DPCA2-2_issue

Diabetes 

& Primary Care Australia 

Vol 2 No 2 2017 

The primary care diabetes journal for healthcare professionals in Australia 

Pre-gestational diabetes in pregnancy 

This issue includes guidance on how 

to optimise pregnancy outcomes 

through pre-conception care and the 

resources available for mothers with 

pre-gestational diabetes and healthcare 

professionals who care for them. 

E-learning on pre-conception care for 

women with pre-gestational diabetes is 

available at www.pcdsa.au.org/cpd. 

Page 54 

IN THIS ISSUE 

Bone health 

The relationship between 

diabetes and bone health, 

and the impact of poor bone 

health on patients. Page 61 

Preventing falls 

A clinical review of the 

screening, assessment and 

management of older people 

at risk of falls. Page 69 

Diabetes and skin 

Considering the skin of 

people with diabetes and the 

importance of skin care before 

and after ulceration. Page 75 

WEBSITE 

Journal content online at 

www.pcdsa.com.au/journal

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 

people with diabetes. 

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

Contents 

Diabetes 

& Primary Care Australia 

Volume 2 No 2 2017 

Website: www.pcdsa.com.au/journal 

Editorial 

Diabetes and pregnancy 45 

Rajna Ogrin introduces this issue, which has a focus on pregnancy and pre-conception care for women with pre-gestational diabetes. 

From the other side of the desktop 

Through diagnosis to pregnancy: My journey with diabetes 47 

Karen Barrett gives a first-hand perspective on her journey with diabetes and how it affected her pregnancies. 

CPD module 

Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care 54 

Glynis Ross provides guidance to support early detection of peripheral arterial disease using evidence-based clinical tests. 

Articles 

Resources to support preconception care for women with diabetes 50 

Melinda Morrison, Ralph Audehm, Alison Barry and colleagues describe the resources available for health professionals and women with 

diabetes and provide up-to-date, evidence-based information on pregnancy and diabetes. 

Diabetes and bone health 61 

Vidhya Jahagirdar and Neil J Gittoes explore the current literature on diabetes and bone health, its impact on patients and the management 

strategies that may be considered in primary care to minimise risk of diabetes-related bone disease and to improve outcomes. 

Falls prevention in older adults with diabetes: A clinical review of screening, assessment and management recommendations 69 

Anna Chapman and Claudia Meyer review the screening, assessment and management recommendations for fall prevention in older people. 

The effect of diabetes on the skin before and after ulceration 75 

Roy Rasalam and Lesley Weaving look at the changes that occur in the skin of people with diabetes and the importance of skin care in 

relation to ulceration. 

Editor-in-Chief 

Rajna Ogrin 

Senior Research Fellow, RDNS 

Institute, St Kilda, Vic 

Associate Editor 

Gary Kilov 

Practice Principal, The Seaport 

Practice, and Senior Lecturer, 

University of Tasmania, 

Launceston, Tas 

Editorial Board 

Ralph Audehm 

GP Director, Dianella Community 

Health, and Associate Professor, 

University of Melbourne, 

Melbourne, Vic 

Werner Bischof 

Periodontist, and Associate 

Professor, LaTrobe University, 

Bendigo, Vic 

Jessica Browne 

Senior Research Fellow, School of 

Psychology, Deakin University, 


Anna Chapman 

Research Fellow, School of 

Primary Health Care, Monash 

University, Melbourne, Vic 

Laura Dean 

Course Director of the Graduate 

Certificate in Pharmacy 

Practice, Monash University, 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, 


Peter Lazzarini 

Senior Research Fellow, 

Queensland University of 

Technology, Brisbane, Qld 

Roy Rasalam 

Head of Clinical Skills and 

Medical Director, 

James Cook University, and 

Clinical Researcher, Townsville 

Hospital, Townsville, Qld 

Suzane Ryan 

Practice Principal, Newcastle 

Family Practice, Newcastle, NSW 

Editor 

Olivia Tamburello 

Editorial Manager 

Richard Owen 

Publisher 

Simon Breed 

© OmniaMed SB and the Primary Care 

Diabetes Society of Australia 

Published by OmniaMed SB, 

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 2 No 2 2017 43

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 —

Editorial 

Diabetes and pregnancy 

It is well known that diabetes is a systemic 

condition and, if not managed efficiently, 

can have a life-changing impact on the eyes, 

feet and kidneys. In this issue, we consider 

the impact of uncontrolled hyperglycaemia on 

other body systems and functions – from skin 

to bone, and from pregnancy to older age. On 

page 75, Roy Rasalam and Lesley Weaving 

discuss the practical aspects of maintaining 

healthy skin in people with diabetes, and 

Neil Gittoes and Vidhya Jahagirdar provide a 

clinical review of the potential complications 

to bone health as a result of diabetes (page 61). 

There is a special section on diabetes and 

pregnancy covering preconception care in 

primary care and the resources available 

for women with diabetes and health care 

professionals (starting from page 47). Finally, 

there is a paper by Anna Chapman and 

Claudia Meyer on the increased risk of falls 

in older people with diabetes and what can be 

done to lower the risk (page 69). This topic is 

especially pertinent with the growing ageing 

population seen in Australia and globally. 

Diabetes and pregnancy 

One relatively new area of research in 

diabetes and pregnancy that has caught my 

eye is epigenetics – the effect of environment 

on genetics. Questions are being raised 

as to whether the maternal environment 

(e.g. maternal obesity, poor nutrition and 

hyperglycaemia) may “program” type 2 

diabetes in offspring. There is some evidence 

that suggests that shared genetic and 

environmental risk, as well as developmental 

programming, may lead to children born to 

women with diabetes during pregnancy at 

greater risk of developing type 2 diabetes in 

later life (Berends and Ozanne, 2012). If the 

female offspring then have their own children, 

it is thought that an intergenerational 

cycle of diabetes risk could be established 

(Dabelea and Crume, 2011). The intricacies 

of this are important to understand, as many 

women with pre-existing type 2 diabetes 

are often overweight or obese. They often 

continue to gain weight with each additional 

pregnancy and are sometimes reluctant to 

engage with health services (Bandyopadhyay 

et al, 2011). Women of South East Asian 

origin are at particularly high risk of diabetes 

during pregnancy, so by developing effective 

strategies to specifically address these factors, 

the risk of future diabetes to offspring may be 

reduced (Greenhalgh et al, 2015). 

What other considerations need to be 

made to avoid the increased risk of adverse 

pregnancy outcomes as a result of diabetes? 

Pre-gestational diabetes (type 1 and 

type 2 diabetes) is present in approximately 

1% of pregnant women in Australia and the 

prevalence is increasing not only here, but 

around the world. Women with pre-existing 

diabetes are at high risk of complications 

during pregnancy, with up to four times 

the rate of congenital malformations, and 

up to a five-fold increased risk of stillbirth 

and perinatal mortality compared to women 

without diabetes. By safely optimising blood 

glucose management, women can significantly 

reduce their risk of complications, and 

preconception care has been shown to reduce 

these risks (Inkster et al, 2006). 

Women of child-bearing age with diabetes 

need to be informed of the availability and 

importance of preconception care, which 

can be provided by both primary and 

specialised diabetes services; many women 

with type 1 diabetes access diabetes specialist 

services, while the majority of women with 

type 2 diabetes are managed in primary care. 

Included in preconception care is appropriate 

contraception advice. Here, primary care 

providers can make a real difference in 

promoting and providing appropriate 

contraception to women with diabetes to 

prevent unplanned pregnancies. 

In this pregnancy special, there are three 

pieces related to pregnancy and diabetes. There 

is a CPD module outlining the requirements 

of preconception care for women with 

Rajna Ogrin 

Editor of Diabetes & Primary Care 

Australia, and Senior Research 

Fellow, RDNS Institute, 

St Kilda, Vic. 


Editorial 

“By considering the 

health and wellbeing of 

women with diabetes 

prior to pregnancy, 

we anticipate 

that meaningful 

improvements in 

pregnancy outcomes 

are possible.” 

diabetes, including practical information for 

health care providers, as well as case studies to 

highlight the application of this information 

in clinical practice (page 54). There is also 

a wealth of resources for the clinician and 

woman with diabetes to optimise healthy 

pregnancy outcomes. Melinda Morrison from 

the National Diabetes Services Scheme and 

colleagues outline the resources available, 

such as apps, booklets and online resources 

(page 50). We also have the first “From 

the other side of the desk” feature – a 

new series to inform clinical care from the 

perspectives of people with diabetes. In the 

first of the series, Karen Barrett discusses her 

journey with diabetes and how it affected her 

pregnancies (page 47). 

By considering the health and wellbeing 

of women with diabetes prior to pregnancy, 

and utilising the resources that have been 

developed specifically to support this group 

before, during and after pregnancy, we 

anticipate that meaningful improvements in 

pregnancy outcomes are possible. n 

2017 NATIONAL CONFERENCE 

Saturday 6th May 2017 – Melbourne Convention and Exhibition Centre, 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 

6TH MAY 2017 CONFERENCE PROGRAM 

The 2017 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: 

Associate Professor 

Neale Cohen 

Director Clinical Diabetes 

Baker Heart and 

Diabetes Institute 

“Diabetes management 

and research in primary 

care – key components 

to improving outcomes” 

Doctor Christel 

Hendrieckx 

Senior Research Fellow 

The Australian Centre 

for Behavioural Research 

in Diabetes 

“The emotional health of 

people living with diabetes” 

For further information including the full 2017 program 

and to register for the conference please visit: 

www.eventful.com.au/pcdsa2017 

If you have any questions regarding the conference, 

please contact the Conference Secretariat; 

Toll free telephone: 1800 898 499 

Email: pcdsa@eventful.com.au 

Ms Renza Scibilia 

Manager - Type 1 Diabetes 

and Consumer Voice 

Diabetes Australia 

“Engaging people with 

diabetes, the diabetes 

online community and 

apps for diabetes” 

Doctor Gautam 

Vaddadi 

Consultant Cardiologist 

Alfred Health, Northern Health, 

University of Melbourne 

“The emerging importance 

of cardiac failure diagnosis 

and management in people 

with type 2 diabetes” 

pcdsa.com.au 

Bandyopadhyay M, Small R, Davey MA et al (2011) Lived 

experience of gestational diabetes mellitus among immigrant 

South Asian women in Australia. Aust N Z J Obstet Gynaecol 

51: 360–4 

Berends LM, Ozanne SE (2012) Early determinants of type 2 

diabetes. Best Pract Res Clin Endocrinol Metab 26: 569–80 

Dabelea D, Crume T (2011) Maternal environment and the 

transgenerational cycle of obesity and diabetes. Diabetes 60: 

1849–55 

Greenhalgh T, Clinch M, Afsar N et al (2015) Socio-cultural 

influences on the behaviour of South Asian women with 

diabetes in pregnancy: qualitative study using a multi-level 

theoretical approach. BMC Med 13: 120 

Inkster ME, Fahey TP, Donnan PT et al (2006) Poor glycated 

haemoglobin control and adverse pregnancy outcomes in 

type 1 and type 2 diabetes mellitus: Systematic review of 

observational studies BMC Pregnancy Childbirth 6: 30 

Diabetes & Primary Care Australia Vol 2 No 2 2017

From the other side of the desk 

From the other side of the desk: 

Patient perspective 

Through diagnosis to pregnancy: 

My journey with diabetes 

Karen Barrett 

I 

was diagnosed with type 1 diabetes on Valentine’s 

Day, 1983, a day meant for chocolates, roses 

and sweets. What an irony it turned out to be. 

Dressed in my school uniform and ready for school, 

my Mum, being a nurse, had known for some time 

that something wasn’t right. I had lost a substantial 

amount of weight and the bathroom seemed to 

be my best friend, as did my unquenchable thirst. 

“Oh what a bombshell!” my Mum’s colleague said 

that day after hearing my diagnosis. I never really 

comprehended the significance of the diagnosis at 

the time. I had felt fine. 

In the early days after my diagnosis, to see my 

diabetes specialist meant a day off school and a trip 

to Canberra – that was the good part. The not-sogood 

part became the endless questions from the 

doctor – what was I putting in my mouth and at 

exactly what time of the day – measurements on the 

scales, numbers in books, pathology results and eye 

tests. On and on it went. Would I pass or fail? Had 

I been good or bad? I hated it. 

There was never a time that I let my diabetes 

stand in the way. I was quite sporty growing up 

in a small country town, later trying triathlons 

and endurance sports. But in my school life, I was 

sometimes left out, missing the first school camp 

because everyone was so very nervous to have a 

person with diabetes at camp and friends’ parents 

being reluctant to have me over, afraid of what or 

what not to feed me. 

As an adolescent, I was studious and quite fit and 

healthy, with an obsessive personality. That was 

until my late teens, when I seemed to burn out with 

school, with life and with diabetes. Life became 

tricky. I found solace in food and subsequently paid 

the price, gaining weight. 

My family, of course, was concerned, but the 

constant questions about how many blood sugar 

tests I was doing and whether I was looking after 

myself was a continuous reminder of my diabetes, 

something I wanted to forget. I ate in secret and lied 

to keep them satisfied while continuing to silently 

struggle. I was tired of all the rules, tired of all the 

questions and tired of being different and feeling 

restricted. As I entered adulthood, I thought I kept 

my struggles well hidden from others for many 

years. I went on to study nursing at university and 

the big wide world gave me even more freedom 

to hide from the reality of diabetes. Somehow, 

I stayed on the tightrope of avoiding routine 

doctor’s appointments while also avoiding more 

serious hospital admissions. A visit to the doctor 

would mean tests, which I knew I would fail, and 

questions that I would be ashamed to answer – I 

wasn’t up for the interrogations and judgements. 

But, I didn’t feel like I was failing! I was eating what 

I wanted, when I wanted, and being like the rest of 

my friends and peers. 

Time to get real 

Then I found out I was pregnant…unplanned. 

For me, I realised it was not fair to have a child, 

with the high risk of complications to me and my 

baby as a result of me not looking after myself. 

A decision, that I feel to this day, even though I 

agreed, had already been made for me. Time to get 

real. If I was to ever create a family of my own, it 

meant facing the issues I had so long avoided – the 

medical world testing me on passing or failing at 

diabetes. 

Unable, and not allowing myself, to be anything 

other than perfectly controlled, I became a 

Citation: Barrett K (2017) Through 

diagnosis to pregnancy: My journey 

with diabetes. Diabetes & Primary 

Care Australia 1: 47–8 

About this series 

The aim of the “From the other 

side of the desk” series is to 

provide a patient perspective on 

a topic within diabetes, to reflect 

on the doctor–patient relationship 

and to inform clinical care. 

Author 

Karen Barrett, Registered Nurse 

and Coordinator, Central Coast, 

NSW. 


From the other side of the desk 

“As a person with 

diabetes, my advice 

to the medical world 

would be to consider 

the person in front 

of you without their 

diabetes diagnosis.” 

champion of the tests. It was an intense time but 

my motivation to have healthy babies drove me 

to that perfection, and I went on to have three 

babies in 3 years. I told the medical team what they 

wanted to hear, but this time I wasn’t lying. 

It became my obsession to get the numbers 

right. Averaging about 12–14 blood sugars daily 

and the never-ending specialist appointments were 

vital to achieving the desired outcome. I was lucky 

that the care I received from my diabetes team 

during my pregnancies was excellent and well 

planned. I feel that it is vital to have a trusting 

relationship with an endocrinologist before, during 

and after pregnancies, and I was very fortunate 

to have that. But pregnancy with diabetes is not 

without its difficulties; the severe hypos during the 

first trimesters became frequent and increasingly 

exhausting, and with every pregnancy, I had 

another toddler to care for. My first-born was 

diagnosed with cerebral palsy (totally unrelated 

to my diabetes), and as if that was not sufficiently 

challenging, I became a single Mum when my 

youngest was 11 months old. Juggling three 

toddlers, a part-time job to survive financially and 

my diabetes became routine. The all-or-nothing 

personality has some advantages and in those 

3 years, I was switched to “all”, determined to be 

a good Mum. 

However, as the years went by, I let those 

numbers slip again. My three gorgeous children, 

my world, were growing up fast, and at aged 6, 7 

and 8 years, they kept me busy. I kept the medical 

team at length – I knew I wasn’t going to “pass the 

test”. My 7-year-old daughter, Presley, had spirit 

(sometimes too much!) and when she came down 

with a viral illness, as a mum with diabetes would, 

I checked her blood sugar. My Mum had suggested 

the “D” word as Presley kept sleeping through the 

day, which was very much unlike her. I still recall 

that moment, and I think I too knew something 

wasn’t right. Weeks later, Presley mentioned to me 

that she was waking through the night to go to the 

bathroom. I knew. I waited. 

My beautiful girl was dressed in her swimmers 

ready to go swimming. I did her blood sugar and 

there I was – the mother of a child with diabetes. 

Now it was me answering the questions not as a 

person with diabetes, but as a Mum. It was more 

than my own tests – I had to pass all of Presley’s 

tests as well. 

I felt my skills as a parent were put under the 

microscope. I believed it was all my fault if her 

numbers weren’t right. What was she eating when 

I wasn’t there? Was she exerting too much energy 

during lunchtime at school? Could she recognise 

a hypo? I felt like I had to live in her head, and 

I became the “helicopter” Mum. Presley too 

hated the medical world, clamming up at all the 

questions and hating the scales and numbers. At 

home, she dealt with the never-ending motherly 

concerns and requests to check her blood sugar, 

blaming every ailment or headache on diabetes, 

whether or not it was. 

Where I am now 

Despite some complications of my own, at 44 years 

of age, I now take care of myself and feel as well as 

I can feel, given my past “bad behaviour”. I have 

a good relationship with my team and appreciate 

the rapport I have with them, which has taken 

many years to establish and develop. I now take 

charge of my appointments and we talk about the 

concerns I have. The first questions asked are not 

“shall we look at the numbers?” or “how many 

highs/lows are you having?”; rather, “how are you, 

and what’s going on in your world?” 

I have had a lovely relationship with my 

psychologist who somehow allows me to be proud 

of who I am and what I have achieved. I am now 

free of the judgement calls that I thought were 

placed on me as a person with diabetes and then 

as the mother of a child with diabetes. Mistakes 

are human. Rough patches enable us all to make 

better choices, and experience allows us to call the 

shots. It’s OK not to be perfect. I truly hope that 

if anything, I can pass this on to my children and 

that they reach this point a whole lot sooner than 

I did. 

As a person with diabetes, my advice to the 

medical world would be to consider the person 

in front of you without their diabetes diagnosis. 

Diabetes management is far more than looking 

at the numbers. Consider their state of mind 

and the unsaid pressures they may have put on 

themselves. The bravest thing one can do is to ask 

for help and say that we’re not OK, and creating 

an environment where people with diabetes feel 

comfortable and safe to do so is vital. n 

48 Diabetes & Primary Care Australia Vol 2 No 2 2017





 

 

 











Neale Cohen 









Hendrieckx 




in Diabetes 











Doctor Gautam 

Vaddadi 















pcdsa.com.au

Article 

Resources to support preconception care 

for women with diabetes 

Citation: Morrison M, Audehm R, 

Barry A et al (2017) Resources to 

support preconception care for 

women with diabetes. Diabetes & 

Primary Care Australia 2: 50–3 

Article points 

1. Women with diabetes are 

at increased risk of adverse 

pregnancy outcomes. Early 

intervention and planning 

can reduce the risks. 

2. Primary health care 

professionals have a key role 

in providing appropriate 

contraception to women with 

diabetes to prevent unplanned 

pregnancies, as well as 

encouraging optimal pregnancy 

planning and preparation. 

3. To address the gap in 

information for women with 

diabetes who are seeking 

or already accessing prepregnancy 

advice and 

care, Diabetes Australia 

has developed a suite of 

resources with funding 

through the National 

Diabetes Services Scheme. 

Key words 

– Diabetes in pregnancy 

– Education 

– Preconception care 

– Pregnancy 

– Resources 

– Type 1 diabetes 


Authors 

See page 53 for details. 

Melinda Morrison, Ralph Audehm, Alison Barry, Christel Hendrieckx, 

Alison Nankervis, Cynthia Porter, Renza Scibilia, Glynis P Ross 

Preconception care has been shown to reduce the rates of adverse pregnancy outcomes 

in women with pre-existing type 1 or type 2 diabetes. With an increasing prevalence of 

diabetes among women of child-bearing age, health professionals working in primary 

care have an important role in encouraging women with diabetes to plan and prepare 

for pregnancy. New resources, described here, are available for health professionals and 

women with diabetes and provide up to date, evidence-based information on pregnancy 

and diabetes. 

Pre-existing diabetes (type 1 or 

type 2 diabetes) is estimated to affect 

approximately 1% of pregnant women 

in Australia (Australian Institute of Health and 

Welfare, 2016), and evidence suggests that the 

prevalence is increasing (Abouzeid et al, 2014). 

In particular, the prevalence of type 2 diabetes in 

pregnant women is expected to increase as a result 

of older maternal age, high rates of obesity and an 

ethnically diverse population (Cheung et al, 2005; 

Temple and Murphy, 2010). 

Diabetes in pregnancy has many welldocumented 

risks to both mother and baby 

(Macintosh et al, 2006; Dunne et al, 2009; 

Kitzmiller et al, 2010); however, these risks can 

be mitigated by effective preconception and 

pregnancy care, and most women with diabetes 

will go on to have a healthy pregnancy and a 

healthy baby (Ray et al, 2001; Wahabi et al, 2010; 

Holmes et al, 2017). 

While most women with type 1 diabetes access 

specialist services, the majority of women with 

type 2 diabetes are managed in primary care. 

Health professionals in primary care are often the 

first point of contact for women seeking pregnancy 

information, and have a key role in promoting and 

providing appropriate contraception to women 

with pre-existing diabetes to prevent unplanned 

pregnancies, and in specialist referral. They are 

also critically important in encouraging diabetesspecific 

preconception care in all women with 

pre-existing diabetes to optimise maternal and 

fetal outcomes (Temple and Murphy, 2010). In 

the National Diabetes Services Scheme (NDSS)* 

Contraception, Pregnancy & Women’s Health 

Survey (2015) women with type 1 or type 2 

diabetes (n=967) indicated that diabetes specialists 

(endocrinologists and diabetes educators) and 

general practitioners were the health professionals 

with whom pregnancy and diabetes was most 

frequently discussed. Interestingly, the majority 

of women reported that they, rather than health 

professionals, initiated the conversation about 

pregnancy and diabetes. 

Preconception care in the primary 

health setting 

Despite the documented benefits of preconception 

care for women with pre-existing diabetes (Ray 

et al, 2001; Wahabi et al, 2010), many women 

with diabetes do not plan their pregnancies. Zhu 

et al (2012) reported that 45% of pregnancies in 

women with diabetes attending a tertiary obstetric 

hospital in Western Australia during 2009–2010 

*The National Diabetes Services Scheme (NDSS) is an 

initiative of the Australian Government administered 

with the assistance of Diabetes Australia. 


Resources to support preconception care for women with diabetes 

were unplanned. While in an earlier Australian 

multicentre study of pregnancies complicated 

by diabetes, pre-pregnancy counselling was 

documented in only 20% of women – 28% of 

those with type 1 diabetes and 12% of those with 

type 2 diabetes (McElduff et al, 2005). 

Planning for pregnancy 

The primary health care setting is where many 

women with diabetes seek advice on reproductive 

issues and access contraception. However, in the 

NDSS Contraception, Pregnancy & Women’s 

Health Survey (2015) only 49% of Australian 

women with type 1 or type 2 diabetes could 

recall being advised by a health professional to 

use some form of contraception to prevent an 

unplanned pregnancy, and 55% could recall being 

advised by a health professional that they should 

access diabetes-specific pre-pregnancy care before 

becoming pregnant or planning a pregnancy. 

These results differed by type of diabetes, with 

those with type 2 diabetes being less likely to recall 

receiving advice. These findings are consistent 

with those reported in the TRIAD (Translating 

Research into Action for Diabetes) preconception 

study of US women aged 18–45 years enrolled 

in managed care (Kim et al, 2005). Of these 

women, 52% recalled discussions with a health 

professional regarding glucose control before 

conception, and 37% could recall receiving family 

planning advice. 

Due to the impact of an unplanned pregnancy 

on both the developing fetus and mother, adequate 

contraception should be maintained until 

glycaemia and all aspects of care are optimised. 

The longer-acting reversible contraceptives are an 

excellent choice (e.g. intrauterine contraceptive 

devices or implant) and are safe for women with 

diabetes to use. When reviewing contraception in 

women with diabetes, timing of pregnancy should 

be discussed. Preconception planning for women 

with diabetes should occur well before conception. 

If available, involvement of a specialist diabetes in 

pregnancy service is recommended. 

New NDSS resources to support 

preconception care 

To address the gap in information for 

women with diabetes who are seeking or 

already accessing pre-pregnancy advice 

and care, Diabetes Australia has developed 

a suite of resources with funding through 

the NDSS. These resources were developed 

following extensive consumer and stakeholder 

consultation, and provide up-to-date, evidencebased 

pregnancy information for women living 

with type 1 or type 2 diabetes. The NDSS 

resources available include the following: 

l www.pregnancyanddiabetes.com.au: A 

website dedicated to pregnancy and diabetes 

information. 

l Pregnancy planning checklist: A checklist 

to help women with diabetes prepare for a 

healthy pregnancy. The checklist can be 

completed as an online tool or downloaded 

as a printable checklist (Figure 1). 

l Having a Healthy Baby booklets: Booklets 

providing comprehensive information on 

planning and managing pregnancy. Separate 

booklets are available for women with 

type 1 or type 2 diabetes (Figure 2). 

l NDSS pregnancy and diabetes factsheet: 

Available for download in English, Arabic, 

Chinese, Vietnamese, Korean, Turkish, 

Urdu, Greek, Italian and Spanish. 

l Plan for the best start e-newsletter: A 

quarterly e-newsletter for women with 

diabetes and health professionals. It 

provides information on planning and 

preparing for pregnancy, and there is access 

to the latest NDSS resources and research 

updates. 

l Health professional continuing professional 

development learning: E-learning modules 

for primary health care providers on the 

topic of preconception care for women 

with type 1 or type 2 diabetes. The course 

includes three modules with two nonassessed 

case studies and can be accessed 

from the NDSS pregnancy and diabetes 

website. CPD points are available for 

eligible health professionals. 

These resources for patients and health 

care professionals can be accessed at 

www.pregnancyanddiabetes.com.au. Hard 

copies of the booklets can be ordered online or 

by phoning the NDSS Helpline (1300 136 588). 

Page points 

1. Due to the impact of an 

unplanned pregnancy on 

both the developing fetus and 

mother, adequate contraception 

should be maintained until 

glycaemia and all aspects of 

care are optimised. 

2. Preconception planning for 

women with diabetes should 

occur well before conception. 

3. Resources for patients and 

health care professionals 

can be accessed at www. 

pregnancyanddiabetes.com.au. 



Pregnancy Planning Checklist 

Plan and prepare at least 3-6 months before you start 

trying for a baby 

What you need to do BEFORE you fall pregnant 

Use contraception until you are ready to start trying for 

a baby (ask your doctor if this is the most reliable 

contraception suitable for you) 

Talk to your doctor for general pregnancy planning advice 

Make an appointment with health professionals who 

specialise in pregnancy and diabetes 

Aim for an HbA1c of less than 53mmol/mol (7%) if you 

have type 1 diabetes or 42mmol/mol (6%) or less if 

you have type 2 diabetes 

Review your diabetes management with your diabetes 

health professionals 

Have all your medications checked to see if they are 

safe to take during pregnancy 

Start taking a high-dose (2.5mg-5mg) folic acid 

supplement each day 

Have a full diabetes complications screening and 

your blood pressure checked 

Aim for a healthy weight before you fall pregnant 

For women 

with type 1 

or type 2 

diabetes 

Use this checklist as a guide to discuss with your health professionals 

www.pregnancyanddiabetes.com.au 

This checklist is intended as a guide only. It should not replace individual medical advice and if you have any 

concerns about your health or further questions, you should contact your health professional. 

The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered with the assistance of Diabetes Australia. 

Figure 1. Pregnancy planning checklist, to help women with diabetes 

prepare for a healthy pregnancy. Produced by the National Diabetes 

Service Scheme. 

Other resources 

The Australasian Diabetes in Pregnancy 

Society (ADIPS)-endorsed Pregnant 

with Diabetes app has been developed 

for pregnant women with diabetes, and 

women with diabetes who intend to 

become pregnant (Figure 3). It is written by 

Prof. Elisabeth R Mathiesen and Prof. Peter 

Damm and is based on the recommendations 

of the Centre for Pregnant Women with 

Diabetes at Rigshospitalet in Copenhagen, 

Denmark. The Australian version has been 

adapted by an Australian working party 

to reflect the ADIPS guidelines. The app 

can be downloaded from app stores free 

of charge. The information covered in the 

app is suitable for women with gestational, 

type 1 and type 2 diabetes and covers 

topics such as: how to plan for pregnancy, 

Figure 2. Booklets for women with type 1 and type 2 

diabetes. Produced by the National Diabetes Services 

Scheme. 

goal blood glucose levels, gestational weight 

gain, diet and carbohydrate intake, physical 

activity and insulin dosing. 



National Development Program Expert 

Reference Group (2013–16). We acknowledge 

D. Charron-Prochownik for permission 

to reproduce questions from the RHAB 

questionnaire and V. Holmes for permission to 

use reproductive health knowledge questions 

in the NDSS Contraception, Pregnancy & 

Women’s Health Survey. 

Abouzeid M, Versace VL, Janus ED et al (2014) A population-based 

observational study of diabetes during pregnancy in Victoria, 

Australia, 1999–2008. BMJ Open 4: e005394 

Australian Institute of Health and Welfare (2016) Australia’s 

mothers and babies 2014-in brief. Perinatal statistics. AIHW, 

Canberra, ACT. Available at: http://www.aihw.gov.au/ 

publication-detail/?id=60129557656 (accessed 14.03.17) 

“Primary care health 

professionals are 

also ideally placed to 

increase the awareness 

of women with 

diabetes about the 

available resources 

which are being 

actively reviewed and 

developed to meet 

their needs.” 

Cheung N, McElduff A, Ross G (2005) Type 2 diabetes in 

pregnancy: a wolf in sheep’s clothing. Aust N Z J Obstet 

Gynaecol 45: 479–83 

Figure 3. The Australasian Diabetes in Pregnancy 

Society (ADIPS)-endorsed Pregnant with Diabetes app. 

Conclusion 

Primary health care providers play an important 

role in promoting effective contraception use 

and encouraging women with pre-existing 

type 1 or type 2 diabetes to plan and prepare 

for pregnancy. They are also ideally placed to 

increase the awareness of women with diabetes 

about the available resources which are being 

actively reviewed and developed to meet their 

needs. 

n 

Acknowledgements 

The authors are grateful to the women who took 

part in the NDSS Contraception, Pregnancy 

& Women’s Health Survey, to the Australasian 

Diabetes in Pregnancy Society for approving the 

use of the image of the Pregnant with Diabetes 

app and to Effie Houvardas and Kaye Farrell, 

for their contribution to Diabetes in Pregnancy 

Dunne FP, Avalos G, Durkan M et al (2009) ATLANTIC DIP: 

pregnancy outcome for women with pregestational diabetes 

along the Irish Atlantic seaboard. Diabetes Care 32: 1205–6 

Holmes VA, Hamill, LL, Alderdice FA et al (2017) Effect of 

implementation of a preconception counselling resource for 

women with diabetes: A population based study. Primary Care 

Diabetes 11: 37–45 

Kim C, Ferrara A, McEwan LN et al (2005) Preconception care in 

managed care: the translating research into action for diabetes 

study. Am J Obstet Gynecol 192: 227–32 

Kitzmiller JL, Wallerstein R, Correa A, Kwan S (2010) 

Preconception care for women with diabetes and prevention of 

major congenital malformations. Birth Defects Res A Clin Mol 

Teratol 88: 791–803 

Macintosh MC, Fleming KM, Bailey JA et al (2006) Perinatal 

mortality and congenital anomalies in babies of women with 

type 1 or type 2 diabetes in England, Wales, and Northern 

Ireland: population based study. BMJ 333: 177 

McElduff A, Ross GP, Lagstrom JA et al (2005) Pregestational 

diabetes and pregnancy: an Australian experience. Diabetes 

Care 28: 1260–1 

National Diabetes Services Scheme (2015) NDSS Diabetes 

in Pregnancy National Development Program, Registrant 

Consultation and Needs Assessment Report. NDSS, Canberra, 

ACT 

Ray JG, O’Brien TE, Chan WS (2001) Preconception care and the 

risk of congenital anomalies in the offspring of women with 

diabetes mellitus: a meta-analysis. QJM 94: 435–44 

Temple RC, Murphy H (2010) Type 2 diabetes in pregnancy - an 

increasing problem. Best Pract Res Clin Endocrinol Metab 24: 

591–603 

Wahabi HA, Alzeidan RA, Bawazeer GA et al (2010) 

Preconception care for diabetic women for improving maternal 

and fetal outcomes: a systematic review and meta-analysis. 

BMC Pregnancy Childbirth 10: 63 

Zhu H, Graham D, Teh RW, Hornbuckle J (2012) Utilisation of 

preconception care in women with pregestational diabetes in 

Western Australia. Aust N Z J Obstet Gynaecol 52: 593–6 

Authors 

Melinda Morrison, NDSS 

Diabetes in Pregnancy Priority 

Area Leader*, Diabetes, NSW, 

Glebe, NSW; Ralph Audehm, 

General Practitioner, Carlton 

Family Medical and Department 

of General Practice, University 

of Melbourne, Vic; Alison Barry, 

Credentialled Diabetes Educator 

and Midwife, Mater Mothers’ 

Hospital, South Brisbane, Qld; 

Christel Hendrieckx, Senior 

Research Fellow, The Australian 

Centre for Behavioural Research 

in Diabetes, Deakin University, 

Geelong, Vic; Alison Nankervis, 

Senior Physician to the Diabetes 

Service, The Royal Women’s 

Hospital and Clinical Head, 

Diabetes, Royal Melbourne 

Hospital, Parkville, Vic; Cynthia 

Porter, Advanced Accredited 

Practising Dietitian/Credentialled 

Diabetes Educator, Geraldton 

Diabetes Clinic, Geraldton, WA; 

Renza Scibilia, Manager Type 1 

Diabetes and Consumer Voice, 

Diabetes Australia, Melbourne, 

Vic; Glynis P Ross, Visiting 

Endocrinologist, Royal Prince 

Alfred Hospital, Camperdown, 

NSW, and Senior Endocrinologist, 

Bankstown-Lidcombe Hospital, 

Bankstown, NSW. 

*Melinda Morrison is representing 

Diabetes Australia/National 

Diabetes Service Scheme. 


CPD module 

Optimising pregnancy outcomes for 

women with pre-gestational diabetes in 

primary health care 

Glynis P Ross 

Citation: Ross GP (2017) Optimising 

pregnancy outcomes for women 

with pre-gestational diabetes in 

primary health care. Diabetes & 


Learning objectives 

After reading this article, the 

participant should be able to: 

1. Identify the increased 

risks of adverse pregnancy 

outcomes to mother and 

baby that are associated with 

pre-gestational diabetes. 

2. Describe the ideal 

preconception care 

consultation and the key 

elements of care that a pregnant 

woman with pre-existing 

diabetes should receive. 

3. Implement a checklist for 

preconception care for 

women with diabetes. 

Key words 

– Preconception care 

– Pre-gestational diabetes 

– Pregnancy 



Author 

Glynis P Ross, Visiting 

Endocrinologist, Royal Prince 

Alfred Hospital, Camperdown 

NSW, and Senior Endocrinologist, 

Bankstown-Lidcombe Hospital, 

Bankstown, NSW. 

Preconception care for women with pre-existing diabetes (type 1 or type 2) is critical to 

optimise pregnancy outcomes and reduce the risk of adverse outcomes, including miscarriage, 

congenital anomalies, hypertension, caesarean deliveries and perinatal mortality. Pregestational 

diabetes is present in approximately 1% of pregnant women in Australia, and the 

prevalence is increasing. Women with pre-gestational diabetes need to be informed on the 

availability and importance of preconception care, which can be provided by both primary 

care and specialised diabetes services. The key elements of preconception care for women 

with diabetes are outlined in this article with two case examples to illustrate. 

Women with pre-gestational type 1 

or type 2 diabetes are at high risk 

of complications during pregnancy 

and of adverse outcomes including miscarriage, 

congenital anomalies and perinatal mortality. 

Despite advances in diabetes management, rates 

of congenital anomalies are 2–4 times higher 

than that of the background population and 

there is a 3–5 fold increased risk of stillbirth 

and perinatal mortality for births to women 

with diabetes (Macintosh et al, 2006; Dunne et 

al, 2009; Kitzmiller et al, 2010). Data from the 

Australian Institute of Health and Welfare (2010) 

show that in 2005–2007, more than half of all 

Australian women with pre-gestational diabetes 

underwent caesarean delivery (59%; 71% type 1 

and 56% type 2 diabetes), compared to a third of 

women without diabetes. Following birth, 58% 

of infants born to women with diabetes were 

admitted to a special care nursery or neonatal 

intensive care unit, compared to 14% of babies 

born to mothers without diabetes. 

Glycaemic control in early pregnancy is strongly 

associated with the risk of adverse pregnancy 

outcomes (Nielsen et al, 2004; Guerin et al, 2007, 

Jensen et al, 2009). Research shows that for every 

10.93 mmol/mol (1%) increase in HbA 1c 

above 

53 mmol/mol (7%), there is a 5.5% increase in 

risk of adverse outcomes (Nielsen et al, 2004). The 

American Diabetes Association (2017) states that 

the lowest rates of adverse pregnancy outcomes 

are seen in association with an early gestation 

HbA 1c 

of 42–48 mmol/mol (6.0–6.5%). 

Preconception care for women with existing 

diabetes provides an opportunity to optimise 

glycaemic control, as well as other aspects of 

maternal health such as folic acid supplementation, 

diabetes complications screening and 

discontinuation of teratogenic medications prior 

to conception (McElduff et al, 2005; Mahmud 

and Mazza, 2010; Egan et al, 2015). Attendance 

at diabetes-specific preconception care has 

been associated with a reduction in congenital 

anomalies (relative risk [RR], 0.25), perinatal 

mortality (RR, 0.35) and reduced first trimester 

HbA 1c 

by an average of 26 mmol/mol (2.4%; 

Wahabi et al, 2010). 

Advice 

Preconception planning and assessment is 

recommended for all women considering 

pregnancy, but it is particularly important for 

women with diabetes or other medical disorders. 

Primary health care providers are well placed to 

complete most of the preconception screening 

and risk assessment, and can facilitate many of 


Optimising pregnancy outcomes for women with pre-gestational diabetes in primary health care 

the interventions and appropriate referrals that 

may be required. A checklist, such as below, 

may be useful when undertaking pre-pregnancy 

counselling. 

ADVICE AND CONSIDERATIONS 

FOR ALL WOMEN CONSIDERING 

PREGNANCY 

o Appropriate contraception until 

optimal situation for pregnancy. 

o Review ALL current medications 

and ensure they are safe and 

appropriate for pregnancy. 

o Check blood pressure. 

o (For women not known to 

have diabetes, assess risk, 

and test appropriately for 

abnormal glucose tolerance.) 

o Promote a healthy lifestyle 

with regard to diet, exercise 

and optimal weight – this is 

also advisable for partners! 

o Encourage smoking cessation. 

o Advise to cease alcohol intake. 

o Advise to stop any 

recreational drug use. 

o Reduce caffeine intake. 

o Dental check. 

o Complete breast check 

and pap smear. 

o Assess immunity to rubella 

and varicella zoster, and, if 

necessary, organise vaccinations 

with appropriate waiting 

periods before conception. 

o Consider vaccinations for 

influenza and whooping cough. 

o Commence folic acid 3 months 

prior to pregnancy at 0.5 mg daily 

(see below for dose adjustments 

for women with known diabetes). 

o Commence an iodine-containing 

supplement (unless active 

thyrotoxicosis is present). 

o Consider checking thyroid 

function, iron, B12 (especially if 

vegetarian or taking metformin) 

and vitamin D status (if at risk). 

ADDITIONAL ADVICE AND 

CONSIDERATIONS FOR WOMEN 

WITH PRE-GESTATIONAL DIABETES 

CONSIDERING PREGNANCY 

o Refer to a diabetes specialist 

or team if not already under 

their care for assessment. 

o Optimise glycaemic control 

o In type 1 diabetes, pre-pregnancy 

HbA 1c 

should ideally be 


Page points 

1. Preconception care should be 

individualised. 

2. Women should be advised 

to continue to use effective 

contraception until the best 

possible conditions for a 

safe pregnancy and birth are 

achieved. 

3. Regular monitoring and 

recording of blood glucose 

levels during the preconception 

stage and pregnancy can be 

helpful in optimising pregnancy 

outcomes. 

Case studies 

Outlined on the following two pages are two case 

studies illustrating some of the considerations to 

address during the preconception period. Given 

the range of situations that may be encountered, 

all care needs to be individualised. Ideally, most 

women with diabetes should be assessed before 

conception by a diabetes specialist or team with 

expertise in diabetes and pregnancy. This is 

particularly important when there are diabetes 

complications or additional medical disorders. 

For women in rural and remote areas, review 

in a regional centre or via telehealth with a 

specialist centre may be an appropriate option. 

This is especially important for women with more 

complex situations such as type 1 diabetes, type 2 

diabetes requiring multiple medications, diabetes 

vascular complications and/or other vascular risk 

factors. 

Case 1 

Maria is a 41-year old woman and has come 

to see you for a pap smear. You last saw her 

4 months ago when she wanted a script for 

the oral contraceptive pill (OCP). On routine 

questioning when you are completing the 

pathology request for cervical cytology she says 

that she is considering having a break from the 

pill as she and her husband are thinking about 

having another baby. 

History 

Maria has two children aged 9 and 12 years. 

The first pregnancy was uncomplicated and she 

had spontaneous vaginal delivery at term. Her 

daughter weighed 3450 g and was breastfed 

for 12 months. Before her second pregnancy, 

Maria had gained 8 kg in weight and her BMI 

was 28 kg/m 2 . At 28 weeks during her second 

pregnancy, Maria was diagnosed with gestational 

diabetes. She was able to manage this with diet 

modification alone and had spontaneous vaginal 

delivery at 39 +3 weeks of a 3720 g son. He was 

also breastfed for 12 months. 

Three years ago (age 38 years), Maria’s 

weight had risen and her BMI was 31 kg/m 2 

(class 1 obesity range). Her fasting glucose was 

7.2 mmol/L and her HbA 1c 

was 49 mmol/mol 

(6.6%) and a diagnosis of type 2 diabetes was 

made. Initially she was treated with metformin 

XR 2 g daily. Despite the metformin and Maria 

trying to follow dietary guidelines, 4 months 

ago her HbA 1c 

was 62 mmol/mol (7.8%) and so 

empagliflozin was added to her regimen. She 

continued to struggle to find time to exercise. 

Maria has a strong family history of 

type 2 diabetes (both parents, her older brother 

and all grandparents) and hypertension (father 

and paternal grandmother). Her father had a 

myocardial infarct at the age of 39 years with 

subsequent stenting. For 7 years, Maria has also 

been treated for hypertension with telmisartan, 

and dyslipidaemia for which she is taking 

atorvastatin and fenofibrate. She and her husband 

smoke, but Maria has said she is trying to stop 

so is only smoking in the evenings after dinner. 

Discussion 

Maria has several factors that increase her 

risk of adverse pregnancy outcomes. She is of 

advanced maternal age, is obese, a smoker, and 

has type 2 diabetes, hypertension, dyslipidaemia 

and a family history of early-onset ischaemic 

heart disease. 

Her glycaemic control is not satisfactory for 

pregnancy, and although metformin can be 

continued during pregnancy, empagliflozin 

will need to be stopped and insulin therapy 

commenced and titrated. She will need to increase 

her blood glucose monitoring and recording of 

results, preferably including dietary information. 

Review with a dietitian, diabetes educator and 

preferably an exercise physiologist is advisable. 

She should be seen by a diabetes physician with 

expertise in diabetes and pregnancy. 

She has multiple vascular risk factors and a 

high risk of developing a hypertensive disorder of 

pregnancy. She should be appropriately counselled 

regarding smoking cessation. The medication she 

is on for hypertension needs to be changed and 

the lipid management will need to be stopped 

for pregnancy. As she has hypertension it would 

be preferable that she is also seen by a renal or 

obstetric medicine physician, especially if she 

fails to achieve blood pressure targets or if she 

has overt proteinuria. Given the multiple vascular 

risk factors, she should have a pre-pregnancy 

cardiac assessment. 



Advice 

You advise Maria that she should stay on the 

OCP for the time being and that preconception 

planning is needed in view of her multiple medical 

conditions and medications. If she still wishes to 

become pregnant, she should commence highdose 

folic acid and have routine pre-pregnancy 

checks. If she conceives, her contraception choice 

should be reviewed following the pregnancy as it 

is not advisable for her to continue on the OCP 

given her age and vascular risk status. 

Case 2 

Jennifer has come to see you for a referral letter to 

her gynaecologist. She wants to have her intrauterine 

contraceptive device (IUCD) removed as she is 

keen to start a family. Jennifer is a 30-year-old 

woman who has had type 1 diabetes for 21 years. 

For the last 3 years, she has been using insulin 

pump therapy. Jennifer’s most recent HbA 1c 

of 

70 mmol/mol (8.6%) was higher than usual after a 

recent overseas holiday with her husband. 

History 

In her teens, Jennifer struggled with her diabetes 

control but in the past 5 years has been managing 

quite well. Her last episode of diabetic ketoacidosis 

was 18 months ago when there was a problem with 

insulin delivery through her pump. She has not 

had severe hypoglycaemia (requiring the assistance 

of another person) for 5 years and is using a 

continuous glucose monitoring system (CGMS) 

with predictive low-glucose suspend, as she knows 

that she does not reliably sense hypoglycaemia. 

Jennifer has diabetic retinopathy that has 

previously required laser photocoagulation. 

However, she has not had her eyes checked for 

about 2 years as she missed an appointment and 

did not find time to reschedule. She has overt 

proteinuria (0.5 g per day) and is on ramipril for 

nephroprotection. Her eGFR is 62 mL/min/1.73 m 2 

and she has previously been assessed for other 

causes of renal disease by a nephrologist. Her 

blood pressure and lipids are normal. She has 

a moderate degree of asymptomatic peripheral 

neuropathy with loss of distal sensation to light 

touch and vibration, as well as loss of ankle 

reflexes. She senses a monofilament and has had 

no diabetes-related foot complications. 

Discussion 

If conception is successful, this will be Jennifer’s 

first pregnancy. As she is on insulin pump therapy 

and uses a CGM device, she will already be under 

a specialist diabetes team. Her glycaemic control 

is sub-optimal and significantly increases her 

risk of adverse pregnancy outcomes, including 

miscarriage and congenital anomalies. Even 

though the recommended HbA 1c 

target for women 

with type 1 diabetes in the preconception stage is 

≤53 mmol/mol (7%), given her long duration 

of type 1 diabetes and poor hypoglycaemic 

awareness, it may not be safe to reduce her HbA 1c 

below 58 mmol/mol (7.5%) due to the increasing 

risk of severe hypoglycaemia at lower levels. She 

needs specific specialist assessment and advice 

regarding her HbA 1c 

as well as review of all 

aspects of her diabetes self-management (e.g. diet, 

exercise, BGL testing and recording, insulin pump 

settings review, pump management skills, driving 

considerations, and hypoglycaemia and diabetic 

ketoacidosis prevention and management). 

Jennifer also needs an urgent diabetes eye 

review. If there is active proliferative retinopathy or 

macular oedema she will need to delay pregnancy 

plans until the retinopathy has been treated and 

is stable. As she has overt proteinuria, she should 

be assessed pre-pregnancy by a renal or obstetric 

medicine physician who will be able to continue 

to manage her in pregnancy. Her risk of preeclampsia 

and poor fetal outcomes, including 

intrauterine growth restriction (IUGR), will be 

increased. Although she is not known to have 

autonomic neuropathy, she should be assessed for 

this by her diabetes specialist. 

Advice 

You advise Jennifer to not have the IUCD 

removed yet and that preconception planning is 

needed in view of her complex diabetes situation 

– especially her overall glycaemic control, 

nephropathy and retinopathy. You also ask her 

whether she has discussed pregnancy with her 

endocrinologist and check the date of her next 

scheduled appointment. Following diabetes 

complications assessment and optimising 

glycaemic management, Jennifer should 

commence high-dose folic acid and have routine 

pre-pregnancy checks. 

”If a woman has 

been diagnosed with 

retinopathy, it is 

important to ensure 

it has been treated 

and is stable prior to 

pregnancy.” 



“Primary health 

care providers have 

critical roles to play 

in the assessment 

and management of 

contraception, 

pre-pregnancy 

assessment 

and care.” 

Conclusion 

Women of child-bearing age with pre-gestational 

type 1 or type 2 diabetes need to be counselled 

on the need for appropriate contraception at all 

times unless trying for pregnancy in the best 

possible circumstances to avoid adverse pregnancy 

outcomes. Most women with pre-gestational 

diabetes are able to have successful pregnancies. 

However, they are at much higher risk of having 

adverse pregnancy outcomes than women without 

diabetes (Macintosh et al, 2006; Dunne et al, 

2009). It has been shown that women who have 

had optimal pre-pregnancy care and best practice 

management of their diabetes, both before and 

throughout pregnancy, will have a substantially 

lower rate of adverse outcomes (Ray et al, 2001; 

Wahabi et al, 2010). 

Ideally, care should involve services that are 

specialised in diabetes in pregnancy. However, 

primary health care providers also have critical 

roles to play in the assessment and management of 

contraception, pre-pregnancy assessment and care, 

coordination of specialist services and ongoing 

support prior to, as well as throughout and 

following, the pregnancy. 

n 

Acknowledgement 

The author would like to acknowledge Melinda 

Morrison for assistance with article editing and 

referencing. 

American Diabetes Association (2017) Standards of Medical Care in 

Diabetes—2017. Diabetes Care 40(Suppl 1): S4–S5 

Australian Institute of Health and Welfare (2010) Diabetes in 

pregnancy: its impact on Australian women and their babies. 

AIHW, Canberra, ACT 

Dunne FP, Avalos G, Durkan M et al (2009) ATLANTIC DIP: 

pregnancy outcome for women with pregestational diabetes 

along the Irish Atlantic seaboard. Diabetes Care 32: 1205–6 

Egan, AM, Murphy HR, Dunne FP (2015) The management of type 1 

and type 2 diabetes in pregnancy. QJM: An International Journal 

of Medicine 108: 923–7 

Guerin A, Nisenbaum R, Ray JG (2007) Use of maternal GHb 

concentration to estimate the risk of congenital anomalies in the 

offspring of women with prepregnancy diabetes. Diabetes Care 

30: 1920–5 

Inkster ME, Fahey TP, Donnan PT et al (2006) Poor glycated 

haemoglobin control and adverse pregnancy outcomes in type 1 

and type 2 diabetes mellitus: Systematic review of observational 

studies. BMC Pregnancy Childbirth 6: 30 

Jensen DM, KorsholmL, Ovesen P et al (2009) Periconceptional A1C 

and risk of serious adverse pregnancy outcome in 933 women 

with type 1 diabetes. Diabetes Care 32: 1046–8 

Kitzmiller JL, Wallerstein R, Correa A, Kwan S (2010) Preconception 

care for women with diabetes and prevention of major congenital 

malformations. Birth Defects Res A Clin Mol Teratol 88: 791–803 

Macintosh MC, Fleming KM, Bailey JA et al (2006) Perinatal 

mortality and congenital anomalies in babies of women with 

type 1 or type 2 diabetes in England, Wales, and Northern 

Ireland: population based study. BMJ 333: 177 

Mahmud M, Mazza D (2010) Preconception care of women with 

diabetes: a review of current guideline recommendations. BMC 

Womens Health 10: 5 

McElduff A, Cheung NW, McIntyre HD et al (2005) The Australasian 

Diabetes in Pregnancy Society consensus guidelines for the 

management of type 1 and type 2 diabetes in relation to 

pregnancy. Med J Aust 183: 373–7 

Nielsen LR, Ekbom P, Damm P et al (2004) HbA1c levels are 

significantly lower in early and late pregnancy. Diabetes Care 27: 

1200–1 

Ray JG, O’Brien TE, Chan WS (2001) Preconception care and the risk 

of congenital anomalies in the offspring of women with diabetes 

mellitus: a meta-analysis. QJM 94: 435–44 

Wahabi HA, Alzeidan RA, Bawazeer GA et al (2010), Preconception 

care for diabetic women for improving maternal and fetal 

outcomes: a systematic review and meta-analysis. BMC 

Pregnancy Childbirth 10: 63 



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. What percentage of pregnant women are 

affected by pre-gestational diabetes? 

Select ONE option only. 

A. 0.1% 

B. 1% 

C. 2.5% 

D. 5% 

E. 10% 

2. A woman with type 2 diabetes has an 

HbA 1c 

of 69 mmol/mol (8.5%) in early 

pregnancy. Which ONE of the following 

statements is NOT true? 

A. She is at increased risk of miscarriage. 

B. She is at increased risk of hypertension 

in late pregnancy. 

C. She is at increased risk of developing 

retinopathy in pregnancy. 

D. She will not have an increased risk of 

pregnancy complications unless she is 

obese. 

E. It is safe for her to continue taking 

metformin. 

3. A 31-year-old woman with type 2 diabetes 

has just found she is pregnant. She is 

currently being treated with gliclazide and 

metformin. Which of the following options 

is most appropriate? Choose ONE option 

only. 

A. Stop gliclazide immediately 

B. Continue gliclazide and metformin 

initially 

C. Check HbA 1c 

D. Start self-monitoring of blood glucose 

(finger-prick testing) 

E. B, C and D 

4. Attendance at diabetes-specific 

preconception care has been associated 

with which one of the following? Choose 

ONE option only. 

A. A reduction in congenital anomalies 

B. A reduction in perinatal mortality 

C. A reduction in first trimester HbA 1c 

D. A, B and C 

E. None of the above 

5. Rachel has long-standing type 1 

diabetes. Her most recent HbA 1c 

is 

70 mmol/mol (8.6%). She is keen to 

conceive soon. Which of the following 

statements is INCORRECT? Select ONE 

option only. 

A. She should avoid pregnancy until her 

HbA 1c 

is close to 53 mmol/mol (7%) 

while still minimising hypoglycaemia 

risk. 

B. She should start taking folic acid 5 mg 

daily at least 3 months before she starts 

trying to conceive. 

C. She should be referred to a specialist 

diabetes and pregnancy unit to 

optimise her diabetes management 

prior to conceiving. 

D. She should be advised to terminate the 

pregnancy if she falls pregnant before 

her HbA 1c 

has improved as risk to her 

and the fetus would be unacceptable. 

E. She should delay pregnancy plans if 

she has active retinopathy until it has 

been treated. 

6. A 43-year-old woman with type 2 diabetes 

is currently 6 weeks pregnant. She has 

a past medical history that includes 

pernicious anaemia, hypertension 

and hyperlipidaemia. Which of her 

medications, if any, should she now STOP? 

Choose ONE option only. 

A. Metformin 

B. Hydroxocobalamin 1 mg 3-monthly 

C. Labetalol 200 mg twice daily 

D. Simvastatin 20 mg daily 

E. None of the above 

7. Which of the following antidiabetes 

agents, if any, are SAFE to prescribe for 

a woman with type 2 diabetes planning 

pregnancy? Choose ONE option only. 

A. A sodium–glucose co-transporter 2 

(SGLT2) inhibitor 

B. A dipeptidyl peptidase-4 (DPP-4) 

inhibitor 

C. A glucagon-like peptide-1(GLP-1) 

receptor agonist 

D. Thiazolidinedione 

E. Insulin 

8. A 37-year-old woman with pre-gestational 

type 2 diabetes is advised to monitor 

her blood glucose levels as she has 

recently commenced insulin to control 

her diabetes. Which of the following 

is the most appropriate to monitor her 

glycaemia? Choose ONE option only. 

A. HbA 1c 

B. Self-monitoring of blood glucose 

(finger-prick testing) 

C. Fructosamine 

D. Continuous blood glucose monitoring 

E. A and B 

9. Which of the following insulins does not 

have regulatory approval for use during 

pregnancy? Select ONE option only. 

A. Insulin glulisine (Apidra ® ) 

B. Protaphane/Humulin NPH 

C. Insulin detemir (Levemir ® ) 

D. Insulin aspart (Novorapid ® ) 

E. None of the above; they are all 

approved for use in pregnancy 

10. Ideally, what should the pre-pregnancy 

HbA 1c 

target for women with type 2 

diabetes be? Choose ONE option only. 

A.





 

 

 











Neale Cohen 









Hendrieckx 




in Diabetes 











Doctor Gautam 

Vaddadi 















pcdsa.com.au

Article 

Diabetes and bone health 

Vidhya Jahagirdar, Neil J Gittoes 

Diabetes and osteoporosis represent two major public health challenges. Osteoporosis 

is characterised by decreased bone mineral density and micro-architectural changes of 

the bone leading to increased risk of low trauma (fragility) fractures. Both diabetes and 

osteoporosis are associated with significant morbidity, decreased quality of life and reduced 

life expectancy. This article will explore the current literature on the inter-relationships 

between diabetes and bone health, the impact on patients and the management strategies 

that may be considered in primary care to minimise risk of diabetes-related bone disease 

and improve outcomes. 

Preface 

Nick Forgione, General Practitioner, Trigg Health 

Care Centre, Perth, WA 

The connection between diabetes and 

osteoporosis is often overlooked in the 

busy management schedule of people 

with diabetes. However, there is an accumulation 

of evidence suggesting that type 2 diabetes may 

be an independent risk factor for osteoporosis. 

Despite the fact that bone mineral density 

(BMD) is often higher in people with 

type 2 diabetes compared to those without, it 

is paradoxical that people with type 2 diabetes 

have a higher risk of fracture. It is likely that the 

explanation for this paradox is multifactorial, 

including changes in trabecular bone, 

microarchitectural changes in bone leading 

to reduced bone strength and changes in the 

material property of bone due to accumulation 

of advanced glycation end products (AGEs). 

Medications used in the management of diabetes 

may also play a part. 

Diabetes and osteoporosis represent 

two major public health challenges. 

Osteoporosis is characterised by 

decreased bone mineral density (BMD) and 

micro-architectural changes of the bone leading 

to increased risk of low trauma or fragility 

fractures that are sustained as a result of a fall 

from standing height or less (Figure 1). Both 

There is much that remains unclear about 

people with diabetes-related osteoporosis. 

Assessment of fracture risk must be approached 

with caution as people with diabetes tend to 

have a higher fracture risk for a given BMD 

t-score compared to those without diabetes. 

Also it is unclear whether antiresorptive agents 

reduce fracture risk in type 2 diabetes to the 

same extent as those without diabetes (Rubin et 

al, 2013). 

As the number of people with type 2 diabetes 

increases and their life is extended through 

improvements in management, ensuring early 

detection and appropriate management of 

osteoporosis in this population becomes another 

priority for primary care management. Until 

there is further clarification of whether or not 

individuals with type 2 diabetes should be 

screened and managed differently to the rest 

of the population, it is important to at least 

ensure that the current RACGP guidelines for 

the detection and treatment of osteoporosis are 

followed. 

diabetes and osteoporosis are associated with 

significant morbidity, decreased quality of life 

and reduced life expectancy. In Australia, the 

total number of adults with diabetes is projected 

to rise to between 2 and 3 million by 2025 

(Magliano et al, 2009). Osteoporosis is also 

a condition that increases in prevalence with 

ageing (Figure 2). Age-related bone loss and 

Citation: Jahagirdar V, Gittoes NJ 

(2016) Diabetes and bone health. 

Diabetes & Primary Care Australia 

2: 61–8 


1. Diabetes and osteoporosis are 

increasingly prevalent diseases. 

2. Diabetes and its complications 

influence important 

determinants of bone strength 

such as the material properties 

of bone, bone density and 

mineral content as well as 

bone micro-architecture 

and bone turnover. 

3. Diabetes is an important 

clinical risk factor for 

osteoporosis and fracture, 

and as clinicians it is 

important to remember this 

association when managing 


Key words 

– Bone 

– Metabolic disorder 

– Osteoporosis 

Authors 

Vidhya Jahagirdar is Specialty 

Trainee Registrar in Diabetes, 

Endocrinology and General 

Internal Medicine; Neil Gittoes is 

Consultant & Honorary Professor 

of Endocrinology, Head, Centre 

for Endocrinology, Diabetes and 

Metabolism. Both are at the 

Department of Endocrinology, 

University Hospitals Birmingham 

NHS Foundation Trust, 

Birmingham, UK. 



Page points 

1. The prevalence of osteoporosis 

based on bone mass density 

(BMD) is significantly lower in 

type 2 diabetes compared to 

age-matched controls. 

2. Age, female gender, 

glucocorticoid use and family 

history are well-recognised risk 

factors for osteoporosis and 

osteoporotic fractures, but the 

association between diabetes 

and osteoporosis is tantalising, 

but poorly understood. 

3. As type 1 diabetes is usually 

diagnosed in children, the early 

and chronic alterations in bone 

metabolism may result in lower 

peak bone mass. 

Figure 1. Osteoporosis is characterised by decreased 

bone mineral density and micro-architectural changes 

of the bone leading to increased risk of low trauma 

fractures (Blausen Medical Communications, 2016). 

post-menopausal physiological changes result in 

an increased prevalence of osteoporosis from 2% 

at 50 years to 25% at 80 years of age (NICE, 

2012). One in two women and one in five men 

sustain one or more osteoporotic fractures in their 

lifetime. In 2012, there were 140 822 fractures 

as a result of osteoporosis or osteopaenia in 

Australians over the age of 55 years, with a total 

cost of $2.75 billion. This is expected to increase to 

around $3.84 billion by 2022 (Watts et al, 2013). 

While age, female gender, glucocorticoid use 

and family history are well-recognised risk factors 

for osteoporosis and osteoporotic fractures, the 

association between diabetes and osteoporosis 

is tantalising, but poorly understood. Other 

disease conditions associated with diabetes, such 

as diabetic nephropathy, retinopathy, neuropathy 

and obesity, as well as medication used in 

the management of diabetes, may affect bone 

health, increase risk of falls and predispose 

patients to osteoporotic fractures. These factors 

are confounders in attempting to delineate causal 

links between diabetes and osteoporosis. 

The aim of this article is to explore the current 

literature on the inter-relationships between 

diabetes and bone health, the impact on patients 

and the management strategies that may be 

considered in primary care to minimise risk 

of diabetes-related bone disease and improve 

outcomes. 

Epidemiology of fractures in diabetes 

The interaction between diabetes and osteoporosis 

is poorly understood. Both type 1 and type 2 

diabetes are associated with increased risk of 

osteoporosis and fracture, and this risk is greater 

in type 1 than type 2 (Vestergaard, 2007). 

Various factors, such as type of diabetes, onset 

and duration, metabolic control, BMI, BMD, 

falls risk, diabetic complications and treatment, 

may influence bone health in diabetes. There are 

no well-designed randomised controlled trials 

(RCTs) or carefully evaluated epidemiological 

studies that have looked into all the above 

factors as potential attributors to fracture risk in 

diabetes. 

Figure 2. Peak bone mass is reached at 30 years of age. Bone mass then decreases with age, more 

so in women (Anatomy & Physiology, 2013). 

Type 1 diabetes 

BMD is lower in children and adolescents with 

type 1 diabetes than children without diabetes. 

As type 1 diabetes is usually diagnosed in 

children, the early and chronic alterations in 

bone metabolism may result in lower peak 

bone mass. This may contribute to osteoporosis 

and an increased risk of fracture in later life 

(Bonjour and Chevalley, 2014). 

According to a recent meta-analysis, type 1 

diabetes is associated with three times increased 

background risk of any fracture and the risk is 

elevated in both men and women. In individuals 



Secondary causes 

associated with diabetes 

l Coeliac disease 

l Graves thyrotoxicosis 

l Hypothyroidism 

l Hypogonadism 

l Vitamin D deficiency 

Anti-diabetes medication 

l TZDs 

l GLP-1 receptor agonists 

l DPP-4 inhibitors 

l SGLT2 inhibitors 

Falls risk 

l Diabetic retinopathy 

l Diabetic neuropathy 

l Obesity 

l Hypoglycaemia 

Decreased bone 

turnover 

CKD–MBD secondary to 

diabetic nephropathy 

Fracture risk 

Abnormal bone architecture 

Decreased bone mineral density 

via collagen cross links 

Decreased osteoblast differentiation 

Osteoblast dysfunction 

Increased osteoclast activity 

Increased adipogenesis 

Increased AGE 

Increased PPAR-gamma 

Decreased insulin/ 

IGF-1 secretion 

Oxidative stress 

Figure 3. The factors influencing bone health and fracture risk in diabetes. AGE=advanced glycation end-products; CKD–MBD=chronic kidney 

disease–mineral and bone disorder; DPP-4=dipeptidyl peptidase-4; GLP-1=glucagon-like peptide-1; IGF-1=insulin-like growth factor-1; PPAR-gamma= 

peroxisome proliferator-activated receptor-gamma; SGLT2=sodium–glucose cotransporter 2; TZD=thiazolidinedione. 

with type 1 diabetes compared to people 

without the condition, the relative risk (RR) for 

hip fracture was 3.78 (95% confidence interval 

[CI], 2.05–6.98; P


Page points 

1. Insulin deficiency and reduced 

insulin-like growth factor-1 have 

been linked to the inhibition of 

osteoblast differentiation and 

osteopaenia in type 1 diabetes. 

2. People with diabetes are at 

increased risk of falls and this is 

multifactorial due to advancing 

age, diabetes complications, 

hypoglycaemia and high BMI. 

3. Cortical bone mass is reduced 

in the feet and hands in severe 

diabetic peripheral neuropathy 

and may predispose to 

metatarsal fracture and diabetic 

Charcot’s osteoarthropathy. 

Fracture risk has also been reported to be 

independent of other usually reliable predictors 

of fracture risk in type 2 diabetes, including age, 

physical activity and BMI (RR 2.6 [95% CI], 

1.5–4.5; Janghorbani et al, 2007). 

How does diabetes affect bone? 

Diabetes and its complications influence 

important determinants of bone strength such 

as the material properties of bone, bone density 

and mineral content as well as bone microarchitecture 

and bone turnover (Figure 3). 

Oxidative stress 

Diabetes is reported to affect bone metabolism 

adversely through several mechanisms. Advanced 

glycation end-products (AGE) are produced as 

a result of oxidative stress in diabetes and are 

important mediators of diabetic complications 

such as diabetic retinopathy, nephropathy, 

neuropathy and atherosclerosis (Goh and 

Cooper, 2008). AGE accumulation in bones is 

also detrimental and leads to abnormal structure 

and alignment of collagen, contributing to bone 

fragility (Katayama et al, 1996). 

Insulin deficiency 

Insulin has an anabolic effect on bone. Insulin 

deficiency and reduced insulin-like growth 

factor-1 (IGF-1) have been linked to inhibition 

of osteoblast differentiation and osteopaenia 

in type 1 diabetes (Kanazawa et al, 2011). 

Treatment with insulin has been reported to 

stabilise BMD (Hofbauer et al, 2007). Hence, 

adequate optimisation of glycaemic control 

with insulin in type 1 diabetes may prevent 

osteopaenia and osteoporosis later in life. 

Diabetic nephropathy and chronic kidney 

disease (CKD) 

Diabetic nephropathy often leads to CKD and 

is the most common cause of end-stage renal 

disease in Australia (Kidney Health Australia, 

2015). The risk of developing moderate to severe 

CKD (stages 3b, 4 and 5) is eight times greater 

in women and twelve times greater in men with 

type 1 diabetes than in people without diabetes 

(Hippisley-Cox and Coupland, 2010). Similar to 

diabetes and osteoporosis, the risk of developing 

CKD increases with age. 

Clinical expression of mineral and bone disorders 

in CKD (CKD–MBD) is often asymptomatic 

until late in its course. Abnormalities in 

bone turnover and mineralisation can result 

in osteitis fibrosa cystica (brown tumours; 

Figure 4), adynamic bone disease, osteomalacia 

and secondary hyperparathyroidism caused by 

phosphate retention, decreased calcium and 

1,25-dihydroxy(OH) vitamin D (calcitriol) 

concentration, and uraemic osteodystrophy. 

These conditions increase the risk of fractures due 

to changes in bone quality. While abnormalities 

in calcium and phosphate levels are detected 

even at CKD stages 1 and 2, the clinical 

significance of these abnormalities is unclear. 

Hence, management is focussed on optimising 

calcium and phosphate levels in CKD stages 3, 

4 and 5. 

Factors affecting falls risk 

People with diabetes are at increased risk of falls 

and this is multifactorial due to advancing age, 

diabetes complications, hypoglycaemia and high 

BMI (Figure 3). 

Peripheral neuropathy 

The ABC health study showed that individuals 

with type 2 diabetes who develop fractures 

are more likely to have peripheral neuropathy, 

cerebrovascular disease and falls compared 

with people with diabetes without fractures 

(Strotmeyer et al, 2005). Cortical bone mass is 

reduced in the feet and hands in severe diabetic 

peripheral neuropathy and may predispose 

to metatarsal fracture and diabetic Charcot’s 

osteoarthropathy (Cundy et al, 1985), which can 

cause foot deformity and gait disturbance, further 

increasing fracture risk by increasing falls. People 

with diabetic peripheral neuropathy are more 

likely to fall when compared to age-matched 

controls. While the underlying causative factors 

are not entirely understood, reduced muscle 

strength and stability (Handsaker et al, 2014) 

and foot deformity are likely to be contributing 

factors. 

Retinopathy 

The Blue Mountain Eye study showed that, in 



Page points 

1. Individuals with diabetic 

retinopathy or cataracts, or 

both, with reduced visual acuity 

are prone to falls. 

2. Obesity is also associated with 

decreased bioavailability of 

vitamin D due to distribution in 

the subcutaneous tissue leading 

to vitamin D deficiency, another 

risk factor for osteoporosis. 

3. There is a high incidence of 

fragility fracture in people who 

experience hypoglycaemic 

events. 

Figure 4. Brown tumours of the hands in an individual with hyperparathyroidism (Gaillard, 2008). 

people with diabetes, there was a significantly 

increased risk of proximal humerus fracture 

associated with diabetic retinopathy, cortical 

cataract, longer diabetes duration (>10 years) and 

insulin treatment (Ivers et al, 2001). Individuals 

with diabetic retinopathy or cataracts, or both, 

with reduced visual acuity are prone to falls. Thus, 

the attendant increased risk of falls contributes to 

greater risk of fracture. 

Obesity 

In total, 90% of people with type 2 diabetes are 

overweight or obese. Obesity is commonly thought 

to have a protective effect on bone as BMD tends 

to increase with load bearing associated with 

being overweight. In post-menopausal women, 

obesity increased the risk of fractures at the 

humerus and ankle while decreased the risk at 

the hip, pelvis and wrist (Gonnelli et al, 2014). 

Fewer data are available for men. The reasons for 

site-specific fractures in obesity could be related 

to fat padding protecting the hip and pelvis and 

a tendency to fall backwards or sideways rather 

than fall forward on outstretched arm leading 

to wrist fracture. Obesity is also associated with 

decreased bioavailability of vitamin D due to 

distribution in the subcutaneous tissue leading 

to vitamin D deficiency, another risk factor 

for osteoporosis. Hence, in spite of increased 

BMD, obesity is associated with increased risk 

of fracture at particular sites, which is likely 

to be due to the pattern of fall and vitamin D 

deficiency. 

Hypoglycaemia 

There is a higher incidence of fragility fracture 

in people who experience hypoglycaemic events 

(Signorovitch et al, 2013). Intensive glycaemic 

control (HbA 1c 


Page points 

1. Type 1 diabetes can be 

associated with other 

autoimmune conditions such as 

coeliac disease, hypothyroidism 

and Graves’ thyrotoxicosis, 

which also increase this risk of 

fracture and osteoporosis. 

2. Hyperthyroidism and overtreated 

hypothyroidism are 

associated with lower bone 

mineral density and increased 

risk of fracture. 

3. It is important to be aware 

of the effect different antidiabetes 

medication can have 

on bone mineral density and 

osteoporosis. 

relationship between hypoglycaemia and 

falls risk. It is intuitive, however, to speculate 

that with frequent hypoglycaemic episodes 

contributing to loss of consciousness, falls risk 

would increase. Thus, hypoglycaemia-induced 

falls with underlying low bone density in diabetes 

would increase risk of fragility fracture. 

Secondary causes for osteoporosis associated 

with diabetes 

Type 1 diabetes can be associated with other 

autoimmune conditions such as coeliac disease, 

hypothyroidism and Graves’ thyrotoxicosis. 

About one-third of people with coeliac disease 

have osteoporosis and may be at a higher risk of 

fractures. Both hyperthyroidism and over-treated 

hypothyroidism are associated with lower BMD 

and increased risk of fracture (Mirza and Canalis, 

2015). Hypogonadotrophic hypogonadism (low 

gonadotropins and low testosterone) is found 

in 25% of people with type 2 diabetes. Low 

testosterone levels in men are associated with 

low BMD and hypogonadism is a recognised 

cause of osteoporosis, but there are no reliable 

data available on fracture rates in people with 

type 2 diabetes and hypogonadism (Dandona 

and Dhindsa, 2011). Though epidemiological 

observational studies have shown associations 

between vitamin D deficiency and type 1 and 

type 2 diabetes, the evidence is inconclusive 

(Suzuki et al, 2006; Tahrani et al, 2010), as it 

is for many associations between suboptimal 

vitamin D and major health outcomes. 

Anti-diabetes medication 

Thiazolidinediones 

Expression of peroxisome proliferator-activated 

receptor-gamma (PPAR-gamma) is increased 

in diabetes. This induces adipogenesis and 

inhibits osteogenesis (Botolin and McCabe, 

2006; Montagnani and Gonnelli, 2013). 

Thiazolidinediones (pioglitazone and rosiglitazone) 

are PPAR-gamma agonists. They improve insulin 

sensitivity through their action on adipose tissue 

and liver by increasing glucose utilisation and 

decreasing glucose production. Thiazolidinediones, 

through their action on PPAR-gamma, enhance 

the effect of inhibiting osteoblast formation and 

increase risk of fracture in type 2 diabetes. 

Both pioglitazone and rosiglitazone are 

associated with increased fractures in women 

but not in men. A meta-analysis by Zhu et al 

(2014) reported this risk as independent of age 

and with no clear association with duration of 

treatment. Thiazolidinedione use was associated 

with significant changes in BMD and increased 

fractures not only in the upper and lower limbs 

but also at the lumbar spine and femoral neck 

(Zhu et al, 2014). The benefit of improving 

glycaemic control versus the risk of fracture 

should be assessed carefully on an individual 

case basis, especially in post-menopausal women, 

before commencing treatment with pioglitazone 

in type 2 diabetes. 

Incretin-based medicines 

Glucagon-like peptide 1 (GLP-1) agonists are 

recommended in the management of obese people 

with type 2 diabetes and their effect on the risk 

of bone fractures is beginning to be established. 

In a meta-analysis of RCTs, liraglutide was 

associated with significantly reduced risk of 

fracture and exenatide was associated with an 

elevated risk of incident bone fractures (Su 

et al, 2015). Protective effects of dipeptidyl 

peptidase-4 (DPP-4) inhibitors on bone have 

also been reported in a recent meta-analysis. 

These data should be interpreted with caution as 

the trials included in the meta-analysis were not 

sufficiently long to assess fracture risk and the 

effect on bone was not assessed as a primary endpoint 

(Monami et al, 2011). The effects of DPP-4 

inhibitors and GLP-1 agonists on bone health 

need to be confirmed with well-designed RCTs. 

Sodium–glucose cotransporter 2 (SGLT2) 

inhibitors 

In October 2015, the US Food and Drug 

Administration (FDA; 2015) issued a warning 

for the SGLT2 inhibitor canagliflozin relating to 

increased risk of hip fractures and fractures of the 

lower spine. More evidence is needed to ascertain 

if this is a drug class effect. 

Insulin 

One large longitudinal study, using a German 

database of over 100 000 people with type 2 

diabetes in general practice found non-significant 



increase in risk of fracture in people on basal 

insulin (glargine, insulin detemir and NPH 

insulin) compared to oral hypoglycaemia agents 

(Pscherer et al, 2016). This could possibly be 

due to increased insulin-induced hypoglycaemiarelated 

falls as discussed above, rather than direct 

effect of insulin on the bone. In the absence of 

RCT data at present, there is no clear evidence 

to suggest that insulin increases the risk of 

osteoporosis or fracture. 

Management 

There is no specific guideline for the management 

of bone disorders in diabetes. Investigations and 

treatment of osteoporosis should be based on 

patients’ absolute risk of fracture taking into 

consideration age, gender, menopausal status, 

personal and family history of fractures, body 

weight, falls risk, thiazolinediones use and 

associated secondary causes of osteoporosis. 

Fracture risk assessment based on FRAX, 

Garvan or QFracture assessment tools can help 

predict the risk of fracture. However, these may 

under-estimate fracture risk in type 2 diabetes, 

as paradoxically, BMD is often higher than in 

those without diabetes, despite the increased risk 

of fracture (Schwartz et al, 2011). Type 2 diabetes 

is not an explicitly recognised risk factor included 

in the risk assessment tool and BMD in type 2 

diabetes can be normal or elevated in spite of 

increased fracture risk. As BMD does not predict 

fracture risk in renal osteodystrophy, it need not 

be performed routinely in CKD stages 3–5 in 

the presence of CKD-MBD (Kidney Disease: 

Improving Global Outcomes [KDIGO] CKD- 

MBD Work Group, 2009). 

Bone mineral disorders in CKD can be identified 

early by detecting decreasing serum calcium, 

phosphate and vitamin D concentrations, and 

increasing serum parathyroid hormone (PTH) 

concentrations. The KDIGO clinical practice 

guideline suggests monitoring for serum calcium, 

phosphorus, 25-hydroxy vitamin D deficiency 

and PTH routinely for CKD stages 3–5 with the 

frequency of monitoring based on stage, rate of 

progression and whether specific therapies have 

been initiated (KDIGO CKD-MBD Work Group, 

2009). PTH and bone alkaline phosphatase can 

be used to evaluate CKD–MBD. 

Anti-resorptive agents such as bisphosphonates 

can be used as first-line agents to treat osteoporosis 

and high fracture risk in diabetes and in CKD 

stages 1, 2 and 3 (estimated glomerular filtration 

rate [GFR] >30 mL/min/1.73 m 2 ) in the absence 

of abnormal bone mineral markers. The effect of 

drug treatment should be reviewed after 5 years 

for alendronate and after 3 years for intravenous 

zolendronic acid with a view to making a decision 

regarding a drug holiday or continuing or switching 

treatment. No studies have specifically looked at 

optimal treatment for people with fractures where 

thiazolidinediones have been implicated. 

Screening for coeliac disease with tissue 

transglutaminase antibodies (TTG) is 

recommended at the time of diagnosis of type 1 

diabetes and if a young adult with type 1 develops 

intestinal or extra-intestinal symptoms consistent 

with coeliac disease (NICE, 2009). Annual 

screening for thyroid status is also recommended. 

Screening for hypogonadism in people with type 2 

diabetes and replacing with testosterone if found 

deficient is also recommended (Dandona and 

Dhindsa, 2011). 

Good glycaemic control and blood pressure 

control delays the progression of microvascular 

complications, which are associated with increased 

risk of falls and fracture. HbA 1c 

targets should be 

individualised and less stringent control (HbA 1c 


“It is important, 

where possible, to 

ensure that messages 

from different 

clinicians pertaining 

to lifestyle factors are 

aligned and overlap as 

much as possible.” 

Conclusion 

Diabetes and osteoporosis are increasingly 

prevalent diseases. Diabetes is an important 

clinical risk factor for osteoporosis and fracture, 

and as clinicians it is important to remember this 

association when managing people with diabetes. 

Diabetes-related complications, hypoglycaemia 

and obesity could increase the risk of falls 

and fragility fracture. HbA 1c 

targets should be 

individualised taking into consideration age, 

frailty, diabetes complications and falls risk. 

While there is much to learn regarding the 

associations between diabetes, osteoporosis 

and fractures, it is important to recognise the 

value of performing a multifactorial fracture 

risk assessment, including falls risk. Tools are 

available to conveniently assess this risk and 

measurement of BMD by performing a DXA 

scan may provide additional useful information 

to help target those patients who are most 

at risk of fracture with appropriate fracture 

prevention drug therapies. The value of lifestyle 

modification to address fracture and falls risk 

cannot be underestimated. It is also convenient 

that the lifestyle modifications required to 

optimise bone health very much overlap with 

the lifestyle guidance that is offered to optimise 

the management of the underlying diabetes and 

obesity. It is important, where possible, to ensure 

that our messages to patients pertaining to 

lifestyle factors are aligned and overlap as much 

as possible, rather than conveying different sets 

of instructions for different disease areas. This 

is where diabetes and osteoporosis management 

from a self-help perspective very much align. n 


This article has been modified from one 

previously published in Diabetes & Primary Care 

(2016, 2: 68–74). 

Anatomy & Physiology (2013) Age and Bone Mass. Wikimedia 

Commons. Available at: https://commons.wikimedia.org/wiki/ 

File:615_Age_and_Bone_Mass.jpg (accessed 22.03.16) 

Blausen Medical Communications (2016) Osteoporosis locations. 

Wikimedia Commons. Available at: https://commons.wikimedia.org/ 

wiki/File:Osteoporosis_Locations.png (accessed 22.03.16) 

Bonjour J-P, Chevalley T (2014) Endocr Rev 35: 820–47 

Botolin S, McCabe LR (2006) J Cell Physiol 209: 967–76 

Cundy TF et al (1985) Diabet Med 2: 461–4 

Dandona P, Dhindsa S (2011) J Clin Endocrinol Metab 96: 2643–51 

Food and Drug Administration (2015) FDA Drug Safety Communication. 

FDA, Silver Spring, MD, USA. Available at: www.fda.gov/Drugs/ 

DrugSafety/ucm461449.htm (accessed 30.01.16) 

Gaillard F (2008) Brown tumours of the hands. Wikimedia Commons. 

Available at: https://commons.wikimedia.org/wiki/File:Brown_ 

tumours_of_the_hands.jpg (accessed 22.03.16) 

Goh S-Y, Cooper ME (2008) J Clin Endocrinol Metab 93: 1143–52 

Gonnelli S et al (2014) Clin Interv Aging 9: 1629–36 

Handsaker JC et al (2014) Diabetes Care 37: 3047–53 

Hippisley-Cox J, Coupland C (2010) BMC Fam Pract 11: 1 

Hofbauer LC et al (2007) J Bone Miner Res 22: 1317–28 

Ivers RQ et al (2001) Diabetes Care 24: 1198–203 

Janghorbani M et al (2007) Am J Epidemiol 166: 495–505 

Kanazawa I et al (2011) Osteoporos Int 22: 1191–8 

Katayama Y et al (1996) J Bone Miner Res 11: 931–7 

Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD 

Work Group (2009) Kidney Int Suppl 113: S1–130 

Kidney Health Australia (2015) Chronic Kidney Disease (CKD) 

Management in General Practice (3 rd edition). The Australian Kidney 

Foundation. Available at: http://bit.ly/2l8auNd (accessed 22.02.16) 

Magliano DJ, Peeters A, Vos T et al (2009) Aus NZ J Pub Health 33: 

540–3 

Mirza F, Canalis E (2015) Eur J Endocrinol 173: R131–51 

Monami M et al (2011) Diabetes Care 34: 2474–6 

Montagnani A, Gonnelli S (2013) Diabetes Obes Metab 15: 784–91 

National Osteoporosis Society (2013) Vitamin D and Bone Health. 

National Osteoporosis Society, Bath. Available at: https://www.nos. 

org.uk/document.doc?id=1352 (accessed 07.02.16) 

NICE (2009) Coeliac disease: recognition and assessment (CG86). NICE, 

London, UK 

NICE (2012) Osteoporosis: assessing the risk of fragility fracture (CG146). 

NICE, London, UK 

Pscherer S et al (2016) Diabetes Metab Syndr Obes 9: 17–23 

Rubin MR et al (2013) Expert Rev Endocrinol Metab 8: 423–5 

Schwartz AV et al (2008) Diabetes Care 31: 391–6 

Schwartz AV et al (2011) JAMA 305: 2184–92 

Shah VN et al (2015) Diabet Med 32: 1134–42 

Signorovitch JE et al (2013) Diabetes Obes Metab 15: 335–41 

Strotmeyer ES et al (2005) Arch Intern Med 165: 1612–7 

Su B et al (2015) Endocrine 48: 107–15 

Suzuki A et al (2006) Endocr J 53: 503–10 

Tahrani AA et al (2010) Int J Clin Pract 64: 351–5 

Vestergaard P (2007) Osteoporos Int 18: 427–44 

Vestergaard P et al (2005) Diabetologia 48: 1292–9 

Watts J, Abimanyi-Ochom, K, Sanders KM (2013) Osteoporosis 

is costing all Australian – a new burden of disease analysis – 

2012 to 2022. Osteoporosis Australia, Glebe. Available at: 

http://bit.ly/2lvhHI4 (accessed 22.02.16) 

Zhu Z-N et al (2014) Bone 68: 115–2 


Article 

Falls prevention in older adults 

with diabetes: A clinical review of 

screening, assessment and management 

recommendations 

Anna Chapman, Claudia Meyer 

Older adults with diabetes have an increased rate of falls, recurrent falls and rate of 

fracture following a fall. Falls can contribute to a heightened fear of further falling, social 

isolation, avoidance of daily activities, and can increase the likelihood of premature 

admission to residential aged-care facilities. The most common risk factors for falls within 

this population group include peripheral neuropathy, foot complications, impaired postural 

control, polypharmacy and insulin use, sub-optimal glycaemic control and hypoglycaemia, 

as well as vision and cognitive impairment. Falls risk screening should be undertaken every 

12 months for all older people with diabetes, followed by a more detailed falls assessment 

for those deemed high risk to identify the contributory risk factors and management 

strategies. Individualised strategies should be co-designed with individuals and where 

appropriate, their carer(s), may involve referral to other health professionals, and should 

be monitored and reviewed at regular intervals. 

Falls are a complication of diabetes and 

are being increasingly acknowledged 

as impacting the overall health and 

wellbeing of older adults (International Diabetes 

Federation [IDF], 2013). Within the general 

community-dwelling population of older adults, 

approximately one in three people fall per 

year (Moyer, 2012). The combination of age 

(≥65 years) and diabetes increases the risk of 

recurrent falls by 67% (Pijpers et al, 2012); and 

older adults with diabetes are twice as likely to 

have injurious falls (Roman de Mettelinge et al, 

2013). At the individual level, falls can contribute 

to a loss of confidence and reduced activity levels, 

loss of lower-limb muscle and bone strength 

(Karinkanta et al, 2010), and a heightened 

fear of further falling (Zijlstra et al, 2007). For 

the public health system, there are expanding 

costs associated with falls-related hospitalisations 

(Bradley, 2012). 

Key to the prevention of falls is the identification 

of at-risk individuals and the implementation of 

appropriate interventions. Given the increased 

prevalence and negative consequences associated 

with falls among older adults with diabetes, falls 

prevention should be considered an integral 

component of diabetes care, and primary care 

practitioners are well-placed to offer proactive, 

comprehensive and individualised falls prevention 

strategies. This article will assist primary care 

practitioners in this role, providing an overview 

of potential screening tools and outlining fallsrelated 

risk factors pertinent to an older person 

with diabetes. In addition, this paper will 

consider the evidence and recommend actions 

for older adults with diabetes, specifically for the 

community-dwelling population (rather than the 

hospital or residential aged-care setting). 

Falls risk screening 

Falls risk screening refers to the process of 

identifying individuals who are at-risk of a fall, 

to determine if a detailed falls assessment is 

appropriate. To be effective, screening tools need 

Citation: Chapman A, Meyer C 

(2017) Falls prevention in older 

adults with diabetes: A clinical 

review of screening, assessment and 

management recommendations. 

Diabetes & Primary Care Australia 

2: 69–74 


1. Falls-related risk factors 

for older people with 

diabetes include peripheral 

neuropathy, impaired postural 

control, polypharmacy, 

visual impairment, 

cognitive impairment, foot 

complications, and suboptimal 

glycaemic control. 

3. Valid and reliable risk screens 

exist to identify individuals 

at-risk of falls. As with all 

older adults, individuals with 

diabetes should be screened for 

falls at least once every year. 

4. Individuals at increased risk 

of falls require a multifactorial 

assessment that examines 

the wide range of fallsrelated 

risk factors. 

5. Falls prevention interventions 

should systematically address 

the risk factors identified and 

should be developed with the 

older person with diabetes, and 

where applicable their carer(s). 

Key words 

– Falls 

– Older people 

Authors 

Author details are on page 74. 


Falls prevention in older adults with diabetes 

Page points 

1. Falls risk screening tools need 

to be validated, quick and easy 

to administer, cost-effective and 

clinically relevant. 

2. Falls risk screening should 

be incorporated into routine 

consultations, involving 

assessment of an individual’s 

falls history over the last 

12 months together with 

examination of balance and 

mobility. 

3. When classified as high risk, 

individuals should undergo a 

comprehensive falls assessment 

in a timely manner to guide 

appropriate and individualised 

falls prevention strategies. 

to be validated, quick and easy to administer, 

cost-effective and clinically relevant. The 

selection of a screening tool should complement 

the setting (community, hospital or residential 

aged-care) and the older adult being screened, 

particularly with regard to age, ethnicity, as 

well as cognitive and functional status. 

The Global Guideline for Managing Older 

People with Type 2 Diabetes recommends that 

falls risk screening be performed during an 

initial visit to a health care provider, reviewed 

annually at a minimum and additionally 

following a fall event (IDF, 2013). Falls 

risk screening should be incorporated into 

routine consultations, involving assessment 

of an individual’s falls history over the last 

12 months (frequency of falls, circumstances 

surrounding each fall, and number of injurious 

falls), together with examination of balance 

and mobility. Table 1 provides a summary 

of available tools and tests for use in the 

primary care setting. As with any screening 

procedure, all falls risk screening outcomes 

should be documented and discussed with the 

older person and their carer(s), and information 

provided to individuals. 

Falls risk assessment to identify fallsrisk 

factors 

Falls risk screening identifies individuals at 

high risk of falls. When classified as such, 

individuals should undergo a comprehensive 

falls assessment in a timely manner to guide 

appropriate and individualised falls prevention 

strategies. 

A recommended falls assessment tool can 

be used to assess the overall risk of falls (as 

summarised in Table 2). In addition, specific 

assessment of individual factors known to 

contribute to falls risk among older adults with 

diabetes can be undertaken. It is important to 

acknowledge, that although falls-related risk 

factors are often referred to independently, 

most falls occur as a result of the interaction 

between intrinsic and extrinsic risk factors 

(Tinetti et al, 1986). A description of the 

specific risk factors that are primarily targeted 

for further assessment with older adults with 

diabetes are discussed below with assessment 

and management recommendations provided 

(Australian Commission on Safety and Quality 

in Healthcare, 2009; American Geriatrics 

Society and British Geriatrics Society, 2010). 

Table 1. Summary of validated tools and tests recommended for screening of falls risk. 

Falls risk screen Description Time to implement Scoring interpretation* 

Balance and mobility tests 

Timed Up and Go (TUG) test 

(Podsiadlo and Richardson, 1991) 

A measure of dynamic balance that assesses the time taken for an individual 

to rise from a chair, walk 3 metres, turn around, walk back to the chair, and 

sit down. Requires a stop-watch and a 43 cm-high straight-backed chair 

with solid seat. 

1–2 minutes 

≥12 seconds is indicative of 

an increased risk of falling. 

Five Times Sit To Stand 

(FTSTS) test 

(Tiedemann et al, 2008) 

A measure of lower-limb strength that assesses the time taken for an 

individual to stand up and sit down as quickly as possible five times, with 

their arms folded across their chest. Requires a stop-watch and a 43 cm-high 

straight-backed chair with solid seat. 

1–2 minutes 



Alternate Step Test (AST) 


A measure of lateral stability that involves weight shifting. An individual 

is required to alternately place the right and left feet (no shoes) as fast as 

possible on a step that is 18 cm high and 40 cm deep, for a total of eight 

steps. A stop-watch is required. 

1–2 minutes 



Multi-item screening tool 

Falls Risk for Older People in the 

Community (FROP-Com) Screen 

(Russell et al, 2009) 

A 3-item screening tool that addresses 12-month falls history, self-perceived 

need for assistance to perform activities of daily living, and the objective 

assessment of steadiness through the observation of an individual standing, 

walking a few metres, turning and sitting. 

Available at: http://bit.ly/2m6PXZX 

1–2 minutes 

Responses for each item are 

scored from 0–3. A total 

score between 0–3 indicates 

low-risk. Scores between 

4–9 indicate high-risk. 

*Scoring criterion based on cut-off scores specified within best practice guidelines for falls prevention (Australian Commission on Safety and Quality in Healthcare, 2009). 

Note: Above mentioned tools not specifically validated for older adults with diabetes. 



Table 2. Summary of recommended falls assessment tools. 

Falls assessment tool Description Time to implement Scoring interpretation* 

FallScreen © : Physiological 

Profile Assessment 

(Lord et al, 2003) 

The short form is a validated five-item instrument that includes a single 

assessment of vision, peripheral sensation, lower-limb strength, reaction 

time and body sway. There is an associated cost for the purchase of the 

tool. 

Available at: http://bit.ly/2lYqPU7 

15–20 minutes 

≥1 is indicative of an 

increased risk of falling. 

FROP-Com 

(Russell et al, 2008) 

A detailed falls risk factor assessment tool that includes 26 items that 

address 13 falls-related risk factors. The tool includes guidelines for 

scoring, and evidence-based referrals and interventions. No equipment is 

required and the tool is available at no cost. 

Available at: http://bit.ly/2mFR8mD 

10–15 minutes 

Total score range is 0–60. 

Scores >18 is indicative of 

high risk. 

QuickScreen © 


A multifactorial falls assessment tool comprised of the following items: 

previous falls, medication usage, vision, peripheral sensation, lower-limb 

strength, balance and co-ordination. Minimal equipment is required. There 

is an associated cost for the purchase of the tool. 

Available at: http://bit.ly/2mlM7P5 

10 minutes 

≥4 is indicative of an 

increased risk of falling. 

*Scoring criterion based on cut-off scores specified within best practice guidelines for falls prevention (Australian Commission on Safety and Quality in Healthcare, 2009). 

The above scores should be used for the purpose of assessment and re-assessment over time. 

Note: Above mentioned tools not specifically validated for older adults with diabetes. 

Peripheral neuropathy 

The most common falls-related risk factor related 

to diabetes is peripheral neuropathy, present 

in approximately 50–70% of older adults with 

diabetes (Kirkman et al, 2012). Peripheral 

neuropathy results in changes to the motor 

and/or sensory components of the foot and 

ankle, potentially leading to postural instability, 

foot complications, altered walking function 

and muscle atrophy (Boulton, 2004; Palma et al, 

2013; Brown et al, 2015). Clinical emphasis is 

placed on the prevention of peripheral neuropathy 

by means of optimal glycaemic control, as well as 

the early recognition of the condition (Royal 

Australian College of General Practitioners 

[RACGP], 2016). Peripheral neuropathy should 

be assessed annually using either the Diabetic 

Neuropathy Symptom (DNS) score (Meijer 

et al, 2002) and/or routine sensory tests (i.e. 

a 10-g monofilament and palpating foot). 

Postural instability 

An increase in postural instability is a risk factor 

for falls (Ganz et al, 2007; Drootin, 2011), which 

is particularly important for people with diabetes 

who experience a decrease in the functioning of 

the neuromuscular and sensorimotor systems 

(Crews et al, 2013). Control of balance to 

maintain postural stability involves a complex 

interplay of the sensory and motor systems and 

integration of, and reaction to, this information 

by the central nervous system. 

In the primary care setting, the assessment 

of postural stability can be easily performed 

by balance and mobility tests (e.g. Table 1). 

To address postural instability, falls prevention 

exercise programs are encouraged (Australian 

Commission on Safety and Quality in Healthcare, 

2009; Gillespie et al, 2012). Exercise interventions 

have recently been found to be effective for older 

adults with diabetes with regard to lower-limb 

strength, static balance and gait measures 

(outcomes vital in the maintenance of postural 

stability; Chapman et al, 2016). In particular, 

individuals are likely to benefit from exercise 

programs that incorporate a challenge to balance, 

when delivered with sufficient frequency (e.g. total 

of 50 hours, preferably at least 2 hours per week). 

It should also be noted that walking programs, 

although beneficial for metabolic control and 

improvement of cardiovascular disease risk, have 

been associated with an increased risk of falls 

(Sherrington et al, 2011). Exercise programs 

should be tailored to existing levels of fitness 

and should consider an individual’s lifestyle 

and any medical contraindications. Referral 

to an appropriate health professional (e.g. a 

physiotherapist or exercise physiologist) may be 



Page points 

1. Foot complications, including 

foot pain, foot ulceration and 

consequent amputations, are 

common among older adults 

with diabetes and are significant 

contributors to increased falls 

risk. 

2. Falls risk among adults with 

diabetes has been found to 

increase steadily at four or more 

prescription medications. 

3. It is important that primary care 

practitioners comprehend the 

overall medication burden as 

it has the potential to lead to 

medication-related problems 

including non-adherence, 

hypoglycaemia and increased 

risk of falls. 

warranted for a detailed assessment of balance, 

and the design of challenging, yet safe exercise 

programs (Australian Commission on Safety 

and Quality in Healthcare, 2009). 

Foot complications 

Foot complications, including foot pain, foot 

ulceration and consequent amputations, are 

common among older adults with diabetes and 

are significant contributors to increased falls 

risk (Al-Rubeaan et al, 2015). In brief, foot-care 

education should be provided to all people 

with diabetes to assist in the prevention of foot 

complications. Education should consist of basic 

foot-care recommendations and, of particular 

relevance to falls, advice regarding appropriate 

footwear. Screening and risk stratification for 

potential foot complications should also be 

performed for all adults with diabetes, with the 

intensity of monitoring and review dependent 

on the associated level of risk. For individuals 

classified as being at intermediate or high risk, 

a podiatry assessment is an integral component 

of a foot protection program (Menz et al, 2006; 

R ACGP, 2016). 

Diabetes-related foot ulcers deserve specific 

mention when considering falls risk. Offloading 

footwear is a common recommendation for 

foot ulcers, yet it has a negative effect on 

postural stability (van Deursen, 2008). In 

particular, total contact casts and removable 

or non-removable cast-walkers are problematic 

for falls. Given their rigid nature, they do not 

allow the foot to make its usual adjustments on 

uneven terrain. 

Sub-optimal glycaemic control 

and hypoglycaemia 

Hypoglycaemia, hypoglycaemic unawareness 

and severe hyperglycaemia are well-established 

risk factors for falls among older adults with 

diabetes (Jafari and Britton, 2015; Sinclair et 

al, 2015). Optimising an individual’s glycaemic 

control can reduce short- and long-term 

complications of diabetes, and can improve 

quality of life, and functional and cognitive 

ability. However, the potential harmful effects 

of hypoglycaemia should be considered when 

setting individual glycaemic targets. Targets 

need be personalised and balanced against 

factors such as an individual’s capabilities, 

life expectancy, medical comorbidities, and 

the potential risk of severe hypoglycaemia, 

especially among frail, older adults with an 

increased risk of falls (RACGP, 2016). For older 

adults with diabetes who have a life expectancy 

>10 years and are functionally independent and 

fit, an HbA 1c 

target of 53 mmol/mol (7.0%) is 

often appropriate. However, less stringent HbA 1c 

targets (i.e. 64 mmol/mol [8%]) are appropriate 

for those with long-standing diabetes, a 

history of severe hypoglycaemia, limited life 

expectancy, advanced complications, and/or 

extensive comorbid conditions (RACGP, 2016). 

Medication and polypharmacy 

Older adults with diabetes are often required 

to take multiple medications in an effort to 

control diabetes-related outcomes and other 

comorbidities, and a significant proportion of 

individuals take upwards of eight medications 

(RACGP, 2016). Falls risk among adults with 

diabetes has been found to increase steadily at 

four or more prescription medications (Huang 

et al, 2010). Falls risk can be heightened as a 

result of medication interaction, medication 

side effects (e.g. dizziness) and even the intended 

effects of medications (e.g. glucose-lowering 

leading to hypoglycaemia). Certain classes of 

medication are more likely to increase the risk 

of falls, and those commonly implicated in falls 

related to older people with diabetes include 

insulin, psychoactive medications (in particular 

benzodiazepines), diuretics, antiarrhythmics 

(class 1a), digoxin, and antidepressants (Berlie 

and Garwood, 2010; Huang et al, 2010). 

It is important that primary care practitioners 

comprehend the overall medication burden 

as it has the potential to lead to medicationrelated 

problems including non-adherence, 

hypoglycaemia and increased risk of falls. 

Medication use (both conventional and 

complementary), should be reviewed at least 

once per year as part of the annual cycle of 

care (RACGP, 2016). Referral for a Home 

Medicines Review has the potential to identify 

medications implicated in falls and consider the 

ongoing need for these medications. 



Vision impairment 

Vision impairment is an important risk factor 

for falls in community-dwelling older adults, 

with vision being a key sensory input for the 

maintenance of balance and the avoidance of 

obstacles. Diabetic retinopathy, occurring as 

a result of microvascular disease of the retina, 

causes visual impairment and blindness, and 

affects more than 30% of adults with diabetes 

(Dirani, 2013). 

All older adults with diabetes should have a 

visual acuity assessment at diagnosis, and at least 

every 2 years (more frequently if vision noted to 

have concerns). Primary care practitioners can 

monitor individuals for retinopathy via retinal 

photography or by examining the eyes through 

dilated pupils. If practitioners are not confident 

with fundoscopy and assessment of the retina, 

referral to an eye specialist is recommended. 

Older people may additionally benefit from an 

assessment by an eye specialist for the provision 

of appropriate spectacle correction (RACGP, 

2016). The use of bifocal or multifocal lenses 

by older people in the community is associated 

with a doubled risk of falls as a result of 

tripping. Individuals with an increased risk of 

falls or established falls history are, therefore, 

recommended to wear single-vision distance 

spectacles when walking and negotiating steps 

(Australian Commission on Safety and Quality 

in Healthcare, 2009; Haran et al, 2010). Other 

effective fall prevention strategies for vision 

include maximising vision through cataract 

surgery on the first eye (Lord et al, 2010). 

Cognition 

Cognitive impairment is a risk factor for falls, 

with 50–80% of people with dementia falling 

in a given year (Allan et al, 2009), and mild 

cognitive impairment linked to greater risk of 

injurious and multiple falls (Delbaere et al, 2012). 

There appears to be a crucial link between the 

decline of cognition and the use of executive 

functioning for the purposes of balance, with this 

decline evident in decreasing ability to control and 

integrate cognitive abilities related to attention 

and perception (Liu-Ambrose et al, 2008). People 

with cognitive impairment may have difficulty 

with planning and executing movements related 

to balance and mobility, and may have difficulty 

limiting sensory input which affects attention to a 

task (e.g. walking while talking; Liu-Ambrose et 

al, 2008). Medication use in people with cognitive 

impairment also impacts falls risk, particularly 

psychotropic medications that may magnify side 

effects of other medications (Hill and Wee, 2012). 

There is no specific literature relating falls, 

diabetes and cognitive impairment. There 

is, however, an emerging body of evidence for 

effective falls prevention strategies for people with 

dementia (Drootin, 2011), with studies showing 

“traditional” falls prevention programs to be 

unsuccessful with people with dementia (Shaw 

et al, 2003). However, a different approach to 

adoption of falls prevention strategies may be 

beneficial with elements of health professional 

involvement, inclusion of the caregiving dyad 

and accommodation of individual needs and 

preferences likely to be important (Meyer et al, 

2013). 

Built environment 

Environmental hazards are considered a risk for 

falls: clutter can be a tripping hazard; lighting 

should be sufficient in order to prevent shadows; 

flooring should be clear of rugs and provide a 

contrast to furniture; and bathroom setup needs 

to prevent slippage on wet surfaces, with grab 

rails provided as needed. Home safety assessment 

and modification interventions are effective in 

decreasing falls risk and rates, especially for 

people with severe visual impairment, which is of 

relevance to the person with diabetes (Gillespie et 

al, 2012). 

Adaptation and modification of the environment 

with an occupational therapist who is trained 

to identify and maximise the benefits of the 

person–environment fit is the crucial factor in 

reducing risk (Clemson et al, 2014). Shared 

decision-making processes with the person with 

diabetes, and with their carer(s) if appropriate, will 

most likely enhance the uptake of environmental 

modifications. 

Conclusion 

Reducing the number of falls among older adults 

with diabetes is dependent upon the identification 

of at-risk individuals and the coordination of 

Page points 

1. Vision impairment is an 

important risk factor for falls 

in community-dwelling older 

adults, with vision being a 

key sensory input for the 

maintenance of balance and the 

avoidance of obstacles. 

2. There appears to be a crucial 

link between the decline 

of cognition and the use of 

executive functioning for the 

purposes of balance. 

3. Environmental hazards are 

considered a risk for falls, and 

efforts should be made to avoid 

them where possible. 



“All primary care 

practitioners should 

have access to 

education about 

falls prevention, and 

every attempt should 

be made to provide 

comprehensive 

and individualised 

education about falls 

to older adults with 

diabetes and where 

appropriate, their 

caregivers and family.” 

Authors 

Anna Chapman, Research Fellow, 

School of Primary Health Care, 

Monash University, Melbourne, Vic; 

Claudia Meyer, Research Fellow, 

Centre for Health Communication, 

School of Public Health and Human 

Biosciences, La Trobe University, 

Melbourne, Vic. Both are at the 

RDNS Institute, St Kilda, Vic. 

appropriate preventive strategies. A diagnosis 

of diabetes in an older adult should trigger to 

primary care practitioners the potential for 

increased falls risk. Systems need to be established 

in the diabetes care pathway to enable falls 

risk screening to be performed annually. All 

primary care practitioners should have access 

to education about falls prevention, and every 

attempt should be made to provide comprehensive 

and individualised education about falls to older 

adults with diabetes and where appropriate, their 

caregivers and family. 

n 

Al-Rubeaan K, Al Derwish M, Ouizi S et al (2015) Diabetic foot 

complications and their risk factors from a large retrospective 

cohort study. PLoS ONE 10: e0124446 

Allan L, Ballard C, Rowan E, Kenny R (2009) Incidence and prediction 

of falls in dementia: A prospective study in older people. PLoS ONE 

4: e5521 

American Geriatrics Society & British Geriatrics Society (2010) 

Prevention of Falls in Older Persons: AGS/BGS Clinical Practice 

Guideline. AGS/BGS 

Australian Commission On Safety And Quality In Healthcare (2009) 

Preventing falls and harm from falls in older people: Best practice 

guidelines for Australian community care. ACSQHC, Canberra, 

ACT 

Berlie HD, Garwood CL (2010) Diabetes medications related to an 

increased risk of falls and fall-related morbidity in the elderly. Ann 

Pharmacother 44: 712–7 

Boulton AJ (2004) The diabetic foot: from art to science. The 18th 

Camillo Golgi lecture. Diabetologia 47: 1343–53 

Bradley C (2012) Hospitalisations due to falls in older people, Australia 

2008-09. Australian Institute for Health and Welfare, Canberra, 

ACT. Available at: http://bit.ly/2mlESXq (accessed 08.03.17) 

Brown SJ, Handsaker JC, Bowling FL et al (2015) Diabetic peripheral 

neuropathy compromises balance during daily activities. 

Diabetes Care 38: 1116–22 

Chapman A, Meyer C, Renehan E et al (2016) Exercise interventions 

for the improvement of falls-related outcomes among older adults 

with diabetes mellitus: A systematic review and meta-analyses. 

J Diabetes Complications 31: 631–45 

Clemson L, Donaldson A, Hill K, Day L (2014) Implementing personenvironment 

approaches to prevent falls: a qualitative inquiry in 

applying the Westmead approach to occupational therapy home 

visits. Aust Occup Ther J 61: 325–34 

Crews R, Yalla S, Fleischer A, Wu S (2013) A growing troubling triad: 

diabetes, aging, and falls. J Aging Res 2013: 342650 

Delbaere K, Kochan NA, Close JC et al (2012) Mild cognitive 

impairment as a predictor of falls in community-dwelling older 

people. Am J Geriatr Psychiatry 20: 845–53 

Dirani M (2013) Out of sight: A report into diabetic eye disease in 

Australia. Baker IDI Heart and Diabetes Institute and Centre for Eye 

Research Australia, Australia 

Drootin M (2011) Summary of the updated American Geriatrics 

Society/British Geriatrics Society clinical practice guideline for 

prevention of falls in older persons. J Am Geriatr Soc 59: 148–57 

Ganz D, Bao Y, Shekelle P, Rubenstein L (2007) Will my patient fall? 

JAMA 297: 77–86 

Gillespie L, Robertson M, Gillespie W et al (2012) Interventions for 

preventing falls in older people living in the community. Cochrane 

Database Syst Rev 12: CD007146 

Haran MJ, Cameron ID, Ivers RQ et al (2010) Effect on falls of 

providing single lens distance vision glasses to multifocal glasses 

wearers: VISIBLE randomised controlled trial. BMJ 340: c2265 

Hill K, Wee R (2012) Psychotropic drug-induced falls in older people: 

A review of interventions aimed at reducing the problem. Drugs 

Aging 29: 15–30 

Huang ES, Karter AJ, Danielson KK et al (2010) the association 

between the number of prescription medications and incident falls 

in a multi-ethnic population of adult type-2 diabetes patients: The 

Diabetes and Aging Study. J Gen Intern Med 25: 141–6 

International Diabetes Federation (2013) IDF Global Guideline for 

Managing Older People with Type 2 Diabetes. International 

Diabetes Federation, Brussels, Belgium 

Jafari B, Britton ME (2015) Hypoglycaemia in elderly patients with 

type 2 diabetes mellitus: a review of risk factors, consequences and 

prevention. J Pharmacy Practice Research 45: 459–69 

Karinkanta S, Piirtola M, Sievanen H et al (2010) Physical therapy 

approaches to reduce fall and fracture risk among older adults. 

Nature Reviews Endocrinology 6: 396–407 

Kirkman MS, Briscoe VJ, Clark N et al (2012) Diabetes in older adults. 

Diabetes Care 35: 2650–64 

Liu-Ambrose T, Ahamed Y, Graf P et al (2008) Older fallers with poor 

working memory overestimate their postural limits. Arch Phys Med 

Rehabil 89: 1335–40 

Lord SR, Menz HB, Tiedemann A (2003) A physiological profile 

approach to falls risk assessment and prevention. Phys Ther 83: 

237–52 

Lord SR, Smith ST, Menant JC (2010) Vision and falls in older people: 

Risk factors and intervention strategies. Clinics Geriatr Med 26: 

569–81 

Meijer JW, Smit AJ, Sonderen EV et al (2002) Symptom scoring 

systems to diagnose distal polyneuropathy in diabetes: the Diabetic 

Neuropathy Symptom score. Diabet Med 19: 962–5 

Menz G, Morris M, Lord S (2006) Foot and ankle risk factors for falls 

in older people: a prospective study. J Gerontol A Biol Sci Med Sci 

61: 866–70 

Meyer C, Hill S, Dow B et al (2013) Translating falls prevention 

knowledge to community-dwelling older PLWD: A mixed-method 

systematic review. Gerontologist 55: 560–74 

Moyer VA (2012) Prevention of falls in community-dwelling older 

adults: U.S. Preventive Services Task Force recommendation 

statement. Ann Intern Med 157: 197–204 

Palma F, Antigual D, Martinez S et al (2013) Static balance in patients 

presenting diabetes mellitus type 2 with and without diabetic 

polyneuropathy. Arch Endocrinol Metab 57: 722–6 

Pijpers E, Ferreira I, De Jongh R et al (2012) Older individuals 

with diabetes have an increased risk of recurrent falls: analysis 

of potential mediating factors: the Longitudinal Ageing Study 

Amsterdam. Age Ageing 41: 358–65 

Podsiadlo D, Richardson S (1991) The Timed “Up & Go”: A test of 

basic functional mobility for frail elderly persons. J Amer Geriatr 

Soc 39: 142–8 

Roman De Mettelinge T, Cambier D, Calders P et al (2013) 

Understanding the relationship between type 2 diabetes mellitus 

and falls in older adults: A Prospective Cohort Study. PLoS ONE 8: 

e67055 

Royal Australian College Of General Practitioners (2016) General 

practice management of type 2 diabetes: 2016-18. RACGP, East 


Russell MA, Hill KD, Blackberry I et al (2008) The reliability and 

predictive accuracy of the falls risk for older people in the 

community assessment (FROP-Com) tool. Age Ageing 37: 634–9 

Russell MA, Hill KD, Day L et al (2009) Development of the Falls Risk 

for Older People in the Community (FROP-Com) screening tool. 

Age Ageing 38: 40–6 

Shaw F, Bond J, Richardson D et al (2003) Multifactorial intervention 

after a fall in older people with cognitive impairment and 

dementia presenting to the accident and emergency department: 

Randomised controlled trial. BMJ 326: 

Sherrington C, Tiedemann A, Fairhall N et al (2011) Exercise to prevent 

falls in older adults: An updated meta-analysis and best practice 

recommendations. N S W Public Health Bull 22: 78–83 

Sinclair A, Dunning T, Rodriguez-Mañas L (2015) Diabetes in older 

people: new insights and remaining challenges. Lancet Diabetes 

Endocrinol 3: 275–85 

Tiedemann A, Shimada H, Sherrington C et al (2008) The comparative 

ability of eight functional mobility tests for predicting falls in 

community-dwelling older people. Age Ageing 37: 430–5 

Tinetti ME, Franklin Williams T, Mayewski R (1986) Fall risk index for 

elderly patients based on number of chronic disabilities. Am J Med 

80: 429–34 

van Deursen, R (2008) Footwear for the neuropathic patient: 

offloading and stability. Diabetes Metab Res Rev 24: S96–S100 

Zijlstra GAR, Van Haastregt JC, Van Rossum E et al (2007) 

Interventions to reduce fear of falling in community-living older 

people: A systematic review. J Am Geriatr Soc 55: 603–15 


Article 

The effect of diabetes on the skin 

before and after ulceration 

Lesley Weaving, Roy Rasalam 

Diabetes affects the skin in many different ways at a microcirculatory level, making it 

more prone to injury and ulceration. These changes not only have an impact on healing 

but also on the resulting scar tissue, which is not as strong as the skin was prior to injury. 

Eight-five percent of amputations are preceded by ulceration, with re-ulceration rates 

reported to be as high as 70% after 5 years. This article looks at the changes that occur 

in the skin of people with diabetes and the importance of skin care before and after 

ulceration. 

A 

history of ulceration is considered 

to be a significant risk factor for 

re-ulceration, and as such, people 

with diabetes are classed as high risk if they 

have a history of foot ulceration (National 

Institute for Health and Care Excellence, 

2015). Australia’s amputation rate as a result 

of diabetes appears to have increased in the 

last decade and is a major contributor to the 

national burden of condition (Lazzarini et al, 

2012). Eighty-five per cent of amputations are 

preceded by ulcers (International Diabetes 

Federation, 2016); therefore, the prevention of 

re-ulceration is an important consideration in 

reducing amputation rates. Varying rates of reulceration 

have been reported in the literature, 

but the rate of re-ulceration is known to 

increase over time from initial ulceration; 

Miller et al (2014) reported 34% re-ulceration 

at 1 year, 61% at 3 years and 70% at 5 years. 

A critical triad of neuropathy, minor foot 

trauma and foot deformity is present in >63% 

of patients’ causal pathways to foot ulceration 

(Reiber et al, 1999). There are many reasons 

that determine whether people with diabetes 

develop ulcers, including their vascular 

status, nutritional status and compliance with 

preventative therapies, such as custom-made 

shoes or insoles (Miller et al, 2014). Despite 

these interventions, one study has reported a 

30% re-ulceration rate over a 2-year period, 

during which individuals received regular 

podiatric review (Westphal et al, 2011). With 

this in mind, do we need to consider other 

factors, such as the health of the skin? What is 

the effect of ulceration on the skin during and 

after healing, and does it play a role in the risk 

of re-ulceration? 

The skin 

The skin is the largest organ of the body. 

Its main functions are to act as a barrier 

to substances entering the body and in the 

prevention of moisture loss. It helps to regulate 

temperature and provides sensory information 

(e.g. pain, touch and temperature). It has 

three layers: the epidermis, the dermis and a 

fat (subcutaneous) layer (see Figure 1). The 

epidermis is the thin outer layer, made of five 

layers. The outermost layer is the stratum 

corneum, which consists of dead cells and is the 

major barrier to chemical and bacterial transfer 

through the skin. The epidermis is thicker on 

the plantar aspect of the foot and is relatively 

waterproof. The second layer of the skin is the 

dermis, which contains nerve endings, sweat 

glands, oil (sebaceous) glands, hair follicles 

and blood vessels. It consists of a thick layer 

of fibrous and elastic tissue, giving the skin its 

flexibility and strength. Below the dermis is a 

Citation: Weaving L, 

Rasalam R (2017) The effect 

of diabetes on the skin before 

and after ulceration. Diabetes & 



1. People with diabetes 

are more prone to skin 

injury and ulceration. 

2. Diabetes impairs the 

skin’s ability to heal. 

3. Scar tissue is not as strong as 

the tissue was before injury. 

4. Skin should be kept in the 

best condition possible to 

prevent re-ulceration. 

Key words 

– Healing 

– Re-ulceration 

– Scar tissue 

– Skin 

Authors 

Lesley Weaving is diabetes 

specialist podiatrist, Leicestershire 

Partnership Trust, Coalville 

Community Hospital, Coalville, 

Leicestershire, UK; Roy Rasalam 

is Director of Clinical Studies, 

College of Medicine, James Cook 

University, Qld, Australia. 


The effect of diabetes on the skin before and after ulceration 

80% of the tensile strength of normal skin 

(Ousey, 2009). Many factors play a role in 

how closely the healed skin resembles the 

original uninjured tissue, including the size, 

depth and location of the wound, as well as 

the nutritional status and overall health of the 

individual (Teller and White, 2009). 

Figure 1. Cross-section through the skin. 

Page points 

1. Skin conditions, such as 

infection, xerosis and 

psoriasis, are common in 


2. Regular moisturising of dry skin 

is recommended as part of a 

routine foot care regimen. 

3. Scar tissue is not as strong 

as the original uninjured 

tissue and so is at increased 

risk of damage. 

subcutaneous layer of fat that helps insulate the 

body from heat and cold, provides protective 

padding and serves as an energy store (Health 

and Safety Executive, 2016). 

The healing process 

When the skin is damaged, a complex healing 

process takes place that can be divided 

into four phases (Box 1). The final stage 

of healing, maturation, lasts from 21 days 

to 2 years. During this process, epithelial 

cells reduce the size of the wound. This is 

followed by re-organisation of the collagen 

by macrophages to form a scar (Brown, 2015). 

In healthy individuals, the resulting scar 

tissue formed after injury has approximately 

Box 1. The wound healing process. 

l Vascular response (haemostasis): injured 

vessels constrict, a clot forms consisting 

of a fibrin mesh that forms a scab, and 

vasodilation of the vessels commences. 

l Inflammation: occurs in acute wounds 

3–5 days after injury and is prolonged in 

chronic wounds. 

l Proliferation: collagen fibres form to 

replace lost tissue. 

l Maturation: in healthy individuals, this 

stage commences 21 days after injury. 

Scarring develops, and the new tissue is 

avascular and contains no hair, sebaceous 

or sweat glands. 

The effect of diabetes on skin healing 

Diabetes can affect the skin in different 

ways. Autonomic neuropathy is a common 

complication of diabetes leading to dry 

skin, loss of sweating and the subsequent 

development of fissures and cracks that break 

the skin barrier, allowing microorganisms to 

enter (Vinik et al, 2003). 

It is now understood that a complex 

relationship exists between sensory 

nerve function and vascular response in 

type 2 diabetes. Dermal neurovascular 

function is regulated by peripheral 

C fibre neurons, which are damaged in 

diabetic neuropathy. This results in an 

imbalance between vasodilators (nitric 

oxide, substance P, and calcitonin generelated 

peptide) and vasoconstrictors 

(angiotensin II and endothelin). This 

dysregulation leads to decreased pain and 

warm thermal perception, leaving skin 

vulnerable to heat and tissue injury (Vinik et 

al, 2001). 

It has also been demonstrated that there is 

a reduced oxygen supply within the tissue of 

people with diabetes, which is accentuated 

in the presence of neuropathy (Greenman 

et al, 2005). Other skin conditions are also 

commonly seen in people with diabetes, 

the prevalences of which are reported to be 

between 30% and 91.2% (Demirseren et al, 

2014). The most frequently reported skin 

condition in people with diabetes is cutaneous 

infection (mainly fungal), followed by xerosis 

(dry skin) and inflammatory skin diseases 

such as psoriasis (Figure 2). These conditions 

are more common in people with diabetes 

who have nephropathy than in those without 

nephropathy, and those who have an HbA 1c 

of >64 mmol/mol (8%) are at the greatest risk 

(Demirseren et al, 2014). 



Figure 2. Psoriasis is one of the most common skin 

conditions experienced by people with diabetes. 

Vascular endothelial cells line the entire 

circulatory system, from the heart to 

capillaries. These cells are important for 

vascular biology and become impaired not only 

with age but also as a result of hyperglycaemia, 

which results in the impairment of blood flow 

to the tissues (Petrofsky, 2011). When pressure 

is applied to healthy skin, the affected tissue 

can become hypoxic; once the pressure is 

released there is reactive hyperaemia (increase 

in blood flow) to oxygenate the tissue. Vascular 

endothelial dysfunction can diminish this 

response. It has also been demonstrated that 

in a standing position, the average person still 

has circulation in the skin but in people with 

diabetes (even those with normal weight) there 

is occlusion to the skin (McLellan et al, 2009). 

This occlusion, together with reduced or no 

post-occlusive hyperaemia, may be the reason 

that feet are so susceptible to wounds and 

skin injury, particularly in people with type 2 

diabetes (Petrofsky, 2011). 

Emollients 

Regular moisturising of dry skin is 

recommended as part of a routine foot care 

regimen to reduce the risk of cracking and 

ulceration. What is not always clear is which 

emollient to use. There is little evidence 

available as to the most effective emollient, 

not only for the general population, but also 

for people with diabetes. A moisturiser that 

the patient is willing or happy to use that 

is supported by the available evidence is 

preferable. The clinician should also check 

that the patient likes the smell, texture and 

absorption of the cream before recommending 

or prescribing one. There is some evidence 

that high-concentration, urea-based emollients 

are beneficial, and these have been shown to 

improve dryness on the feet of people with 

diabetes (Bristow, 2013). 

For twice-a-day application, it is 

recommended that an emollient is applied just 

before getting into bed. Covering the foot with 

a damp undersock and then a dry oversock may 

enhance the effect of the emollient (Bristow, 

2013). For once-a-day application, the cream 

should form part of a patient’s daily regimen 

of washing, drying and checking their feet 

thoroughly. It is recommended that emollients 

be used to lubricate the skin, but not between 

the toes (International Working Group on 

the Diabetic Foot, 2015). A pump dispenser 

is considered by some clinicians a more userfriendly 

way of delivering the right amount of 

emollient than a tub and also decreases the risk 

of contamination (Carr et al, 2008), although 

tubes are also commonly used. 

Silicones 

Once skin has healed, silicone gel has been 

proven to be effective in scar-tissue management 

on non-weight-bearing areas; however there 

is little evidence to support its use on weightbearing 

areas (Westphal et al, 2011). Figure 3 

and Figure 4 demonstrate that silicone gel may 

be useful in protecting newly healed skin 

during the maturation process. A person with 

type 2 diabetes who suffered from psoriasis 

had developed ulceration and subsequent 

osteomyelitis at the base of the fifth metatarsal 

Page points 

1. Regular moisturising of dry 

skin is recommended as 

part of a routine foot-care 

regimen to reduce the risk 

of cracking and ulceration. 

2. Once skin has healed, 

silicone gel has been proven 

to be effective in scar-tissue 

management on non-weightbearing 

areas; however there 

is little evidence to support its 

use on weight-bearing areas. 



Page points 

1. There are many factors 

affecting a person’s skin 

when they have diabetes. 

2. From available evidence, the 

healing of a diabetic foot ulcer 

should not be considered 

the end result of a patient’s 

journey, but the beginning of 

a process to remain healed. 

3. Further research is required 

on the most-effective 

way to care for the skin of 


head, which had healed well with the use of 

a removable cast device. However, once they 

returned to wearing their bespoke shoes with 

total contact insole, the skin re-ulcerated 

(Figure 3). Silicone sheeting was used to protect 

the area once epithelisation was achieved and for 

8 weeks afterwards, and no further ulceration 

occurred during this time (Figure 4). This 

suggests that the silicone sheeting provided 

some protection to the newly healed skin during 

the early stages of the maturation process 

(Weaving, 2014). However, a pilot study of 

30 people with diabetes found that silicone gel 

sheeting did not reduce the risk of ulceration 

(Westphal, 2011). 

Why it’s important to keep the 

skin healthy 

There are many factors affecting a person’s skin 

when they have diabetes. These factors can lead 

to ulceration and contribute to delayed healing. 

Poor glycaemic control of diabetes has been 

shown to affect the microcirculation, along 

with poor oxygen supply, occlusion in the skin 

during weight bearing, changes to the vascular 

endothelial cells, dry skin and reduction in 

elasticity all putting the skin at greater risk 

of injury. This is further complicated by the 

reduced strength of the scar tissue that forms 

after the ulcer has healed. 

Eighty per cent of ulcers are caused by some 

form of trauma and are, therefore, considered 

to be preventable (Healy et al, 2013). While 

custom-made footwear is used to prevent 

re-ulceration, it appears to be most effective for 

those with foot deformity (Reiber et al, 2002). 

Not every insole or shoe is a perfect fit to each 

patient’s foot (Miller et al, 2014). It is therefore 

important that the skin on the foot is kept in the 

best condition it can be to cope with the stresses 

placed upon it, whether it is from shoe wear or 

simple day-to-day weight-bearing activities. 

Conclusion 

There is little evidence on how best to look 

after the skin of people with diabetes. From 

the available evidence, the healing of a diabetic 

foot ulcer should not be considered the end 

result of a patient’s journey, but the beginning 

Figure 3. A patient with type 2 diabetes and psoriasis 

experienced re-ulceration after changing from a 

removable cast device back to their bespoke shoes. 

Figure 4. The patient continued to use silicone sheeting 

for 8 weeks after the ulcer had healed, which prevented 

re-ulceration. 

of a process to remain “healed”. We want 

patients to be active and keep mobile to 

help with their overall health and wellbeing; 

however, the impact of diabetes on their skin 

makes them vulnerable to skin breakdown, 

particularly where there is scar tissue from 

previous ulceration. Further research is 

required on the most-effective way to care 

for the skin of people with diabetes not just 

when dry, but also post-healing during the 

maturation process when the stresses and 

strains of simple weight bearing could lead 

to re-ulceration and, subsequently, potential 



loss of a limb. This is a worthwhile endeavour 

when we consider that every 30 seconds a 

lower limb is lost somewhere in the world as a 

consequence of diabetes (Boulton et al, 2005). 

 

n 


This article has been modified from one 

previously published in The Diabetic Foot Journal 

(2016, 3: 142–8). 

Lazzarini PA, Gurr JM, Rogers JR et al (2012) Diabetes foot 

disease: the Cinderella of Australian diabetes management? 

J Foot Ankle Res 5: 24 

McLellan K, Petrofsky JS, Zimmerman G et al (2009) The 

influence of environmental temperature on the response 

of the skin to local pressure: the impact of aging and 

diabetes. Diabetes Technol Ther 11: 791–8 

Miller JD, Salloum M, Button A et al (2014) How can I 

maintain my patient with diabetes and history of foot ulcer 

in remission? Int J Low Extrem Wounds 13: 371–7 

“This is a worthwhile 

endeavour when we 

consider that every 

30 seconds a lower 

limb is lost somewhere 

in the world as a 

consequence of 

diabetes.” 

Boulton AJ, Vilikyte L, Ragnarson-Tennvall G et al (2005) 

The global burden of diabetic foot disease. Lancet 366: 

1719–24 

National Institute for Health and Care Excellence (2015) 

NICE guideline 19. Diabetic foot problems: prevention 

and management. NICE, London, UK. Available at: www. 

nice.org.uk/guidance/ng19 (accessed 02.09.2016) 

Bristow I (2013) Emollients in the care of the diabetic foot. 

The Diabetic Foot Journal 16: 61–6 

Ousey K (2009) Chronic wounds – an overview. J Commun 

Nursing 21: 4–9 

Brown A (2015) Wound management 1: Phases of the wound 

healing process. Nursing Times 111: 12–3 

Carr J, Akram M, Sultan A et al (2008) Contamination of 

emollient creams and ointments with Staphylococcus 

aureus in children with atopic dermatitis. Dermatitis 19: 

282 

Demirseren DD, Emre S, Akoglu G et al (2014) Relationship 

between skin diseases and extracutaneous complications 

of diabetes mellitus: clinical analysis of 750 patients. 

Am J Dermatol 15: 65–70 

Greenman RL, Panasyuk S, Wang X et al (2005) Early 

changes in the microcirculation and muscle metabolism 

of the diabetic foot. Lancet 366: 1711–5 

Healy A, Naemi R, Chockalingam N (2013) The effectiveness 

of footwear as an intervention to prevent or to reduce 

biomechanical risk factors associated with diabetic foot 

ulceration: a systematic review. J Diabetes Complications 

27: 391–400 

Petrofsky JS (2011) The effect of type-2-diabetes-related 

vascular endothelial dysfunction on skin physiology and 

activities of daily living. J Diabetes Sci Technol 5: 657–67 

Reiber GE, Vileikyte L, Boyko EJ et al (1999) Causal pathways 

for incident lower-extremity ulcers in patients with diabetes 

from two settings. Diabetes Care 22: 157–62 

Reiber GE, Smith DG, Wallace C et al (2002) Effect of 

therapeutic footwear on foot reulceration in patients 

with diabetes. A randomised controlled trial. JAMA 287: 

2552–8 

Teller P, White TK (2009) The physiology of wound healing: 

injury through maturation. Surg Clin North Am 89: 599– 

610 

Vinik AI, Erbas T, Park TS (2001) Dermal neurovascular 

dysfunction in type 2 diabetes. Diabetes Care 24: 1468–75 

Health and Safety Executive (2016) Structure and 

functions of the skin. HSE, London, UK. Available at: 

http://bit.ly/ZIW36y (accessed 02.09.16) 

Vinik AI, Maser RE, Mitchell BD, Freeman R (2003) Diabetic 

autonomic neuropathy. Diabetes Care 26: 1553–66 

International Diabetes Federation (2016) Diabetes 

and the Foot. IDF, Brussels, Belgium. Available at: 

http://bit.ly/2cUTPJB (accessed 13.09.16) 

Weaving L (2014) KerraPro pressure reducing pads 

in preventing pressure ulceration. Harrogate 2014 

Conference Posters. Harrogate, Wounds UK, UK. Available 

at: http://bit.ly/2m75Rab (accessed 02.09.16) 

International Working Group on the Diabetic Foot (2015) 

Prevention and management of foot problems in diabetes: 

a Summary Guidance for daily practice 2015. IWGDF 

Guidance documents. IDF, Brussels, Belgium. Available at: 

http://bit.ly/2kLpS69 (accessed 22.02.16) 

Westphal C, Neame IM, Harrison JC, et al (2011) A diabetic 

foot ulcer pilot study: does silicone gel shee ting reduce 

the incidence of reulceration? J Am Podiatr Med Assoc 

101: 116–23 


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

DPCA2-2_issue

Create successful ePaper yourself

Delete template?

Save as template?