What are the Australian guidelines for the management of diabetes?

Australian Guidelines for Diabetes Management

While the evidence provided primarily references American Diabetes Association and international guidelines rather than specific Australian diabetes management guidelines, the core principles of diabetes management are consistent across developed healthcare systems, with Australian practice aligning closely with these evidence-based recommendations.

Initial Assessment and Diagnosis

• Check for ketosis/ketoacidosis, random blood glucose levels, and HbA1c to determine diabetes type and severity 1
• Test for pancreatic autoantibodies to differentiate between type 1 and type 2 diabetes 1
• For patients with HbA1c ≥8.5% or random glucose ≥250 mg/dL with symptoms, or presence of ketosis, initiate insulin therapy immediately 1

Lifestyle Interventions as Foundation

All patients with diabetes must receive comprehensive diabetes self-management education focusing on healthy eating patterns and physical activity as the cornerstone of treatment 2

Physical Activity Requirements

• Perform at least 150 minutes per week of moderate-intensity aerobic activity (50-70% maximum heart rate), spread over at least 3 days with no more than 2 consecutive days without exercise 3
• Add resistance training at least twice per week 3
• Reduce sedentary time throughout the day 2

Nutritional Management

• Provide individualized medical nutrition therapy (MNT) by a registered dietitian familiar with diabetes MNT components 3
• Focus on nutrient-dense, high-quality foods while decreasing calorie-dense, nutrient-poor foods 2
• Target 5% weight loss for all overweight or obese individuals 3
• Choose from low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets—all are effective for weight loss up to 2 years 3
• For low-carbohydrate diets specifically, monitor lipid profiles, renal function, and protein intake (especially in nephropathy patients), and adjust hypoglycemic therapy accordingly 3

Specific Dietary Targets

• Limit dietary fat and saturated fat to less than 30% and 10% of energy intake respectively 2
• Consume at least 15 g/1000 kcal dietary fiber 2
• Reduce sodium to less than 2,300 mg/day 3
• If consuming alcohol, limit to one drink per day for women and two drinks per day for men, with extra precautions to prevent hypoglycemia 3

Pharmacologic Management for Type 2 Diabetes

First-Line Therapy

Initiate metformin at or soon after diagnosis if not contraindicated, starting at 500 mg daily, increasing by 500 mg every 1-2 weeks up to 2,000 mg daily in divided doses 2, 1

When to Use Insulin First Instead of Metformin

• Ketosis or diabetic ketoacidosis present 2
• Random blood glucose ≥250 mg/dL 2
• HbA1c >9% (>75 mmol/mol) 2
• Severe hyperglycemia with catabolism 2
• Symptomatic diabetes with polyuria, polydipsia, and weight loss 2

For insulin initiation, begin with basal insulin at 0.5 units/kg/day and titrate based on blood glucose monitoring 1

Treatment Intensification Algorithm

When metformin monotherapy at maximum tolerated dose fails to achieve or maintain HbA1c target over 3 months, add a second agent 2, 1:

• SGLT-2 inhibitors 2
• GLP-1 receptor agonists 2, 1
• Sulfonylureas 2
• Thiazolidinediones 2
• DPP-4 inhibitors 2
• Basal insulin 2

Glycemic Targets and Monitoring

• Target HbA1c <7% for most adults, with more stringent targets (such as <6.5%) for selected individuals 2, 1
• Monitor HbA1c every 3 months until target is reached, then at least twice yearly 2, 1
• Individualize blood glucose monitoring plans based on pharmacologic treatment 1
• Consider continuous glucose monitoring for patients on multiple daily insulin injections 1

Hypoglycemia Management

• Treat conscious individuals with hypoglycemia using 15-20 g of glucose (preferred treatment), though any carbohydrate containing glucose may be used 3, 2
• Recheck blood glucose 15 minutes after treatment; if hypoglycemia continues, repeat treatment 3
• Once blood glucose returns to normal, consume a meal or snack to prevent recurrence 3
• Prescribe glucagon for all individuals at significant risk of severe hypoglycemia, and train caregivers or family members in its administration 3
• For patients with hypoglycemia unawareness or one or more episodes of severe hypoglycemia, raise glycemic targets to strictly avoid further hypoglycemia for at least several weeks 3

Psychosocial Care

• Include assessment of psychological and social situation as ongoing part of medical management 3
• Screen for depression, diabetes-related distress, anxiety, eating disorders, and cognitive impairment when self-management is poor 3
• Address psychosocial issues in diabetes self-management education, as emotional wellbeing is associated with positive diabetes outcomes 3

Bariatric Surgery Consideration

• Consider bariatric surgery for adults with BMI >35 kg/m² and type 2 diabetes, especially if diabetes or associated comorbidities are difficult to control with lifestyle and pharmacologic therapy 3

Multidisciplinary Team Approach

• Establish an interprofessional diabetes team including a physician, diabetes care and education specialist, registered dietitian nutritionist, and behavioral health specialist or social worker 1

Australian Context

The Sydney Diabetes Prevention Program demonstrated successful community-based translational implementation in Australia, showing that lifestyle modification programs can be effectively delivered through primary care settings 4. The Victorian Life! program further validated large-scale diabetes prevention implementation in Australia, with participants completing the 8-month program achieving average weight loss of 2.4 kg (2.7% of starting body weight) 5.