetes (e.g. associated with cystic fibrosis). 

Current literature 

The potential advantages and disadvantages 

associated with the GPwSI role are manyfold 

([see Table 1] Gerada et al, 2002; Wilkinson 

et al, 2005; Jiwa et al, 2012). Some specialists 

have voiced concerns about the potential for 

destabilisation of secondary care services, while 

others do not acknowledge a place for GPwSIs 

participating across primary and secondary care 

(Karet, 2007). However, the current shortage 

of specialists has been amongst the drivers for 

development of the GPwSI role. 

A mixed-methods study evaluating GPwSI-led 

primary care diabetes clinics in Bradford, UK 

was carried out in 2004. Sixteen of the 19 clinics 

were led by GPs, and the researchers found that 

the primary care clinics were valued because of 

geographical accessibility, short waiting times, 

continuity of staff and availability of specialists 

in the community setting (Nocon et al, 2004). 

Whilst the costs of these clinics were similar 

to hospital clinics, the study did not compare 

the primary care clinics to clinics that had 

diabetologist input. 

Disadvantages 

Fragmentation of care 

De-skilling of the GP workforce 

GPs may not refer to GPwSI 

Relies on good communication between GPs and GPwSI 

Framework for GPwSI accreditation does not currently exist 

in Australia 

In the Netherlands, GPs with an interest in 

diabetes can undertake additional training to 

become a “Diabetes Executive”. This role extends 

past consultation and care of individual patients 

and includes outreach work to practices within 

diabetes care groups. Diabetes care groups are 

legal entities that sign contracts with health 

insurance companies to ensure the delivery of 

diabetes care in different geographical areas 

(Struijs et al, 2010). 

In Australia, a number of GPs work within 

areas of special interest. Examples include skin 

cancer, women’s health and travel, cosmetic and 

sports medicine. Some practitioners working 

in these fields have additional qualifications; 

however, a framework like that existing in the 

UK does not exist here (Wilkinson et al, 2005). 

The Brisbane South Complex Diabetes Service 

(BSCDS) operating at Inala Primary Care, 

Brisbane, Qld, provides one example of how 

something akin to a GPwSI role can work within 

a multidisciplinary team to provide positive 

outcomes for people with diabetes (Jackson et al, 

2010). The BSCDS was developed in partnership 

with Princess Alexandra Hospital, Brisbane, a 

tertiary level hospital, to address the current 

waiting time of 12 months for individuals to 

access diabetes outpatient services. Advanced 

skills GPs called “clinical fellows”, who have 

completed postgraduate training in advanced 

diabetes care as part of a Master of Medicine 

program at the University of Queensland, 

Brisbane, work with an endocrinologist and 

Box 1. Quick guide 

to patient groups 

with diabetes best 

referred straight to 

secondary care. 

l Children and 

adolescents. 

l Pregnant women. 

l People with unstable 

type 1 diabetes. 

l People on new or 

complex treatments 

(e.g. pumps). 

l People with extensive 

complications. 

l People requiring 

psychological support. 

l People with rare types 

of diabetes. 


Evolution of health professional roles 

“The Brisbane 

South Complex 

Diabetes Service has 

demonstrated some 

positive results on 

reducing waiting time 

and improving clinical 

outcome for people 

with diabetes when 

advanced skills GPs 

are employed to 

provide care.” 

allied health professionals to provide care to 

individuals with diabetes who have been referred 

to the hospital in a community setting. The 

model contains an element of specialist outreach 

as the endocrinologist attends the clinic in the 

community and both the endocrinologist and 

GPs co-consult with the patient. This service 

includes insulin initiation and titration. 

Compared to the hospital clinic, the BSCDS 

has a waiting time of 4 weeks, their patients have 

significantly lower HbA 1c 

at 12 months, there is 

a reduced number of non-attendees at 12 months 

compared to that at the hospital, a significantly 

higher percentage of patients are discharged 

back to general practice, and care per visit cost 

is approximately one fifth of that occurring at 

the hospital outpatient department. This allows 

for a greater number of follow-up visits whilst 

still delivering a clinic at a lower cost (Russell 

et al, 2013). 

Another initiative exploring the potential for 

the GPwSI in diabetes role to develop in Australia 

is the National Faculty of Specific Interests 

of the Royal Australian College of General 

Practitioners, which commenced in 2011. 

Conclusion 

GPs have been working within areas of special 

interest for many years in Australia, but in 

countries such as the UK and Netherlands 

the role has been formalised. No such GPwSI 

framework exists in Australia; however, the 

BSCDS has demonstrated some positive results 

on reducing waiting time and improving clinical 

outcome for people with diabetes. n 

Association of British Clinical Diabetologists (2002) General 

Practitioners with a Special Interest in Diabetes – a 

discussion paper. ABCD, Malmesbury, UK. Available at: 

http://bit.ly/1VgJMNX (accessed 12.02.16) 

Gerada C, Wright N, Keen J (2002) The general practitioner with a 

special interest: new opportunities or the end of the generalist 

practitioner? Br J Gen Pract 52: 796–8 

Goenka N, Turner B, Vora J (2011) Commissioning specialist 

diabetes services for adults with diabetes: Summary of a 

Diabetes UK Task and Finish Group report. Diabet Med 28: 

1494–500 

Jackson C, Tsai J, Brown C et al (2010) GPs with special interests 

impacting on complex diabetes care. Aust Fam Physician 39: 

972–4 

Jiwa M, Meng X, Sriram D et al (2012) The management of Type 2 

diabetes: A survey of Australian general practitioners. Diabetes 

Res Clin Pract 95: 326–32 

Karet B (2007) Intermediate care in diabetes: a rose between two 

thorns? Practical Diabetes International 24: 389–91 

Nocon A, Rhodes P, Wright P et al (2004) Specialist general 

practitioners and diabetes clinics in primary care: a qualitative 

and descriptive evaluation. Diabet Med 21: 32–8 

Royal College of General Practitioners, Department of Health 

(2003) Guidelines for the appointment of General Practitioners 

with Special Interests in the Delivery of Clinical Services – 

Diabetes. DoH, London, UK 

Russell A, Baxter KA, Askew DA et al (2013) Model of care for 

the managment of complex type 2 diabetes managed in the 

community by primary care physicians with specialist support: 

an open controlled trial. Diabet Med 30: 1112–21 

Struijs JN, van Til JT, Baan CA (2010) Experimenting with a bundled 

payment system for diabetes care in the Netherlands. Centre for 

Prevention and Health Services Research, Public Health and 

Health Services Division, The Netherlands 

Wilkinson D, Dick MLB, Askew DA (2005) General practitioners 

with special interests: risk of a good thing becoming bad. Med 

J Aust 183: 84–6 

Join the discussion! 

QDo you think there is a place for 

the GPwSI in Australia? 

QAre you a GP with a special 

interest in diabetes or a health 

professional working with one? What are 

your experiences of the role? Should it be 

formally recognised? 

QCould the formalised GPwSI 

role assist in the provision of 

intermediate care in areas of medical 

workforce shortage (e.g. rural areas in 

which access to endocrinologists may be 

limited)? 

QAre you a nurse, pharmacist or 

allied health professional extending 

beyond the “traditional” role in assisting 

with the management of diabetes? 

Tweet @PCDSAus or comment on our 

LinkedIn page: www.linkedin.com/ 

primary-care-diabetes-society-of-australia 


Article 

Blood glucose: To monitor or not in type 2 

diabetes? The practical implications of the 

Choosing Wisely recommendation 

John Furler, Jessica Browne, Jane Speight 

Originating in the USA in 2012 and launched in Australia in 2015, the Choosing Wisely campaign 

is a professionally driven initiative that aims to encourage clinicians and consumers to question 

the use of medical tests, treatments and procedures. One of the most widely adopted campaign 

recommendations focuses on diabetes, and the role of routine self-monitoring of blood glucose. 

In this article, the authors explain the Choosing Wisely recommendation for self-monitoring 

of blood glucose in diabetes and put forward their view on how it fits with today’s diabetes 

environment. They also describe a structured way to use self-monitoring with the ultimate aim 

of empowering people with diabetes and improving glucose control. 

Launched in Australia in 2015, the Choosing 

Wisely campaign is a professionally driven 

initiative that aims to encourage clinicians 

and consumers to question the use of medical 

tests, treatments and procedures. The aim is 

to eliminate those that are not supported by 

evidence, that duplicate other tests or procedures, 

may cause harm and are not truly necessary. 

Thirteen countries have now implemented 

locally adapted versions of the Choosing Wisely 

campaign. 

One of the most widely adopted campaign 

recommendations in the US, Canada, UK 

and Australia focused on diabetes. Developed 

by the Royal Australian College of General 

Practitioners (RACGP) through evidence reviews 

and consultation with members and experts, the 

Choosing Wisely Australia recommendation was 

to not advocate routine self-monitoring of blood 

glucose (SMBG) for people with type 2 diabetes 

who are only on oral medication (Choosing 

Wisely Australia, 2015). The recommendation 

suggested that SMBG may possibly reduce 

HbA 1c 

levels by 0.25–0.3% (2.7–3.2 mmol/mol), 

but this was considered clinically insignificant. 

SMBG actually increased hypoglycaemia risk, 

although the reason for this was unclear. The 

recommendation, therefore, concluded that 

HbA 1c 

levels should be used to guide therapy, 

and promote lifestyle interventions regardless 

of diabetes control. The recommendation 

acknowledged that there are exceptions where 

SMBG is appropriate for people with type 2 

diabetes who are on oral medication, such as 

symptomatic hypoglycaemia; heavy machinery 

operators on a sulfonylurea; elderly people with 

renal failure and pregnant women. SMBG may 

also be appropriate as a possible short-term 

education tool for how diet influences blood 

glucose. We believe that such education ought to 

focus also on the impact of physical activity for 

regulating glycaemic levels. 

The concern about SMBG was not only that 

it may be clinically unhelpful, but also costly. 

The Choosing Wisely recommendation (2015) 

noted that, in 2012, $143 million was spent on 

test strips by the Australian Government, and 

that people with diabetes who are not on insulin 

and who use SMBG, on average use 300 test 

strips a year. While it is worth noting that only 

35% of this spend was for those people with 

non-insulin-treated type 2 diabetes, nevertheless 

this is not insubstantial. In Australia, type 2 

diabetes costs $15 billion annually (Colagiuri 

Citation: Furler J, Browne J, Speight J 

(2016) Blood glucose: To monitor or 

not in type 2 diabetes? The practical 

implications of the Choosing Wisely 

recommendation. Diabetes & 

Primary Care Australia 1: 55–8 


1. The Choosing Wisely 

campaign is a professionally 

driven initiative that aims 

to encourage clinicians 

and consumers to question 

the use of medical tests, 

treatments and procedures. 

2. There is concern that selfmonitoring 

of blood glucose 

(SMBG) is not only clinically 

unhelpful, but also costly. 

3. Structured SMBG does not 

duplicate other forms of 

monitoring but, rather, adds 

detail and value to what 

can be learnt from HbA 1c 

. 

Key words 

– Monitoring 

– Self-care 

– Type 2 diabetes 

Authors 

John Furler is Principal Research 

Fellow and Associate Professor, 

Department of General Practice, 

University of Melbourne, Vic; 

Jessica Browne is Senior Research 

Fellow, The Australian Centre for 

Behavioural Research in Diabetes, 

Diabetes Victoria, Melbourne, 

Vic; Jane Speight is Chair at the 

School of Psychology, Deakin 

University, Burwood, Vic. 


Blood glucose: To monitor or not in type 2 diabetes? 

Page points 

1. How to safely, effectively 

and efficiently achieve target 

glycaemic levels for people 

with type 2 diabetes to prevent 

downstream complications is a 

priority. 

2. The Choosing Wisely 

campaign aims to encourage a 

conversation between clinicians 

and patients about tests, 

treatments and procedures that 

may provide little or no value 

and that may cause harm. 

3. One way that could inform the 

conversation is to distinguish 

between structured and 

unstructured self-monitoring of 

blood glucose. 

Figure 1: A 3-day structured self-monitoring blood glucose profile. 

et al, 2014). Globally, up to 15% of national 

health budgets are spent on diabetes, between 

a quarter and a half of which is for blood 

glucose-lowering medications including insulin 

(Gregg et al, 2014). The problem of how 

to safely, effectively and efficiently achieve 

target glycaemic levels for people with type 2 

diabetes to prevent downstream complications 

is a priority. However, the Choosing Wisely 

recommendation suggests that SMBG should 

not be part of the solution – at least not until 

people are using insulin, initiated typically 

several years after diagnosis and often long after 

increased risk of downstream complications is 

established. 

Around the same time as the Choosing 

Wisely Australia campaign was launched, the 

Federal Government concluded an extensive, 

2-year review and consultation process focused 

on the use of SMBG in people with non-insulintreated 

type 2 diabetes, undertaken within 

the Pharmaceutical Benefits Scheme. Based on 

that process, the Government have announced 

that access to subsidised SMBG strips will 

be restricted from 1 July 2016 for those with 

type 2 diabetes who are not using insulin 

and who have their blood glucose level under 

control (Australian Government Department 

of Health, 2013). The Pharmaceutical Benefits 

Advisory Committee also recommended that 

these patients be limited to a 6-month supply 

(approximately 100 strips) following changes to 

their diabetes management, with an additional 

6-months’ supply available at the prescriber’s 

discretion. Unrestricted access to SMBG 

strips will continue for people with type 2 

diabetes using insulin or other medicines (e.g. 

corticosteroids and sulfonylureas) to detect 

asymptomatic hypoglycaemia or during illness 

that may cause fluctuations in blood glucose 

(Australian Government Department of 

Health, 2013). 

What should we advise people with 

type 2 diabetes? 

The Choosing Wisely campaign aims to 

encourage a conversation between clinicians 

and patients about tests, treatments and 

procedures that may provide little or no value 

and that may cause harm (Hoffmann et al, 

2015). Every person with type 2 diabetes is 

indeed different and conversations about SMBG 

need to be person-centred and tailored to 

the individual and their circumstances. So, 

what sort of conversation should we be having 

about monitoring of glycaemia? Is there a more 

nuanced and helpful message than simply “stop 

monitoring your blood glucose levels”? 

One way that could inform the conversation 

is to distinguish between structured and 

unstructured SMBG. We have written two 

papers to contribute to the conversation about 

this issue (Speight et al, 2013; 2015) and revisit 

some of the evidence and controversy here. 

The reviews that informed the Choosing 

Wisely recommendation (e.g. a 2012 Cochrane 



review [Malanda et al, 2012]) and the changes 

in Government subsidies included several 

randomised controlled trials. However, these 

trials varied significantly in the instruction 

and support provided for the frequency of selfmonitoring 

checks and the sort of feedback 

and self-management support individuals were 

given. This may obscure a potentially important 

difference between monitoring that is routine, 

random and low frequency (unstructured 

SMBG), and monitoring that is more strategic 

(structured SMBG). To paraphrase George 

Orwell, all monitoring is equal, but some 

monitoring is more equal than others. 

Certainly the experience of practitioners and 

people with type 2 diabetes around unstructured 

SMBG is largely negative. Unstructured SMBG 

is ineffective because (a) it does not easily allow 

the identification of blood glucose patterns 

by people with type 2 diabetes or their health 

professionals, and (b) it can not inform rational 

therapeutic and self-management choices (e.g. 

food intake or physical activity). GPs can find 

the blood glucose diaries that a person with 

type 2 diabetes might bring to clinic quite 

difficult to interpret and act upon and may not 

lend them much weight. For people with type 2 

diabetes, for whom monitoring can be “painful”, 

“inconvenient” and “expensive”, the dismissal of 

their glucose diaries by health professionals can 

be demotivating and frustrating (Speight et al, 

2015). 

Structured SMBG 

Structured SMBG involves a short burst of 

multiple daily blood glucose checks, for example, 

seven times a day – before and 2 hours after each 

meal and before bed – over 3 days. Recording 

of meal sizes and energy levels are also made to 

provide context to the readings. This is sufficient 

to identify times below, above and within 

target range and recognise meaningful blood 

glucose patterns – which HbA 1c 

alone cannot do 

(Figure 1). Importantly, structured SMBG is best 

implemented within a collaborative therapeutic 

relationship with a supportive health professional 

who is trained in interpretation of SMBG data 

(Box 1). The collaborative consultation and 

interpretation of the SMBG pattern can drive 

shared plans for how to change diet, activity and 

medication to improve glucose levels. Structured 

SMBG may be more empowering for people 

with type 2 diabetes as well as their health 

professionals. It might also drive more targeted 

use of the money spent on blood glucose-lowering 

medications. It is worth noting that this type of 

monitoring uses as few as 84 test strips per year 

(i.e. 21 strips over 3 days, every 3 months prior 

to a GP visit). 

There is a small but emerging evidence base 

for structured SMBG. The STeP (Structured 

Testing Program) Study, a randomised trial in 

primary care in the US, evaluated the use of 

structured SMBG on four occasions per year 

and found a statistically significant reduction 

in HbA 1c 

(−0.3%, P


“We believe a 

more positive 

recommendation 

would be for health 

professionals to 

advocate for structured 

self-monitoring of 

blood glucose for all 

people with type 2 

diabetes not using 

insulin or other 

hypoglycaemiainducing 

medications.” 

2011]). Furthermore, structured SMBG leads to 

other important psychological benefits reported 

in this trial and other studies (Fisher et al, 2012; 

Speight et al, 2013). 

Future developments 

There is no doubt that even structured SMBG on 

just four occasions per year can be burdensome to 

patients. Some patients in the STeP Study did not 

complete the required monitoring. There is now 

growing interest in the potential for wearable 

devices (such as continuous glucose monitors) 

worn on occasions to provide similarly structured 

(but more detailed) patterns of glycaemia to 

people with type 2 diabetes and their health 

professionals, without the burden of finger pricks 

and active recording of glucose levels. With 

growing evidence that people are increasingly 

interested in wearable devices to support health 

improvements and behaviour change, this is a 

promising avenue for future research. 

We are now embarking on a National Health 

and Medical Research Council funded study to 

investigate the effectiveness of such an approach 

to monitoring. Any GPs in Victoria who are 

interested in participating in the GP-OSMOTIC 

study can contact Associate Professor John 

Furler at the University of Melbourne or read 

the study pamphlet for more information 

(http://bit.ly/1UVbB0i). 

Conclusion 

The aim of the Choosing Wisely campaign is 

to eliminate those clinical practices that are not 

supported by evidence, duplicate other tests 

or procedures, may cause harm and are not 

truly necessary. While there is evidence that 

unstructured monitoring is ineffective, there is 

some evidence that structured monitoring may 

be effective, although implementation barriers 

remain. Structured SMBG does not duplicate 

other forms of monitoring but, rather, adds detail 

and value to what can be learnt from HbA 1c 

alone. 

Structured monitoring does not cause harm but, 

rather, generates a range of positive psychological 

benefits. Structured monitoring may well be a 

necessary part of collaborative care for all people 

with type 2 diabetes, as all diabetes is serious and 

all diabetes leads to complications if not monitored 

and managed appropriately. As we wrote last year 

(Speight et al, 2015), we believe a more positive 

recommendation would be for health professionals 

to advocate for structured SMBG for all people 

with type 2 diabetes not using insulin or other 

hypoglycaemia-inducing medications. n 

Conflicts of interest 

John Furler received fellowship support from NHMRC CCRE 

in Diabetes Science and is supported by NHMRC-PHCRED 

Career Development Fellowship. He has received unrestricted 

educational grants for research support from Roche, Sanofi and 

Medtronic. 

Jessica Browne and Jane Speight are funded by the collaboration 

between Diabetes Victoria and Deakin University that supports 

The Australian Centre for Behavioural Research in Diabetes. 

Jessica Browne has received consultancy income from Roche 

Diagnostics Australia and Sanofi Diabetes. 

Jane Speight is a member of the Accu-Check Advisory Board 

(Roche Diagnostics Australia). Her research group has received 

unrestricted educational grants from Medtronic and Sanofi 

Diabetes; sponsorship to host or attend educational meetings 

from Lilly, Medtronic, MSD, Novo Nordisk, Roche Diagnostics 

Australia, and Sanofi Diabetes; consultancy income from Abbott 

Diabetes Care, Roche Diagnostics Australia and Sanofi Diabetes. 

Australian Government Department of Health (2013) The 

Pharmaceutical Benefits Scheme: post-market review of products 

used in the management of diabetes. DoH, Canberra, ACT. 

Available at: http://bit.ly/1UmuQka (accessed 01.06.2015) 

Choosing Wisely Australia (2015) 5 things clinicians and 

consumers should question. The Royal Australian College 

of General Practitioners, East Melbourne, Vic. Available at: 

http://www.choosingwisely.org.au (accessed 09.02.16) 

Colagiuri R, Dain K, Moylan J (2014) The global response to 

diabetes: action or apathy? Med J Austr 201: 581–3 

Fisher L, Polonsky WH, Parkin CG et al (2012) The impact of 

structured blood glucose testing on attitudes toward selfmanagement 

among poorly controlled, insulin-naïve patients 

with type 2 diabetes. Diabetes Res Clin Pract 96: 149–55 

Gregg EW, Li YF, Wang J et al (2014) Changes in diabetes-related 

complications in the United States, 1990-2010. New Eng J Med 

370: 1514–23 

Hoffman T, Del Mar C (2015) Less is the new more: choosing 

medical tests and treatments wisely: The Conversation. The 

Conversation Trust (UK) Limited, London, UK. Available at: 

http://bit.ly/1EBoeWD (accessed 02.02.16) 

Malanda UL, Welschen LMC, Riphagen II et al (2012) Selfmonitoring 

of blood glucose in patients with type 2 diabetes 

mellitus who are not using insulin. Cochrane Database Syst Rev 1: 

CD005060 

Polonsky WH, Fisher L, Schikman CH et al (2011) Structured selfmonitoring 

of blood glucose significantly reduces A1C levels in 

poorly controlled, noninsulin-treated type 2 diabetes: results from 

the Structured Testing Program study. Diabetes Care 34: 262–7 

Speight J, Browne JL, Furler J (2013) Challenging evidence and 

assumptions: is there a role for self-monitoring of blood glucose 

in people with type 2 diabetes not using insulin? Curr Med Res 

Opin 29: 161–8 

Speight J, Browne JL, Furler JS (2015) Testing times! Choosing Wisely 

when it comes to monitoring type 2 diabetes. Med J Aust 203: 

354–6 


Article 

Diabesity and periodontal disease: 

Relationship and management 

Rajesh Chauhan, Mark Kennedy, Werner Bischof 

There is an increased incidence of periodontal disease among people with diabetes and 

obesity, and a growing body of evidence that suggests improving dental health may lead to 

improvements in glycaemic control. Healthcare professionals in dental and primary care 

should work together to identify individuals with periodontal disease at risk of progressing to 

chronic conditions, and ensure that those with diabetes and/or obesity are offered dental care 

in the same way people with diabetes are routinely offered retinal screening and foot care. 

The ever-growing burden of diabetes and 

obesity on health care and society has 

been widely reported in the medical 

literature and mainstream media, with these 

chronic conditions being described as global 

epidemics (World Health Organization, 2013). 

Though less widely discussed, periodontal 

disease is also a major health burden, with 

epidemiological studies revealing more than 

two-thirds of the world’s population have some 

form of chronic periodontal disease (Dahiya 

et al, 2012). 

This article examines the potential 

bidirectional relationship between periodontal 

disease and diabesity, and highlights the role 

the dental practitioner can play – alongside their 

colleagues in primary care – in both screening 

and caring for people with these conditions. 

Periodontal disease 

Periodontal disease is an infectious, oral 

condition affecting the supporting structures 

of the teeth that is caused by the interaction 

between pathogenic bacteria and the host’s 

immune system. Oral bacteria are required, 

but are alone insufficient, for disease initiation 

(Graves, 2008); persistent host inflammatory 

response is needed before the soft and 

mineralised periodontal tissues become eroded 

and disease is established (Graves, 2008; Liu et 

al, 2010). 

Periodontal disease comprises gingivitis 

(Figure 1a) and periodontitis (Figure 1b). 

Gingivitis – inflammation of the gum – is 

most-commonly associated with plaque buildup 

around a tooth and is usually reversible with 

good oral hygiene. If left untreated, gingivitis 

can lead to periodontitis. 

Periodontitis is the more advanced stage 

of periodontal disease, occurring when 

microorganisms colonise and progressively 

destroy the periodontal ligament and alveolar 

bone, with pocket formation or recession (or 

both) around diseased teeth. This process is 

multifactorial and occurs in the presence of 

microbial challenge alongside other genetic, 

(a) 

(b) 

Figure 1. Examples of (a) gingivitis and (b) periodontitis. 

Note that the bleeding of the gums from gingivitis usually 

precedes receding gums and bone loss associated with 

periodontitis. 

Citation: Chauhan R, Kennedy M, 

Bischof W (2016) Diabesity and 

periodontal disease: Relationship 

and management. Diabetes & 

Primary Care Australia 1: 59–63 


1. Periodontal disease is an 

inflammatory condition that is 

linked to diabetes and obesity. 

2. The significance of the link is 

not widely understood among 

healthcare professionals. 

3. Dental practitioners should 

be part of an integrated 

healthcare team – alongside 

primary care professionals 

– that engages in screening, 

provision of preventative 

advice and education, and 

referrals for individuals at 

risk of chronic conditions. 

4. Improving dental health 

may contribute to improved 

glycaemic control, reducing 

the risk of diabesity-related 

complications, although further 

studies are needed to firmly 

establish these relationships. 

Key words 

- Dental health practitioner 

- Diabesity 

- Periodontal disease 

Authors 

See page 63 for author 

information. 

Diabetes and Primary Care Australia Vol 1 No 2 2016 59

Diabesity and periodontal disease: Relationship and management 

Page points 

1. There is evidence to suggest 

a bidirectional relationship 

between diabetes and 

periodontal disease; 

however, more research is 

needed to unequivocally 

establish a relationship 

between these conditions. 

2. Meta-analysis and observational 

evidence suggest that 

periodontitis may also be 

related to the development of 

type 2 diabetes (and possibly 

gestational diabetes). 

3. It has been suggested that the 

chronic conditions at hand 

– metabolic dysregulation, 

periodontal disease and 

diabetes – are linked by changes 

in the inflammatory state. 

environmental and acquired risk factors. The 

destructive tissue changes observed in cases 

of periodontitis are the result of the host’s 

inflammatory response to chronic oral infection. 

Diabetes 

There is evidence to suggest a bidirectional 

relationship between diabetes and periodontal 

disease. However, interpretation of these data 

is not straightforward due to differences in 

study designs. More research is needed to 

unequivocally establish a relationship between 

these conditions. 

Large epidemiological studies have shown 

that individuals with diabetes are three-times 

more likely to develop periodontal disease than 

those without (Shlossman et al, 1990; Emrich 

et al, 1991) and the extent of glycaemic control 

may determine risk. The NHANES (US 

National Health and Nutrition Examination 

Survey) III study demonstrated that adults 

with poorly-controlled diabetes (HbA 1c 

>9% 

[74.9 mmol/mol]) had a 2.9-fold increased 

risk of periodontitis than those without the 

condition, and that individuals with wellcontrolled 

diabetes had no significant increase 

in risk (Tsai et al, 2002). Furthermore, those 

with both conditions show an increased severity 

of periodontal destruction compared with those 

without diabetes (Mealey, 2006; Lakschevitz 

et al, 2011). These findings lead to suggestions 

that, when glycaemia is uncontrolled, diabetes 

can reduce the body’s ability to appropriately 

respond to the microbial challenge presented 

by pathogenic oral bacteria, leading to a greater 

extent of periodontal destruction in this group 

(Oppermann et al, 2012). 

Suggestive of a bidirectional relationship 

between glycaemic control and periodontal 

disease, the results of cross-sectional and 

prospective epidemiological studies have also 

found that periodontitis increases the risk of 

poor glycaemic control and is related to the 

development of complications in people with 

diabetes. Meta-analysis and observational 

evidence suggests that periodontitis may also be 

related to the development of type 2 diabetes 

(and possibly gestational diabetes [Borgnakke 

et al, 2013; Esteves et al, 2016]). The biological 

plausibility of such a relationship is based on 

increasing evidence showing that inflammation 

is linked to insulin resistance and precedes the 

development of diabetes, and that inflammatory 

periodontal disease contributes to cumulative 

inflammatory burden (Wang et al, 2013). Thus, 

the level of glycaemic control may be a key factor 

in determining risk of periodontal disease, and 

vice versa. However, further large, longitudinal 

studies are required to validate these findings. 

Obesity 

The detrimental metabolic dysregulation 

commonly associated with obesity has been 

well described. Obesity contributes to insulin 

resistance through the elevation of circulating 

free fatty acids that inhibit glucose uptake, 

glycogen synthesis and glycolysis (Tunes et al, 

2010). Beyond the association with dyslipidaemia, 

adipose tissue is recognised as an immune organ 

that secretes numerous immunomodulatory 

factors (Wisse, 2004). Thus, it has been suggested 

that the chronic conditions at hand – metabolic 

dysregulation, periodontal disease and diabetes – 

are linked by changes in the inflammatory state, 

and that a complex, bidirectional relationship 

exists, with each being a risk factor for further 

systemic complications (Mealey and Ocampo, 

2007; Mealey and Rose, 2008; Dahiya et al, 2012; 

Levine, 2013; Palle et al, 2013). Levine (2013) 

has suggested that because periodontitis may 

stimulate inflammatory change in adipose tissue, 

the relationship between obesity, diabetes and 

periodontal disease may actually be a triangular 

self-generating cycle of morbidity. 

Towards better management: 

Improving glycaemic control 

and oral health 

It should be recognised that periodontal disease 

is preventable through adequate oral hygiene and 

associated professional care where indicated. The 

early detection and management of gingivitis 

can prevent the progression to periodontitis. The 

current gold standard for treating periodontal 

disease involves managing oral infection with 

the choice of treatment depending on the extent 

of disease. Periodontitis is usually managed with 

interventional, non-surgical therapies, together 

60 Diabetes and Primary Care Australia Vol 1 No 2 2016


with the use of antiseptic mouthwashes. Dental 

scaling (polishing) and root planing (also known 

as debridement) are most commonly used. 

Scaling involves removing plaque and tartar 

(hardened plaque) by scraping it from the tooth 

and around the gum line. Root planing – a more 

intensive type of cleaning – removes bacteria 

from the root of the tooth. In more extreme 

cases, periodontal surgery may be required to 

remove the affected tooth. Adjunctive systemic 

antibiotic therapy can be also be used to further 

minimise infection. 

Impact of dental treatment 

Accepting that a link between oral ill-health, 

poor glycaemic control and obesity-related 

metabolic dysregulation and increased proinflammatory 

markers exists, some authors 

have hypothesised that successful periodontal 

treatment that also reduces systemic 

inflammation may improve diabetes control 

through a reduction in systemic insulin 

resistance (Mealey and Rose, 2008). 

A recent Cochrane review (Simpson et al, 

2015) examined evidence relating to treatment 

of periodontal disease for glycaemic control 

in people with diabetes mellitus. The review 

showed that treatment of periodontal disease 

by scaling and root planing did improve 

glycaemic control with a mean reduction in 

HbA 1c 

of 0.29% (3.2 mmol/mol) at 3–4 months. 

However, there was insufficient evidence to 

show maintenance of this benefit beyond 

4 months. The authors concluded that ongoing 

professional periodontal treatment would be 

required to maintain clinical improvements 

beyond 6 months. 

There was no evidence supporting any one 

periodontal therapy being more effective than 

others in improving glycaemic control in people 

with diabetes at this time. The authors also 

concluded that further research is required to 

determine whether adjunctive drug therapies 

should be used with periodontal treatment, to 

examine the long-term glycaemic benefits of 

ongoing periodontal treatment and to investigate 

the impact of such treatments on reducing 

periodontal inflammation in people with 

diabetes. 

Impact of improved diabetes management 

Of all systemic conditions, diabetes provides 

the greatest risk factor for periodontitis and is 

associated with increased prevalence, severity 

and progression of disease (Lalla and Lamster, 

2012). There is evidence to suggest that the level 

of diabetes control can have an influence on the 

response to periodontal treatment. The response 

to scaling and root planing in people with wellcontrolled 

diabetes appears similar to those 

without diabetes. Although many people with 

diabetes show improvement following treatment, 

individuals with poorer glycaemic control may 

have a more rapid recurrence of disease and a 

less favourable long-term prognosis (Mealey and 

Oates, 2006). 

Towards better health: Implications for 

practice 

While the results of meta-analyses and 

population-based studies suggest that 

periodontal treatment is associated with 

improved glycaemic control, there is a 

paucity of trials of sufficient statistical power 

to substantiate this claim. Further larger, 

randomised trials are warranted in populations 

with similar baseline levels of periodontal disease 

and glycaemic control (Preshaw et al, 2012). 

Though not yet fully substantiated, the 

evidence to-date has been convincing for many. 

A growing number of recognised health care 

bodies and institutions have seen fit to include 

oral care as an element of holistic care for the 

patient with long-term conditions, such as 

diabetes and obesity. 

The American Diabetes Association’s (2016) 

Standards of Medical Care in Diabetes highlights 

periodontal disease as a common comorbidity 

of diabetes. These guidelines emphasise dental 

practitioner involvement in a comprehensive 

diabetes evaluation, recommending that 

people with diabetes be referred for periodontal 

examination. Furthermore, the European 

Federation of Periodontology’s (EFP; 2014) 

manifesto, Perio and General Health – following 

recommendations from the first joint EFP/ 

American Academy of Periodontology (AAP) 

Working Group on Periodontitis and Systemic 

Health – is a call to action for dental professionals 

Page points 

1. Results are inconclusive 

on whether periodontal 

treatment such as scaling 

and root planing are effective 

in treating periodontitis in 

people with diabetes. 

2. Accepting that a link between 

oral ill-health, poor glycaemic 

control and obesity-related 

metabolic dysregulation and 

increased pro-inflammatory 

markers exists, managing 

one or more of these factors 

should have a positive 

impact on the others. 

3. Although many people with 

diabetes show improvement 

following treatment, individuals 

with poorer glycaemic control 

may have a more rapid 

recurrence of disease and a less 

favourable long-term prognosis. 



Page points 

1. Dental professionals have 

the opportunity and the 

responsibility to assume 

an active role in the early 

identification, assessment and 

management of their patients 

who present with or are at 

risk of developing diabetes. 

2. Although the association 

between diabetes and 

periodontal disease is long 

established, many people 

are unaware of the strength 

of this relationship. 

3. Physicians should be aware 

of the common signs and 

symptoms of periodontal 

disease, including gingival 

bleeding, red/dark red 

discoloration and inflammation 

of gingiva, halitosis, an 

itching sensation in the 

gums, sensitivity to hot/ 

cold temperatures, presence 

of toothache without caries 

and any mobility, extrusion 

or migration of teeth. 

to engage in the screening of, and education 

for, people at risk of chronic disease, including 

diabetes (Chapple and Genco, 2013). The 

British Dental Association recently followed suit 

(Chapple and Wilson, 2014). 

Role of the dental professional 

Oral health can indicate signs of metabolic 

or systemic ill-health. A recent pilot study 

demonstrated that people at risk of developing 

type 2 diabetes could be identified in primary, 

community and secondary dental care settings 

(Preshaw, 2014), underlining the importance 

of the dental practitioner. Dental practitioners 

have the opportunity and the responsibility to 

assume an active role in the early identification, 

assessment and management of their patients 

who present with or are at risk of developing 

diabetes (Lalla and Lamster, 2012). They are 

well placed to provide counselling on the oral 

complications of overweight, obesity and diabetes; 

offer weight prevention and management advice 

and education; implement obesity and diabetes 

screening programmes (e.g. using weight-toheight 

ratio or waist circumference measurements 

to determine visceral adiposity and/or HbA 1c 

as an indicator of glycaemic control), and 

importantly, to appropriately refer patients to 

primary care practitioners. Guidelines have 

been set out by the joint EFP/AAP for health 

professionals to use in diabetes practice and in 

dental practice (Chapple and Genco, 2013). The 

guidelines recommend: 

● Informing people with diabetes of the 

increased risk of periodontal disease and 

that having periodontal disease may make 

glycaemic control more difficult, and 

informing individuals that they are at higher 

risk of diabetic complications. 

● A thorough oral examination as part of the 

initial evaluation of people with type 1, type 2 

and gestational diabetes. 

● A periodontal examination for all newly 

diagnosed individuals with type 1 and type 2 

diabetes (with annual review) as part of their 

ongoing management of diabetes. 

● A prompt periodontal evaluation for people 

with diabetes presenting with overt signs and 

symptoms of periodontitis (i.e. loose teeth, 

spacing or spreading of teeth and/or gingival 

abscesses). 

● Dental rehabilitation to restore adequate 

mastication for proper nutrition in people 

with diabetes who have extensive tooth loss. 

● Oral health education for all people with 

diabetes. People with diabetes are at increased 

risk of oral fungal infections and experience 

poorer wound healing. Practitioners should 

advise that other oral conditions (such as dry 

mouth and burning mouth) may occur. 

● Annual oral screening from the age of 

6–7 years for children and adolescents 

diagnosed with diabetes. 

Role of the healthcare professional 

Although the association between diabetes 

and periodontal disease is long established 

and periodontal disease has been described 

as the sixth complication of diabetes for over 

two decades (Loe, 1993), many patients are 

unaware of the strength of this relationship 

(Weinspach et al, 2013). The inclusion of 

dental practitioners as foundation members of 

the primary care multidisciplinary care team is 

currently not well established. Efforts should be 

made to increase awareness among primary care 

providers of the link between poor oral health 

and systemic disease – and vice versa. Alongside 

better awareness of the signs and symptoms 

of periodontal disease, primary care providers 

should proactively inquire when their patients 

last visited a dental practitioner, particularly 

in individuals with visceral adiposity and/or 

diabetes. 

Physicians should be aware of the common 

signs and symptoms of periodontal disease, 

including gingival bleeding, red/dark red 

discoloration and inflammation of gingiva, 

halitosis, an itching sensation in the gums, 

sensitivity to hot/cold temperatures, presence 

of toothache without caries and any mobility, 

extrusion or migration of teeth. If the patient 

has any of the above, they should be referred 

to a dentist or a periodontist. Perhaps more 

importantly, physicians could further help 

their dental colleagues by providing the results 

of laboratory tests (e.g. HbA 1c 

) to dentists on 

request, if not routinely (Dahiya et al, 2012). 

62 Diabetes and Primary Care Australia Vol 1 No 2 2016


Conclusion 

A number of healthcare bodies and institutions 

have recognised the utility of dental 

professionals in the multidisciplinary team 

to screen, and provide preventive education 

to, people at risk of chronic diseases, such as 

diabetes. Despite this, gaps between primary 

health care and dental care exists. Further 

engagement between the dental professional and 

primary care team could free-up up time in the 

busy GP clinic, and provide more holistic care.n 

Acknowledgement 

This article has been modified from one 

previously published in Diabesity in Practice 

(2014, 3: 49–53). 

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care in diabetes 2016. Diabetes Care 39 (Suppl 1): S107–8 

Borgnakke WS, Ylöstalo PV, Taylor GW, Genco RJ (2013) 

Effect of periodontal disease on diabetes: systematic review 

of epidemiologic observational evidence. J Periodontol 84 

(Suppl 4): S135–52 

Chapple IL, Genco R (2013) Diabetes and periodontal 

diseases: consensus report of the Joint EFP/AAP Workshop 

on Periodontitis and Systemic Diseases. J Clin Periodontol 

40(Suppl 14): S106–12 

Chapple IL, Wilson NH (2014) Manifesto for a paradigm shift: 

periodontal health for a better life. Br Dent J 216: 159–62 

Dahiya P, Kamal R, Gupta R (2012) Obesity, periodontal and 

general health: relationship and management. Indian J 

Endocrinol Metab 16: 88–93 

Liu YC, Lerner UH, Teng YT (2010) Cytokine responses against 

periodontal infection: protective and destructive roles. 

Periodontol 52: 163–206 

Loe H (1993) Periodontal disease. The sixth complication of 

diabetes mellitus. Diabetes Care 16: 329–34 

Mealey BL (2006) Periodontal disease and diabetes: a two-way 

street. J Am Dent Assoc 137(Suppl): 26S–31S 

Mealey BL, Oates TW (2006) Diabetes mellitus and periodontal 

diseases. J Periodontol 77: 1289–303 

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periodontal disease. Periodontol 2000 44: 127–53 

Mealey BL, Rose LF (2008) Diabetes mellitus and inflammatory 

periodontal diseases. Curr Opin Endocrinol Diabetes Obes 

15: 135–41 

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disease and systemic complications. Braz Oral Res 26 

(Suppl 1): 39–47 

Palle AR, Reddy CM, Shankar BS et al (2013) Association between 

obesity and chronic periodontitis: a cross-sectional study. 

J Contemp Dent Pract 14: 168–73 

Preshaw P (2014) Summary of: type 2 diabetes risk screening in 

dental practice settings: a pilot study. Br Dent J 216: 416–7 

Preshaw PM, Alba AL, Herrera D et al (2012) Periodontitis and 

diabetes: a two-way relationship. Diabetologia 55: 21–31 

Shlossman M, Knowler WC, Pettitt DJ, Genco RJ (1990) 

Type 2 diabetes mellitus and periodontal disease. J Am Dent 

Assoc 121: 532–6 

Simpson TC, Weldon JC, Worthington HV et al (2015) 

Treatment of periodontal disease for glycaemic control in 

people with diabetes mellitus. Cochrane Database Syst Rev 

11: CD004714 

“A number of 

healthcare bodies 

and institutions have 

recognised the utility 

of dental professionals 

in the multidisciplinary 

team to screen, and 

provide preventive 

education to, people at 

risk of chronic diseases, 

such as diabetes.” 

Emrich LJ, Shlossman M, Genco RJ (1991) Periodontal disease 

in non-insulin-dependent diabetes mellitus. J Periodontol 62: 

123–30 

Esteves L, Esteves Lima R, Cyrino R et al (2016) Association 

between periodontitis and gestational diabetes mellitus: 

systematic review and meta-analysis. J Periodontol 87: 48–57 

European Federation of Periodontology (2014) Perio and General 

Health. EFP, Madrid, Spain. Available at: http://bit.ly/SnDJfK 


Graves D (2008) Cytokines that promote periodontal tissue 

destruction. J Periodontol 79(8 Suppl): 1585S–1591S 

Lakschevitz F, Aboodi G, Tenenbaum H, Glogauer M (2011) 

Diabetes and periodontal diabetes and periodontal diseases: 

interplay and links. Curr Diabetes Rev 7: 433–9 

Lalla E, Lamster IB (2012) Assessment and management of 

patients with diabetes mellitus in the dental office. Dental 

Clinics of North America 56: 819–29 

Levine RS (2013) Obesity, diabetes and periodontitis–a 

triangular relationship? Br Dent J 215: 35–9 

Tsai C, Hayes C, Taylor GW (2002) Glycemic control of 

type 2 diabetes and severe periodontal disease in the US 

adult population. Community Dent Oral Epidemiol 30: 

182–92 

Tunes SR, Foss-Freitas MC, Nogueira-Filho Gda R (2010) Impact 

of periodontitis on the diabetes-related inflammatory status. 

J Can Dent Assoc 76: a35 

Wang X, Bao W, Liu J et al (2013) Inflammatory markers and risk 

of type 2 diabetes: a systematic review and meta-analysis. 

Diabetes Care 36: 166–75 

Weinspach K, Staufenbiel I, Memenga-Nicksch S et al (2013) 

Level of information about the relationship between diabetes 

mellitus and periodontitis – results from a nationwide 

diabetes information program. Eur J Med Res 18: 6 

Wisse BE (2004) The inflammatory syndrome: the role of 

adipose tissue cytokines in metabolic disorders linked to 

obesity. J Am Soc Nephrol 15: 2792–800 

World Health Organization (2013) Obesity and Overweight. 

Fact Sheet Number 311. WHO, Geneva, Switzerland. 

Available at: http://bit.ly/18pCdAN (accessed 23.04.14) 

Authors 

Rajesh Chauhan is Specialist in 

Oral Surgery, Lister Hospital, 

Stevenage and Queen Elizabeth II 

Hospital, Welwyn Garden City, 

Hertfordshire, and a General 

Dental Practitioner, Watton 

Place Clinic, Watton-at-Stone, 

Hertfordshire, UK; Mark 

Kennedy is Honorary Clinical 

Associate Professor, University 

of Melbourne, Melbourne, Vic; 

Werner Bischof is a Periodontist 

and Associate Professor, La Trobe 

University, Bendigo, Vic, and 

Clinical Advisor, Specialist Care, 

Dental Health Services Victoria. 


The PCDSA is a multidisciplinary society with the aim 

of supporting primary health care professionals to deliver 

high quality, clinically effective care in order to improve 

the lives of people with diabetes. 

The PCDSA will 

Share best practice in delivering quality diabetes care. 

Provide high-quality education tailored to health professional needs. 

Promote and participate in high quality research in diabetes. 

Disseminate up-to-date, evidence-based information to health 

professionals. 

Form partnerships and collaborate with other diabetes related, 

high level professional organisations committed to the care of 


Promote co-ordinated and timely interdisciplinary care. 

Membership of the PCDSA is free and members get access to a quarterly 

online journal and continuing professional development activities. Our first 

annual conference will feature internationally and nationally regarded experts 

in the field of diabetes. 

To register, visit our website: 

www.pcdsa.com.au

Article 

The “NO TEARS” diabetes 

medication review 

Jane Diggle 

A medication review offers an ideal opportunity to critically examine a person’s medicines 

with the individual, with the goal of ensuring that the treatment regimen is effective, safe 

and acceptable to the person. It can give individuals the opportunity to express any concerns 

they have about their treatment and should help to: improve medication concordance and 

patient satisfaction; reduce unnecessary medicine wastage; and, hopefully, optimise health 

outcomes. A medication review should be a key element of every diabetes consultation 

and, in this article, the author describes various strategies to support more effective 

diabetes medication reviews, with a focus on the “NO TEARS” tool. 

Publisher’s note 

This article was originally published in the UK in Diabetes & Primary Care 17: 125–30. It has been 

reproduced with kind permission from the author. 

The Australian context 

Cik Yin Lee, Pharmacist at Frost’s Pharmacy, Rosanna, Vic, and Research Fellow at Royal District 

Nursing Service, St Kilda, Vic; Rajna Ogrin, Senior Research Fellow at Royal District Nursing Service, 

St Kilda, Vic. 

With the progression of diabetes, its 

effective management will require 

the addition of pharmacotherapy to 

achieve optimal outcomes, with intensification of 

therapy over time likely in many cases. Furthermore, 

people with diabetes may develop complications 

of the disease, as well as comorbidities common 

with ageing, necessitating the administration of 

a number of medications. There are a number 

of medication management system supports in 

Australia, called Medication Management Review 

(MMR) programs (Department of Health, 2014a; 

2014b), similar to the UK Medicines Use Review 

services outlined in this article. The MMRs are 

provided by pharmacists, and they are funded by 

the Australian Government to support GPs to ensure 

their patients are taking the right medications for 

them, thereby increasing the likelihood of patient 

concordance with therapy, optimising the impact 

of the medicines and minimising the number of 

medication-related problems. The MMR programs 

currently available in Australia are as follows: 

Home Medicines Review (HMR) 

Developed for people living in the community, 

the HMR is a comprehensive clinical assessment 

involving a consumer living at home in the 

community, an accredited pharmacist, their GP 

and their regular community pharmacy. The aim 

of this program is to identify, resolve and prevent 

drug-related problems. 

Residential Medication Management Review 

(RMMR) 

A comprehensive clinical assessment provided to a 

permanent resident of an Australian Governmentfunded 

residential care facility by an accredited 

pharmacist. Like the HMR, the aim of the RMMR 

program is to identify, resolve and prevent drugrelated 

problems. 

Medication Use Review (MedsCheck) and 

Diabetes Medication Management (Diabetes 

MedsCheck) 

These services are structured pharmacy services, 

Citation: Diggle J (2016) The “NO 

TEARS” diabetes medication review. 

Diabetes & Primary Care Australia 

1: 65–72 


1. There are many issues relating 

to medication, including 

the need for optimisation of 

therapy over time and the role 

of medicines in risk reduction, 

that need to be discussed in 

helping people with diabetes 

to set personalised goals and 

agree realistic expectations. 

2. Medication reviews provide 

an opportunity to assess 

the efficacy, acceptability, 

safety and tolerability of 

drugs, which should improve 

medication concordance, 

enhance patient satisfaction, 

reduce unnecessary wastage 

of medicines and maximise the 

benefit of the interventions. 

3. Using tools such as 

“NO TEARS” should help 

to structure the review 

process and support 

healthcare professionals in 

making the most efficient 

use of limited time. 

Key words 

– Medication review 

– NO TEARS 

– Patient involvement 

Author 

Jane Diggle is a Practice Nurse 

with a particular interest 

in diabetes. Jane works 

in the Wakefield District, 

West Yorkshire, UK. 


The “NO TEARS” diabetes medication review 

“Having a tool that 

is similar to the UK’s 

‘NO TEARS’ medicines 

review strategy may 

help to improve the 

provision of medication 

review services within 

primary care.” 

involving face-to-face consultations between the 

pharmacist and consumer in the community. 

These services are designed to sit between ad hoc 

medication reviews that occur at the time of 

dispensing and HMRs. They are conducted by a 

registered pharmacist in the pharmacy’s designated 

consultation area (Department of Health, 2014b). 

These services are not comprehensive clinical 

reviews in the manner of the HMR and are limited 

by the information available at the time of the 

consultation. They aim to facilitate discussion with 

the consumer focusing on improving medicine 

use through education, self-management and 

medication adherence strategies, with the goal of 

improved health outcomes. 

These services include an additional focus to 

assist consumers with the management of type 2 

diabetes. For example: 

l They provide access to the necessary 

information and skills to self-manage their 

disease. 

l They improve consumers’ use of blood glucose 

monitoring devices through training and 

education. 

l They achieve greater blood glucose control 

through encouraging medication adherence 

and adopting lifestyle choices that achieve the 

goals of optimum diabetic management (e.g. 

smoking cessation, increasing exercise and 

minimising alcohol consumption). 

To be eligible to receive Diabetes MedsCheck, 

consumer criteria are as follows: 

l Diagnosed with type 2 diabetes within the past 

12 months or their type 2 diabetes is less than 

ideally controlled, and 

l Is unable to gain timely access to existing 

diabetes education/health services in their 

community. 

Unfortunately, the uptake of MMR programs 

in the Australian community is low, despite there 

being many individuals at risk of medicationrelated 

problems who would benefit from the 

services. For example, the uptake of HMR within 

the at-risk community is less than 10% (Lee et al, 

2010). The main reasons identified for the low 

uptake of HMR was low referral by GPs and the 

poor awareness of the availability of HMR services 

among patients (Lee et al, 2012). 

Similarly, there is a low uptake of Diabetes 

MedsCheck services in the community. 

For example in 2012, the population eligible 

for Diabetes MedsCheck was estimated to be 

580 000. However, less than a third of the 286 

pharmacies registered for delivering the service 

claimed for the service, and only 149 Diabetes 

MedsCheck service were provided (Deloitte 

Access Economics, 2012). Low uptake was due 

to the inability to integrate service delivery into 

the pharmacists’ daily workflow and inadequate 

staffing resources (Deloitte Access Economics, 

2012). 

Having a tool that is similar to the UK’s 

“NO TEARS” medicines review strategy may 

help to improve the provision of medication 

review services within primary care, particularly 

if undertaken collaboratively by GPs, pharmacists 

and others involved in providing diabetes care. 

Although there are similar guidelines for Australian 

pharmacists to provide the MMR services (e.g. 

Pharmaceutical Society of Australia, 2011; 2012), 

the “NO TEARS” strategy is a simpler tool that 

provides a comprehensive checklist of items that 

prompts health professionals to consider several 

key elements when providing the medication 

review service. 

Deloitte Access Economics (2012) Evaluation of the MedsCheck 

and Diabetes MedsCheck Pilot Program. DH, Canberra, ACT. 

Available at: http://bit.ly/1Tct0jZ (accessed 29.01.16) 

Department of Health (2014a) Medication management reviews. 

DH, Canberra, ACT. Available at: http://bit.ly/1PH8zab 


Department of Health (2014b) Medication Use Review 

(MedsCheck) and Diabetes Medication Management Services 

(Diabetes MedsCheck). DH, Canberra, ACT. Available at: 

http://bit.ly/1QbdXBI (accessed 29.01.16) 

Lee CY, George J, Elliott RA, Stewart K (2010) Prevalence of 

medication-related risk factors among retirement village 

residents: a cross-sectional survey. Age Ageing 39: 581–7 

Lee CY, George J, Elliott RA, Stewart K (2012) Exploring 

stakeholder perspectives on medication review services for 

older residents in retirement villages. Int J Pharm Pract 20: 

249–58 

Pharmaceutical Society of Australia (2011) Guidelines 

for pharmacists providing Home Medicines Review 

(HMR) services. DH, Canberra, ACT. Available at: 

http://bit.ly/1o5Mefb (accessed 29.01.16) 

Pharmaceutical Society of Australia (2012) Guidelines for 

pharmacists providing medicines use review (MedsCheck) 

and diabetes medication management (Diabetes 

MedsCheck) services. DH, Canberra, ACT. Available at: 

http://bit.ly/1TWsKpT (accessed 29.01.16) 



Lifestyle factors and non-medicinal 

interventions are a key aspect of effective 

diabetes management; nevertheless, most 

people with diabetes will progress to require 

medication to maintain or improve control of their 

condition. With there now being seven classes 

of oral blood-glucose-lowering drugs to choose 

from, along with several glucagon-like peptide-1 

receptor agonists and many different types of 

insulin, the pharmacological management of 

type 2 diabetes has become complex. Furthermore, 

diabetes prescribing now accounts for nearly 10% 

of all prescription costs. In England, during 

the financial year 2013–14, there were just over 

45 million items prescribed to treat diabetes at 

a cost of £803 million (Health and Social Care 

Information Centre, 2014). 

The progressive nature of the type 2 diabetes 

means that blood-glucose-lowering therapies often 

need to be intensified over time. In addition to 

antihyperglycaemic agents, medication is often 

indicated to reduce cardiovascular risk, with many 

people being prescribed drugs for hypertension 

and dyslipidaemia. Some individuals also 

develop diabetes-related complications, including 

peripheral neuropathy and erectile dysfunction, 

which may necessitate drug therapy. Common 

comorbidities such as depression may also need 

to be managed pharmacologically. In short, 

the potential pill burden for many people with 

diabetes is considerable. 

Treatment challenges 

Despite strong evidence to support the benefits 

of good diabetes management, especially early 

in the condition (Holman et al, 2008), and 

an abundance of evidence-based guidance to 

which clinicians are encouraged to refer (e.g. 

SIGN, 2010; Inzucchi et al, 2015; NICE, 2015), 

in practice we are guilty of “clinical inertia” – 

favouring an approach which fails to intensify 

therapies in a timely fashion (Heine et al, 2006). 

People with type 2 diabetes may, therefore, have 

sup-optimal blood glucose control for prolonged 

periods and be placed at an increased risk of 

developing complications. 

Poor medication concordance is another major 

obstacle to achieving maximum benefit with 

drug treatments. It has been estimated that only 

around half of the medicines prescribed for longterm 

conditions are actually taken (Department 

of Health, 2001). Furthermore, over a decade ago, 

DARTS (the Diabetes Audit and Research Tayside 

Study; Donnan et al, 2002) demonstrated very 

poor concordance with oral hypoglycaemic drug 

therapy. Of the 2920 people included in the study, 

“adequate adherence” (defined as ≥90%) was found 

in only around one-third of those prescribed either 

sulphonylurea or metformin alone. The association 

between poor adherence and daily number of 

tablets was linear and statistically significant. 

Also pertinent here, from a health system 

perspective, is the issue of wastage. The gross annual 

cost to the NHS of medicines wastage in England 

has been estimated to be around £300 million 

(York Health Economics Consortium and School 

of Pharmacy – University of London, 2009). 

The reasons for poor medication concordance 

are highly complex, with many potential 

influencing factors, including denial over the 

diagnosis, forgetfulness, absence of symptoms and 

concerns about side effects. 

The stories about medications that people 

encounter in newspapers, on television or on the 

Internet can, alongside advice and opinion from 

family and friends, have a considerable impact 

on attitudes regarding medication; but, as we all 

know, such information may be unreliable and 

inaccurate. The medication review is an ideal 

opportunity to dispel any myths that proliferate 

in this way. 

Patient involvement 

in treatment decisions 

Current health policy advocates greater patient 

involvement in decisions about treatment, hence 

the slogan “No decision about me, without 

me” (Department of Health, 2010). It has been 

suggested that increasing the involvement of 

patients in prescribing decisions and supporting 

them in taking their medicines will lead to 

improvements in patient safety, health outcomes 

and satisfaction with care (Shaw, 2002). 

The extent to which an individual wishes to 

engage in this process will vary, but it is something 

we should offer to every patient. People can 

only make informed decisions if they have a 

good understanding of their condition and the 

Page points 

1. Despite strong evidence to 

support the benefits of good 

diabetes management, in 

practice we can be guilty of 

“clinical inertia” – favouring an 

approach that fails to intensify 

therapies in a timely fashion. 

2. Current health policy advocates 

greater patient involvement in 

decisions about treatment, and 

it is believed that this will lead 

to improvements in patient 

safety, health outcomes and 

satisfaction with care. 



Box 1. Some of the key factors for healthcare professionals to take into 

account during a medication review. 

l The medication prescribed being appropriate for the individual’s needs 

l The medication being effective for the individual 

l The cost-effectiveness of the choice 

l Any monitoring that is required having been carried out 

l Drug interactions 

l Side effects 

l Adherence – are they taking it? 

l Concordance – do they want to take it? 

l Concomitant use of over-the-counter or complementary medicines 

l Lifestyle and non-medical interventions 

l The current evidence base (benefit versus risk) 

l Changes to the person’s condition and the development of any comorbidities 

that may impact current treatment 

therapies that are being prescribed to manage 

it. The fascinating Diabetes Information Jigsaw 

Report investigated what people with diabetes 

understood about their condition and how it was 

treated and revealed that one in three people did 

not know what their medication was for or how 

Box 2. Examples of questions that the “Ask about Medicines” campaign 

suggested patients might like to ask their healthcare professional. 

l Why do I need to start taking medicines? 

l When and how should I take them? 

l What will happen if I don’t take these medicines? 

l Why is it important to take these tablets? 

l Will these cure my diabetes? 

l Do I have to pay for my prescriptions? 

l What different tablets are available? 

l What are the side effects I should look out for? 

l What should I do if I get any of the side effects? 

l Are there any alternatives to these tablets? 

l Is it alright to take these tablets with the other tablets I am already taking? 

l What happens if the tablets don’t work for me? 

l Will I need to take other tablets as well? 

l Do I have to have any tests to see if the tablets are working? 

to take it (Browne et al, 2000). One of the most 

eye-opening findings was that just 10% of those 

taking a sulphonylurea were aware that it could 

cause hypoglycaemia. According to Diabetes UK, 

not all people with diabetes wish to undertake 

formal education courses; nevertheless, it is hugely 

disappointingly that only 12% of people newly 

diagnosed with type 2 diabetes were offered 

structured education in 2011–12 (Diabetes UK, 

2014). 

Markers of poor concordance 

Failure to order sufficient quantity of medication 

or failure to collect prescriptions on time, or 

indeed at all, provides evidence of poor medication 

concordance and is worth checking as part of 

the review process. However, it is important to 

recognise that collection of a prescription does not 

guarantee its use. 

Medication reviews 

NICE (2011) recommends that “people with 

diabetes agree with their healthcare professional 

to start, review and stop medications to lower 

blood glucose, blood pressure and blood lipids,” as 

part of its quality standard for diabetes in adults. 

One aspect of this process is the measurement 

of the proportion of people with diabetes who 

have received a medication review in the previous 

12 month period. 

The medication review has been defined as 

“a structured, critical examination of a patient’s 

medicines with the objective of reaching an 

agreement with the patient about treatment, 

optimising the impact of medicines, minimising 

the number of medication-related problems and 

reducing waste” (Shaw, 2002). Up until 2012, there 

was a “medication review” indicator within the 

Quality and Outcomes Framework (QOF), with 

a requirement to undertake a medication review 

every 15 months for all patients being prescribed 

repeat medicines. Despite being “retired” as a 

QOF indicator, most GP clinical systems continue 

to provide prompts to carry out medicine reviews. 

The underlying principles of such a review 

include the following (Shaw, 2002). 

l All individuals should have a chance to raise 

questions and highlight problems about their 

medicines. 



l Medication review seeks to optimise the 

impact of treatment for the individual. 

l The review should be undertaken in a 

systematic way, by a competent person. 

l Any changes resulting from the review should 

be agreed with the individual. 

l The review should be documented in the 

individual’s notes. 

l The impact of any change should be 

monitored. 

During the review, the healthcare professional 

will be checking, among other things, the factors 

presented in Box 1. The quantity and breadth 

of items presented in Box 1 illustrates the fact 

that a great deal needs to be covered in the 

relatively short time-frame of a typical diabetes 

consultation, and any strategies to make the most 

efficient use of the time would thus be useful. As 

part of this, I believe that we could do a lot more 

to help individuals prepare for their medication 

review. 

The “Ask about Medicines” campaign ran from 

2003 to 2009 and its mission was to encourage 

better communication between patients and 

their health professionals (Shaw, 2009). Central 

to the campaign were some suggested questions 

that patients might like to ask their healthcare 

professional (examples appear in Box 2). 

Following on from this campaign, a guide specific 

to diabetes medicines was produced and may 

still be downloaded from http://bit.ly/1HfjW75 

(accessed 14.05.15). 

If such a resource were given to individuals 

prior to their review, they could formulate 

pertinent questions about their medication and 

be better prepared. The healthcare professional 

could then concentrate effort on what really 

matters to the individual. 

Another useful resource is the “NO TEARS” 

tool, which was designed to provide a framework 

upon which to structure a medication review 

(Lewis, 2004). As the focus of this paper, this 

tool is described in detail below. 

The “NO TEARS” tool 

The “NO TEARS” tool can be used as a mental 

prompt, but it also has sufficient flexibility that it 

can be tailored to suit the individual practitioner’s 

particular consulting style. Its purpose is to 

maximise the value of a medication review 

within the confines of a 10-minute consultation. 

Given the increasing complexities of diabetes 

management, this time constraint presents a 

real challenge; nevertheless, this is a useful tool 

providing a structure for diabetes medication 

reviews. The name “NO TEARS” is a mnemonic 

(see Box 3), and the seven components are 

described below in the context of diabetes, based 

on my own clinical experience. 

Box 3. The “NO TEARS” medicines review strategy (adapted from Lewis, 2004). 

Need and indication 

l Does the person know why each drug is being taken? 

l Is each drug still needed? 

l Is the diagnosis refuted? 

l Is the dose appropriate? 

l Was long-term therapy intended? 

l Would non-pharmacological treatment be better? 

Open questions 

l Allows patients to express views 

l Helps to reveal any problems they may have 

Tests and monitoring 

l Assess disease control 

l Are any conditions undertreated? 

l Use an appropriate reference for monitoring advice (e.g. the British National 

Formulary) 

Evidence and guidelines 

l Has the evidence base changed since initiating drug? 

l Are any drugs now deemed “less suitable”? 

l Is dose appropriate (e.g. frail and elderly)? 

l Are other investigations now advised (e.g. echocardiography)? 

Adverse events 

l Are the any side effects? 

l Are any over-the-counter or complementary medicines being taken? 

l Check for interactions, duplicates or contraindications 

l Don’t misinterpret an adverse reaction as a new medical condition 

Risk reduction or prevention 

l Opportunistic screening 

l Risk reduction (e.g. falls) – are drugs optimised to reduce the risks? 

Simplification and switches 

l Can treatment be simplified? 

l Does the person know which treatments are most important? 

l Explain any switches related to cost-effectiveness 



Page points 

1. One of the most important 

considerations in medication 

reviews is why each drug is being 

prescribed and whether the 

patient benefits from taking it. 

2. Encouraging patients to be 

more actively involved in 

prescribing decisions by asking 

open questions may improve 

concordance. 

3. It is useful to use several 

methods to assess the 

effectiveness of diabetes 

medications, these include 

biochemical testing, as well 

asking about symptom relief. 

N – Need and indication 

One of the most important considerations 

in medicines reviews is why each drug is 

being prescribed and whether the patient 

benefits from taking it. This might involve 

confirmation that the correct diagnosis was 

made in the first place (e.g. was hypertension 

diagnosed based on a blood pressure reflecting 

the evidence base?). 

The rationale for prescribing each drug should 

be questioned (e.g. is it for symptom control or 

is it to reduce long-term complications?) so 

that efficacy may be measured against expected 

outcome. It is important to reassess ongoing 

need and determine whether circumstances 

have changed (e.g. weight loss may alter 

treatment requirements and drug doses). It is 

an opportunity to consider lifestyle, changes 

to which can make a significant difference to 

long-term outcomes. Sometimes people will 

try to improve lifestyle in order to reduce 

medication, and seeing a positive outcome can 

be a powerful motivator. 

Some drugs are meant to be used for a fixed 

period (e.g. dual antiplatelet therapy postmyocardial 

infarction) but may not have been 

stopped. Conversely, certain medications are 

stopped prior to procedures. For example, it 

is recommended that metformin be suspended 

before intravascular administration of 

iodinated contract agents and not recommenced 

earlier than 48 hours after the test (electronic 

Medicines Compendium, 2015). Similarly, 

metformin tends to be stopped during the acute 

phase of an illness – owing, for instance, to the 

risk of lactic acidosis in people taking this drug 

who experience an acute worsening of renal 

function (electronic Medicines Compendium, 

2015) – but it is worth checking that it has 

subsequently been re-instated. 

People with diabetes can develop other 

conditions, or there may have been a 

deterioration of pre-existing conditions, which 

can affect management or the ongoing safety 

of the drugs being prescribed. Recent hospital 

admissions and outpatient appointments may 

have resulted in changes to medication or 

the addition of new drugs that may not be 

compatible with current medications. 

O – Open questions 

Individuals’ understanding of their treatment, 

as well as their health beliefs and attitudes, will 

influence whether or not they take prescribed 

medications, and so this is an important area to 

explore. 

Open questions like those listed below are 

useful because they encourage a person to express 

their views. 

l What do you think about your medications? 

l What are you taking regularly? 

l What other over-the-counter medications do 

you take? 

l How and when do you take your medications? 

l Do you know why you are taking X? 

l Have you any concerns or worries about 

taking your medication? 

Encouraging patients to be more actively 

involved in prescribing decisions may improve 

concordance. Asking, as non-judgementally as 

possible, whether they miss any medications, 

or have difficulties accessing their prescription, 

opening the packaging or swallowing tablets, 

is also useful (this may require some closed 

questions). Other areas that may be useful to 

explore with individuals include: who collects 

their prescriptions; and whether a dosette box 

might be beneficial. 

T – Tests and monitoring 

There are several ways of assessing the effectiveness 

of diabetes medications. It may be appropriate to 

ask about symptom relief for those who were 

experiencing symptoms. However, for many, the 

primary goal of therapy is to reduce the risk of 

developing complications rather than symptom 

control. HbA 1c 

is often regarded as the definitive 

measure of good glycaemic control and it may be 

used to assess a person’s response to a new therapy 

and for gauging ongoing efficacy. The HbA 1c 

is, 

however, a composite measure reflecting both 

fasting and postprandial hyperglycaemia, and so, 

in certain circumstances and for certain bloodglucose-lowering 

therapies (including insulin), it 

may be more appropriate to check the individual’s 

own blood glucose monitoring record. 

A periodic review of other parameters is vital, 

including renal and liver function, as these affect 



the metabolism of oral agents and thus have a 

potential impact on safety (e.g. Scheen, 2014). 

Agreeing realistic targets and sharing results 

with individuals can help them see the benefits 

of taking certain medications and can help to 

reinforce ongoing medication concordance. 

E – Evidence and guidelines 

The evidence base in medicine is constantly 

evolving. As new evidence emerges, treatment 

recommendations may change, and so it is 

essential to consider whether the approach is still 

in line with current guidelines or whether any of 

the prescribed drugs are now considered to be 

less suitable and if the most appropriate doses are 

being used. 

A – Adverse events 

Most drugs are associated with potential side effects 

(adverse reactions to medicines are implicated in 

5–17% of hospital admissions [Zhang et al, 

2009]), and where these are troublesome, people 

may decide to stop taking them or to take them 

less often than recommended. Individuals should 

be asked about side effects and given strategies 

to deal with them, such as adjusting doses, 

switching to another medicine with a different 

side-effect profile, or even changing the timing of 

taking medicines. Other drugs may be prescribed 

to mitigate side effects, although it may be 

more appropriate to consider alternatives that are 

better tolerated or better suited to an individual. 

Preparing people for likely side effects is also a 

useful strategy. 

Some diabetes medications are associated 

with well-recognised risks, such as that of 

hypoglycaemia with sulphonylureas and insulin. 

With regard to hypos, it is essential that 

individuals know how to minimise the risk, how 

to recognise signs and symptoms, and how to 

manage episodes appropriately. The implications 

for driving and for certain occupations need to be 

discussed and documented. 

R – Risk reduction or prevention 

A key objective of diabetes treatment is to 

reduce the risk of developing complications. 

In the absence of troublesome symptoms, it 

can be difficult to convey the value of taking 

medications now to prevent potential problems 

in the future (Ortendahl and Fries, 2006). 

Healthcare professionals need to translate raw 

data from clinical trials or risk calculators into 

information that individuals can understand and 

use to make an informed choice. This involves 

helping them to decide if the benefits of a therapy 

outweigh all the possible known side effects or 

risks associated with the drug itself. 

S – Simplification and switches 

Keeping drug regimens simple helps to improve 

adherence and some regimens are unnecessarily 

complicated. Findings from the aforementioned 

DARTS (Donnan et al, 2002) suggested the 

following potential ways to improve medication 

concordance: simplifying drug regimens; 

minimising tablet counts; and using oncedaily, 

modified-release or fixed-combination 

preparations. That is not to say that simplifying 

and switching is without issues, but it is worth 

considering, and in some cases there are 

substantial potential benefits. 

Conclusion 

There are many issues relating to medication 

that we need to convey to people with 

diabetes, including the need for optimisation 

of therapy over time and the role of medicines 

in risk reduction. We have to identify barriers 

related to medication-taking and help people 

to set personalised goals and agree realistic 

expectations. 

The NHS spends a huge amount on medication, 

and diabetes is a condition which tends to require 

multiple medicines. The evidence suggests 

that medication concordance is a particular 

problem for those with long-term conditions, 

and, given the current economic constraints, it is 

imperative that we make the most efficient use of 

scarce resource. Medication reviews provide an 

opportunity to assess the efficacy, acceptability, 

safety and tolerability of drugs, which should 

improve medication concordance, enhance 

patient satisfaction, reduce unnecessary wastage 

of medicines and maximise the benefit of the 

interventions. 

Improving how we help patients prepare for 

their medication review and using tools like 

Page points 

1. Healthcare professionals need 

to translate raw data from 

clinical trials or risk calculators 

into information that individuals 

can understand and use to 

make informed choices. 

2. Keeping drug regimens simple 

helps to improve adherence 

and some regimens are 

unnecessarily complicated. 

3. It is important to identify 

barriers related to medicationtaking 

and help people to set 

personalised goals and agree 

realistic expectations. 



Further information 

from the UK 

A Guide to Medicines Review 

(National Prescribing Centre) 

http://bit.ly/1MHyYE6 

A Single Competency 

Framework for all Prescribers 

(National Prescribing Centre) 

http://bit.ly/1GJWGPO 

“NO TEARS” should help to structure the 

process and support healthcare professionals in 

making the most efficient use of limited time.n 

Browne DL, Avery L, Turner BC et al (2000) What do patients with 

diabetes know about their tablets? Diabet Med 17: 528–31 

Department of Health (2001) National Service Framework for Older 

People. DH, London. Available at: http://bit.ly/1PkUqEy (accessed 

14.05.15) 

Inzucchi S, Bergenstal RM, Buse JB et al (2015) Management of 

hyperglycemia in type 2 diabetes, 2015: A patient-centered 

approach. Diabetes Care 38: 140–99 

Lewis T (2004) Using the NO TEARS tool for medication review. BMJ 

329: 434 

NICE (2011) Diabetes in adults quality standard. NICE, London. 

Available at: https://www.nice.org.uk/guidance/qs6 (accessed 

14.05.15) 

Department of Health (2010) Equity and excellence: Liberating the 

NHS. DH, London. Available at: http://bit.ly/1g6YkNw (accessed 

14.05.15) 

NICE (2015) Type 2 diabetes in adults: management (NG28). NICE, 

London. Available at: https://www.nice.org.uk/Guidance/NG28 


Ortendahl M, Fries JF (2006) Discounting and risk characteristics in 

clinical decision-making. Med Sci Monit 12: RA41–5 

Diabetes UK (2014) Position statement: Adult learning within Self 

Management and Support. Diabetes UK, London. Available at: 

http://bit.ly/1ICSvWn (accessed 14.05.15) 

Scheen AJ (2014) Pharmacokinetic and toxicological considerations 

for the treatment of diabetes in patients with liver disease. Expert 

Opin Drug Metab Toxicol 10: 839–57 

Donnan PT, MacDonald TM, Morris AD (2002) Adherence to 

prescribed oral hypoglycaemic medication in a population of 

patients with type 2 diabetes: a retrospective cohort study. Diabet 

Med 19: 279–84 

Shaw J (2002) Room for review: A guide to medication review. 

Pharmaceutical Press, Wallingford, UK 

electronic Medicines Compendium (2015) Glucophage 500 mg 

and 850 mg film coated tablets. eMC, Leatherhead. Available 

at: http://www.medicines.org.uk/emc/medicine/1043 (accessed 

14.05.15) 

Shaw J (2009) Ask about medicines: helping patients to ask questions. 

Prescriber 17: 33–9 

Health and Social Care Information Centre (2014) Prescribing for 

Diabetes, England: 2005–06 to 2013–14. HSCIC, Leeds. Available 

at: http://www.hscic.gov.uk/catalogue/PUB14681 (accessed 

14.05.15) 

SIGN (2010) Management of diabetes: A national clinical 

guideline (116). SIGN, Edinburgh. Available at: 

http://www.sign.ac.uk/pdf/sign116.pdf (accessed 14.05.15) 

Heine RJ, Diamant M, Mbanya JC, Nathan DM (2006) Management 

of hyperglycaemia in type 2 diabetes: the end of recurrent failure? 

BMJ 333: 1200–4 

York Health Economics Consortium, School of Pharmacy – University 

of London (2009) Evaluation of the Scale, Causes and Costs of 

Waste Medicines. Available at: http://bit.ly/1nR1NCJ (accessed 

14.05.15) 

Holman RR, Paul SK, Bethel MA et al (2008) 10-year follow-up of 

intensive glucose control in type 2 diabetes. N Engl J Med 359: 

1577–89 

Zhang M, Holman CD, Price SD et al (2009) Co-morbidity and repeat 

admission to hospital for adverse drug reactions in older adults: 

retrospective cohort study. BMJ 338: a2752 


INAUGURAL 

NATIONAL 

CONFERENCE 

30th April 2016 

University of Melbourne, 

Parkville Victoria, Australia 

The conference has been specifically designed for all 

primary care health professionals working in diabetes care to: 

 

 

 

Advance their education and learning in the field 

of diabetes health care 

Promote best practice standards and clinically 

effective care in the management of diabetes 

Facilitate collaboration between health professionals 

to improve the quality of diabetes primary care across Australia 

PROGRAM 

The 2016 PCDSA national conference program will combine cutting 

edge scientific content with practical clinical sessions, basing the 

education on much more than just knowing the guidelines. 

The distinguished panel of speakers will share their specialised 

experience in an environment conducive to optimal learning. The 

Speaking faculty include, amongst others: Professor Peter Colman, 

Professor John Dixon, Professor Trisha Dunning, Professor Jane 

Speight, and Sir Michael Hirst, former President 

of the International Diabetes Federation (IDF). 

For further information and to register for the conference please visit: 

www.eventful.com.au/pcdsa 

If you have any questions regarding the conference, 

please contact the Conference Secretariat; 

Toll free telephone: 1800 898 499 

Email: pcdsa@eventful.com.au 

pcdsa.com.au

The PCDSA is a multidisciplinary society with the aim 

of supporting primary health care professionals to deliver 

high quality, clinically effective care in order to improve 

the lives of people with diabetes. 

The PCDSA will 

Share best practice in delivering quality diabetes care. 

Provide high-quality education tailored to health professional needs. 

Promote and participate in high quality research in diabetes. 

Disseminate up-to-date, evidence-based information to health 

professionals. 

Form partnerships and collaborate with other diabetes related, 

high level professional organisations committed to the care of 


Promote co-ordinated and timely interdisciplinary care. 

Membership of the PCDSA is free and members get access to a quarterly 

online journal and continuing professional development activities. Our first 

annual conference will feature internationally and nationally regarded experts 

in the field of diabetes. 

To register, visit our website: 

www.pcdsa.com.au

DPCA 1-2 full issue

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