Individual care plan

• At the time of a confirmed diagnosis of type 1 diabetes, the diabetes specialist team should develop with the person an individualized care plan. This aims to:
  • Confirm an accurate diagnosis of type 1 diabetes. 
  • Ensure that appropriate acute care is given when needed.
  • Review and assess for concomitant medical conditions, complications, and medications that may affect the person's type 1 diabetes.
  • Assess the person's social, home, and work situation, including nutrition, exercise and physical activity, and lifestyle factors such as substance use. 
  • Assess the person's cultural and educational background, including knowledge about diabetes and to enable optimal advice about treatment options and diabetes education programmes.
  • Assess the person's emotional state and well-being to provide an appropriate pace of education. 
• An initial diabetes assessment should include:
  • Medical history, including diabetes and other conditions.
  • Social, cultural, and educational history and lifestyle review.
  • History of any symptoms and complications.
  • Family history of diabetes or cardiovascular disease.
  • Medications.
  • Cardiovascular risk factors, including smoking status. See the section on Managing cardiovascular risk for more information.
  • Psychological and emotional wellbeing.
  • Attitudes to medication and self-care.
  • Immediate family and social relationships and support. 
  • General examination; weight and body mass index (BMI); blood pressure; foot, eye and vision check.
  • Urine albumin creatinine ratio (ACR) and serum creatinine, estimated glomerular filtration rate (eGFR), full lipid profile, thyroid function tests, and coeliac screen.
• An individual and culturally appropriate care plan for the person with type 1 diabetes should include:
  • Diabetes education (including site and time of diabetes education and nutrition advice).
  • Insulin therapy (including insulin injections, regimens, and dose adjustment) and self-monitoring of blood glucose. See the CKS topic on Insulin therapy in type 1 diabetes for more information.
  • Treatment targets. See the section on Target HbA1c for more information.
  • Hypoglycaemia (symptoms, avoidance, maintaining awareness, risk factors, and management). See the section on Suspecting hypoglycaemia and the CKS topic on Insulin therapy in type 1 diabetes for more information.
  • Management of special situations such as driving, fasting, shift work, exercise and physical activity, holidays and travel. See the section on Lifestyle advice and the CKS topic on Insulin therapy in type 1 diabetes for more information.
  • Management of diabetes during intercurrent illness. See the section on Managing intercurrent illness for more information.
  • Cardiovascular risk factor monitoring and management. See the section on Managing cardiovascular risk for more information.
  • Complications monitoring and management. See the section on Regular review and monitoring for more information.
  • How to contact the diabetes specialist team, including during working hours and out of hours, if appropriate.
  • The frequency and content of follow-up appointments, including review of HbA1c levels and targets, assessment of any hypoglycaemia episodes, and the next annual review.
  • Contraception and pregnancy planning advice, if appropriate. See the CKS topic on Pre-conception - advice and management and the National Institute for Health and Care Excellence (NICE) guideline on Diabetes in pregnancy: management from preconception to the postnatal period for more information.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024a] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023c], the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], and the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication Sick day management in children and adolescents with diabetes [Phelan, 2022].

Offering a structured diabetes education programme

• These recommendations are largely based on the NICE guideline on adults [NICE, 2024a], and are supported by the ADA/EASD consensus report [Holt, 2021].
  • The NICE guideline states that a structured diabetes education programme has specific aims and learning objectives, and supports the person and their relatives/carers to develop attitudes, beliefs, knowledge, and skills to help self-manage diabetes. It suggests offering an education programme 6–12 months after diagnosis of type 1 diabetes, as the first few months post-diagnosis are a period of considerable adjustment for the person and relatives/carers. The guideline committee felt that engaging in intensive education at this early stage may be less worthwhile and potentially counterproductive.  
  • The ADA/EASD consensus report recommends offering diabetes self-management education and support to people with type 1 diabetes and relatives/carers, to provide the knowledge, skills, and confidence to successfully self-manage diabetes on a daily basis and reduce the risks of acute and long-term complications, while empowering them and maintaining their quality of life. In particular, it notes that structured education programmes which provide informed support for active insulin dose self-adjustment are important for the prevention of hypoglycaemia.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Type 1 diabetes in adults: diagnosis and management [NICE, 2024a] and the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021].

Frequency of HbA1c measurement

• These recommendations are largely based on the NICE guideline on adults, which noted a lack of evidence in the literature on the optimal frequency of HbA1c testing [NICE, 2024a].
• The ADA/EASD consensus report recommends monitoring blood glucose levels at least every 3 months if a person's treatment has changed or if they are not meeting blood glucose targets [Holt, 2021].

HbA1c treatment targets

• These recommendations are largely based on the NICE guideline on adults [NICE, 2024a] and are supported by the ADA/EASD consensus report [Holt, 2021].
  • Low-quality evidence identified by the NICE guideline showed that lowering the HbA1c towards the non-diabetic range with intensified insulin therapy reduced the risk of microvascular and macrovascular complications. However, it also showed that attainment of lower HbA1c levels was associated with a greater risk of severe hypoglycaemia. NICE therefore advises that targets for blood glucose control should take into account the person's ability to achieve them without increasing the risk for severe hypoglycaemia.
  • CKS notes that the ADA/EASD consensus report recommends a target HbA1c for most adults of less than 53 mmol/mol without significant hypoglycaemia, or a lower target if this can be achieved safely without adverse effects of treatment, such as hypoglycaemia. Less tight HbA1c targets may be appropriate for some people if the harms of treatment outweigh the potential benefits, for example in people with advanced complications from diabetes.

Advice on diet

• Advise an adult with type 1 diabetes on the effects of nutrition on blood glucose control, body weight, and risk of cardiovascular disease (CVD).
  • Advise that carbohydrate intake in particular has a major effect on blood glucose levels, and people with type 1 diabetes need to understand the effect of food on their diabetes and plan meals accordingly.
  • Recommend a structured education programme that covers carbohydrate-counting training (a meal planning technique for managing blood glucose levels which matches carbohydrate intake to insulin doses and physical activity) as part of diabetes self-management.
    • Consider carbohydrate-counting courses for people who are waiting for a more detailed structured education programme or are unable to take part in a stand-alone structured education programme.
    • Do not routinely recommend foods with a low glycaemic index for blood glucose control.
  • Consider arranging referral to a dietitian and/or the diabetes specialist team to enable the person to make optimal dietary choices and appropriate insulin dose changes to maintain an optimal body mass index (BMI) and blood glucose control.
    • See the CKS topic on Obesity for more information if the person has overweight or obesity.
    • See the CKS topic on Eating disorders for more information if there is suspected or confirmed disordered eating.
  • Advise about a healthy, balanced diet to reduce the risk of CVD.
    • The Diabetes UK (website www.diabetes.org.uk) resources Carbohydrates and diabetes: what you need to know and Eating with diabetes may be helpful.
    • The British Dietetic Association food fact leaflets Type 1 diabetes and Hypertension may be helpful.
    • The Kidney Care UK (website www.kidneycareuk.org) information Healthy diet support may be helpful.
  • See the CKS topic on Insulin therapy in type 1 diabetes for more information on cultural and religious diets, feasting, and fasting.

Advice on physical activity and exercise

• Advise adults with type 1 diabetes about the potential benefits of regular physical activity and exercise as part of a healthy lifestyle.
  • Explain that exercise may lower blood glucose levels, may reduce cardiovascular risk in the medium and longer term, and can help with weight management. See the CKS topic on Obesity for more information.
• Provide the person with information about:
  • The role of blood glucose monitoring with changing insulin requirements, carbohydrate intake, and exercise or activity levels. See the CKS topic on Insulin therapy in type 1 diabetes for detailed information about blood glucose monitoring.
  • The effect of physical activity and exercise on blood glucose levels when insulin levels are adequate, the associated risk of hypoglycaemia, and to have a supply of carbohydrate available to prevent and treat hypoglycaemia.
  • The effect of physical activity and exercise on blood glucose levels when the person is hyperglycaemic or hypoinsulinaemic (risk of worsening hyperglycaemia and ketonaemia). See the section on Suspecting diabetic ketoacidosis for more information.
  • The appropriate adjustments of insulin dosage and/or nutritional intake needed for periods during and immediately after exercise, and the following 24 hours.
  • Alcohol should be avoided before and during exercise as it may increase the risk of hypoglycaemia, including nocturnal hypoglycaemia after exercise, and impair performance.
  • Further information on Exercise for diabetes and Does exercise lower blood sugar levels? is available on the Diabetes UK website (www.diabetes.org.uk).

Advice on alcohol intake

• Advise a person with type 1 diabetes about safe alcohol limits and the potential impact of alcohol on blood glucose levels.
  • Advise to avoid drinking alcohol on an empty stomach as alcohol will be absorbed faster.
  • Advise to eat a carbohydrate-containing snack (such as a sandwich or crisps) before and after drinking alcohol. Additional insulin is not needed.
  • Advise to measure blood glucose levels regularly, and to maintain blood glucose levels with appropriate carbohydrate intake.
  • Advise that signs of hypoglycaemia may be less obvious following alcohol intake, delayed hypoglycaemia may occur (hours after alcohol consumption), including nocturnal hypoglycaemia, and alcohol may exacerbate or prolong the effect of insulin therapy.
  • Advise that increased alcohol consumption is associated with an increased risk of diabetic ketoacidosis.
    • Further information on Alcohol and diabetes and Type 1 diabetes and drinking is available on the Diabetes UK website (www.diabetes.org.uk).
    • Advise to always wear or carry some form of diabetes identification, as reduced hypoglycaemia awareness may be confused with alcohol intoxication. See the CKS topic on Insulin therapy in type 1 diabetes for more information about hypoglycaemia and safety issues, including different forms of diabetes identification available.
  • See the CKS topic on Alcohol - problem drinking for more information on the recommended weekly alcohol intake for men and women, the risks of excess alcohol, and ways to safely reduce alcohol intake.

Advice on smoking and substance misuse

• Advise adults with type 1 diabetes that smoking is a risk factor for macrovascular and microvascular complications of diabetes.
  • Offer smoking cessation advice to current smokers. Reinforce this annually for people who currently do not plan to stop smoking, and at all clinical contacts. See the CKS topic on Smoking cessation for more information. Further information on Help with giving up smoking is available on the Diabetes UK website (www.diabetes.org.uk).
  • Advise young adult non-smokers never to start smoking.
• Advise about the general dangers of substance misuse and the possible effects on blood glucose levels.
  • Advise that recreational drugs such as cannabis, cocaine, and other stimulant drugs may potentially increase the risk for diabetic ketoacidosis.
  • Further information on Recreational drugs and diabetes is available on the Diabetes UK website (www.diabetes.org.uk).

Advice on oral health

• Advise adults with type 1 diabetes that they are at higher risk of periodontitis than the general population.
  • Advise about the importance of good oral hygiene and regular oral health reviews for preventing periodontitis.
  • Advise that appropriate management of periodontitis can improve blood glucose control and can reduce the risk of hyperglycaemia. See the CKS topic on Gingivitis and periodontitis for more information.
  • Advise the person to attend regular oral health reviews (their oral healthcare or dental team will advise on the frequency, based on their oral health needs).
  • Further information on Diabetes and teeth, gum and mouth problems is available on the Diabetes UK website (www.diabetes.org.uk).

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024a] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023c], the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], and the International Society for Pediatric and Adolescent Diabetes (ISPAD) publications Clinical practice consensus guidelines 2022: Exercise in children and adolescents with diabetes [Adolfsson, 2022] and Clinical practice consensus guidelines 2022: Microvascular and macrovascular complications in children and adolescents with diabetes [Bjornstad, 2022].

Advice on diet

• These recommendations are based on the NICE guideline on adults [NICE, 2024a] and the ADA/EASD consensus report [Holt, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.
  • The NICE guideline recommends providing appropriate nutritional advice to people with type 1 diabetes and/or their family/carers to enable them to make appropriate dietary choices and insulin dose adjustments, as well as advice about weight management, cardiovascular risk, snacks, and the effects of alcohol on blood glucose and calorie intake. It identified very limited evidence showing no significant benefit of a low glycaemic index diet on blood glucose control or frequency of hypoglycaemia.
  • The ADA/EASD consensus report notes that carbohydrate counting is the most common meal planning approach in type 1 diabetes, and is useful in adjusting mealtime insulin doses for optimal blood glucose control. It recommends that people with type 1 diabetes are given individualized nutritional advice by a dietitian with appropriate knowledge and skills about the diabetes technology being used. It stresses that this advice should vary depending on the person's preferences, socioeconomic status, cultural background, and any comorbidities. It also notes that if a person has extreme low weight, their eating habits and relationship with food should be reviewed, including the possibility of insulin omission and 'eating distress'.

Advice on physical activity and exercise

• These recommendations are based on the NICE guideline on adults [NICE, 2024a] and the ADA/EASD consensus report [Holt, 2021], and are also extrapolated from the ISPAD clinical practice consensus guidelines on exercise [Adolfsson, 2022].
  
  • The recommendations about the potential benefits of regular exercise and activity are based on the NICE guideline, the ADA/EASD consensus report, and the ISPAD publication. The ADA/EASD consensus report notes that interventions promoting weight loss and maintenance including nutritional advice and physical activity are important for people with type 1 diabetes who have overweight or obesity. Specifically, 'exercise is associated with improved fitness, increased insulin sensitivity, leading to reduced insulin requirement, improved cardiovascular health with better lipid profile and endothelial function, and decreased mortality'. In addition, it notes that regular physical activity is associated with a reduced risk of microvascular complications, osteoporosis, and cancer, and can improve sleep quality and mental wellbeing in people with type 1 diabetes.
  • The recommendation about the importance of blood glucose monitoring is based on the NICE guideline and the ADA/EASD consensus report, which notes that the impact of exercise on blood glucose levels will vary, depending on the person's baseline fitness level; the type, intensity and duration of activity; the amount of insulin and blood glucose concentration before exercise; and the composition of the last meal or snack [Holt, 2021].
  • The recommendation about the risks and management of hypoglycaemia is based on the NICE guideline and the ISPAD clinical practice consensus guidelines.
  • The recommendation about the risks of hyperglycaemia and diabetic ketoacidosis (DKA) is based on the NICE guideline.
  • The recommendation about adjustments to insulin dosage and nutritional intake are based on the NICE guideline.
  • The recommendation about the potential effect of alcohol on blood glucose levels is based on the NICE guideline and is also extrapolated from the ISPAD clinical practice consensus guidelines.

Advice on alcohol intake

• These recommendations are based on the NICE guidelines on adults [NICE, 2024a] and are also extrapolated from the NICE guideline on children and young people [NICE, 2023c], and the ADA/EASD consensus report [Holt, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.
  • The NICE guideline on adults recommends that people with type 1 diabetes should be given appropriate information on the effects of alcohol on blood glucose control and exercise.
  • The ADA/EASD consensus report notes that alcohol inhibits hepatic gluconeogenesis, leading to an increased risk for hypoglycaemia for up to 24 hours after the last alcoholic drink. It also states that alcohol promotes ketosis, and in the context of consumption of sugary alcoholic drinks, this may increase the risk of diabetic ketoacidosis (DKA). In addition, excessive alcohol consumption impairs cognitive function and symptom awareness, potentially resulting in a reduced ability to self-manage diabetes.
  • The recommendation to wear or carry a form of diabetes identification is extrapolated from the ADA/EASD consensus report. It is also pragmatic, based on what CKS considers to be good clinical practice.

Advice on smoking and substance use

• The recommendations about smoking are based on the NICE guidelines on adults [NICE, 2024a] and on children and young people [NICE, 2023c], together with the ADA/EASD consensus report [Holt, 2021] and the ISPAD clinical practice consensus guidelines on complications [Bjornstad, 2022].
  • The ISPAD clinical practice consensus guidelines on complications note that prevention or stopping smoking will reduce progression of albuminuria and cardiovascular disease.
• The recommendations about substance misuse are extrapolated from the NICE guideline on children and young people [NICE, 2023c] and are based on the ADA/EASD consensus report [Holt, 2021].
  • The ADA/EASD consensus report notes that an association between cannabis use and a more than two-fold increased risk for DKA has been noted in the literature. In addition, use of cocaine and other stimulant drugs increase glucose production and inhibit glucose clearance, which increases the risk for DKA and all-cause mortality.

Advice on oral health

• These recommendations are based on the NICE guideline on adults, which notes that people with type 1 diabetes are at increased risk of periodontitis, and non-surgical treatment can improve blood sugar control. It stresses the importance of discussing the risk of periodontitis with a person with type 1 diabetes at annual reviews [NICE, 2024a].

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024a] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023c], and the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021].

• The recommendation to arrange emergency hospital admission if diabetic ketoacidosis (DKA) is suspected is extrapolated from the NICE guideline on children and young people [NICE, 2023c].
• The recommendation to discuss precipitating factors after an episode of DKA is extrapolated from the NICE guideline on children and young people [NICE, 2023c] and is based on the ADA/EASD consensus report [Holt, 2021].
• The recommendation about management of intercurrent illness and 'sick-day rules' is based on the NICE guideline on adults [NICE, 2024a], and the ADA/EASD consensus report, which highlights that diabetes self-management education is an effective tool in reducing the risk of DKA. It also notes that 24-hour access to medical advice about how to manage hyperglycaemia and raised urinary or blood ketones at home can reduce the risk of hospital admission [Holt, 2021].

Sick-day rules

If a person has an episode of intercurrent illness that does not require hospital admission, advise the person to follow 'sick-day rules':

• Never stop or omit insulin therapy.
  • The dose of insulin may need to be altered during periods of illness. Seek advice from the diabetes specialist team if the person is unsure how to adjust insulin doses. See the CKS topic on Insulin therapy in type 1 diabetes for more information.
• Monitor blood glucose levels more frequently, for example, every 1–2 hours, including through the night.
  • The insulin dose should be titrated according to the blood glucose levels. See the CKS topic on Insulin therapy in type 1 diabetes for more information.
• Consider checking blood or urine ketone levels regularly, for example, every 3–4 hours, including through the night. This may need to be increased to every 1–2 hours, depending on the results.
  • If the urine ketone level is greater than 2+ or the blood ketone levels are greater than 3 mmol/L, seek urgent medical advice. See the section on Suspecting diabetic ketoacidosis for more information.
• Maintain the person's normal meal pattern, if possible, if appetite is reduced. 
  • Advise to replace normal meals with carbohydrate-containing drinks (such as milk, milk shakes, fruit juices, and sugary drinks), if needed.
• Maintain hydration and aim to drink at least 3 L of fluid each day to prevent dehydration.
  • If blood glucose levels are normal or high, advise drinking water or carbohydrate-free fluids.
  • If blood glucose levels are low, advise taking carbohydrate-containing drinks as well as fast-acting carbohydrates, if possible. See the CKS topic on Insulin therapy in type 1 diabetes for more information on the management of acute hypoglycaemia.
  • Avoid the use of carbonated drinks.
• Seek urgent medical advice if the person has vomiting, is unable to drink, and/or has signs of severe dehydration, as hospital admission and intravenous fluids may be needed.
• While the person is recovering, continue to monitor blood glucose levels frequently until they return to normal.
  • Advise to seek urgent medical advice if blood glucose levels remains uncontrolled. See the CKS topic on Insulin therapy in type 1 diabetes for more information on monitoring blood glucose levels.
• Further information on Diabetes when you're unwell and Hyperglycaemia (hyper) is available on the Diabetes UK website (www.diabetes.org.uk).

[BSPED, 2021; Phelan, 2022; NICE, 2023b]

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024a] and Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023c], and the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication Sick day management in children and adolescents with diabetes [Phelan, 2022].

Assessing the need for hospital admission or specialist advice

• The recommendations to arrange emergency hospital admission if there is suspected diabetic ketoacidosis (DKA) or high risk of DKA are extrapolated from the NICE guidelines on adults [NICE, 2024a] and on children and young people [NICE, 2023c]. They are also pragmatic, based on what CKS considers to be good clinical practice.
• The recommendations about when to consider hospital admission or seeking urgent specialist advice are extrapolated from the ISPAD guidelines on sick day management [Phelan, 2022].

Managing intercurrent illness in primary care

• These recommendations are largely extrapolated from the ISPAD guidelines on sick day management [Phelan, 2022]. They are also pragmatic, based on what CKS considers to be good clinical practice.
  • The ISPAD guidelines on sick day management note that most febrile illnesses increase blood glucose levels due to higher levels of circulating stress hormones which promote glycogenolysis, gluconeogenesis, and insulin resistance. Conversely, decreased food intake, delayed gastric emptying, poor intestinal absorption, and/or overt diarrhoea with more rapid transit time in gastroenteritis, for example, may contribute to the risk of hypoglycaemia during intercurrent illness.

Advising about sick-day rules

• These recommendations are extrapolated from the NICE guidelines on adults [NICE, 2024a], on children and young people [NICE, 2023c], and the ISPAD guidelines on sick day management [Phelan, 2022]. They are also pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation not to stop insulin is based on the fact that 'even in the fasting state, insulin is required for basal metabolic needs, which may increase during an acute illness, when counter-regulatory or stress hormone levels are elevated' [Phelan, 2022].
  • The ISPAD guidelines on sick day management note that regular blood ketone monitoring during illness can reduce emergency department attendance and hospitalization. In addition, hydration is a key treatment for ketosis, to avoid water and electrolyte deficits that may progress to acidosis and DKA [Phelan, 2022].
  • The recommendation to avoid carbonated fluids is due to the fact these may alter the distribution of food within the stomach and may contribute to bloating in some people when unwell [Phelan, 2022].

Managing hypertension

If an adult has a diagnosis of type 1 diabetes:

• Aim for the following blood pressure targets, using clinical judgement, particularly for people with frailty, multimorbidity, and/or target organ damage due to diabetes complications:
  • If the urine albumin:creatinine ratio (ACR) is less than 70 mg/mmol — a clinic systolic blood pressure less than 140 mmHg (target range 120 to 139 mmHg) and a clinic diastolic blood pressure less than 90 mmHg.
  • If the urine ACR is 70 mg/mmol or more — a clinic systolic blood pressure less than 130 mmHg (target range 120 to 129 mmHg) and a clinic diastolic blood pressure less than 80 mmHg.
  • In adults aged 80 years or over (irrespective of the urine ACR level) — a clinic systolic blood pressure less than 150 mmHg and a clinic diastolic blood pressure less than 90 mmHg.
• Start a trial of a renin-angiotensin system blocking drug as first-line treatment for hypertension in adults with type 1 diabetes.
  • Offer an angiotensin-converting enzyme (ACE) inhibitor, provided there are no contraindications. If an ACE inhibitor is contraindicated or not tolerated, offer an angiotensin-II receptor antagonist (AIIRA) if appropriate.
    • Start with a low dose and titrate up to the maximum tolerated dose (within the maximum licensed dose) by doubling the dose every 1–2 weeks.
    • After each upward titration, monitor the person's renal function, serum potassium level, and blood pressure.
    • See the section on Prescribing information in the CKS topic on Hypertension for detailed information on prescribing ACE inhibitors and AIIRAs.
  • If a person has type 1 diabetes and diabetic kidney disease, see the section on Diabetic kidney disease and the CKS topic on Chronic kidney disease for more information.
  • Be aware that it may be necessary to prescribe other antihypertensive drugs to improve blood pressure control.
    • Cardioselective beta-blockers (such as atenolol and metoprolol) may be used for adults on insulin.
    • Low-dose thiazides may be combined with a beta-blocker.
    • If prescribing a calcium-channel blocker, use a long-acting preparation.
    • See the section on Prescribing information in the CKS topic on Hypertension for more information on prescribing different antihypertensive medication.
• Provide information on lifestyle changes to improve blood pressure control and reduce the risk of associated complications. See the section on Lifestyle management for more information.

Lipid modification

• Offer statin treatment with atorvastatin 20 mg for the primary prevention of cardiovascular disease (CVD) to an adult with type 1 diabetes who:
  • Is aged over 40 years, or
  • Has had diabetes for more than 10 years, or
  • Has established chronic kidney disease, or
  • Has other CVD risk factors.
• Consider statin treatment with atorvastatin 20 mg for the primary prevention of CVD for adults aged 18 to 40 years with type 1 diabetes, including those who have had diabetes for 10 years or less.
• Offer statin treatment with atorvastatin 80 mg for the secondary prevention of CVD for people with type 1 diabetes who have established CVD (for example, a history of ischaemic heart disease, stroke, transient ischaemic attack, or peripheral arterial disease).
  • See the CKS topic on Lipid modification - CVD prevention for detailed information about starting lipid-lowering treatment for the primary and secondary prevention of CVD, assessing response to treatment, and optimizing treatment.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024a] and Cardiovascular disease: risk assessment and reduction, including lipid modification [NICE, 2023d], the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], the joint Association of British Clinical Diabetologists and UK Kidney Association (ABCD-UKAA) summary guideline Management of hypertension in patients with diabetic kidney disease [Banerjee, 2022], and the Kidney Disease Improving Global Outcomes (KDIGO) publication KDIGO 2022 Clinical practice guideline for diabetes management in chronic kidney disease [KDIGO, 2022].

Assessing cardiovascular risk

• The NICE guideline on cardiovascular disease risk assessment recommends not to use a risk assessment tool for people who are at high risk of cardiovascular disease (CVD), such as people with type 1 diabetes [NICE, 2023d].
• The recommendation to assess for CVD risk factors regularly is based on the NICE guideline on cardiovascular disease risk assessment [NICE, 2023d] and the NICE guideline on diabetes in adults [NICE, 2024a].
  • The NICE guideline on cardiovascular disease risk assessment notes that uncontrolled diabetes is a common secondary cause for dyslipidaemia.

Managing hypertension

• These recommendations are based on the NICE guideline on diabetes in adults [NICE, 2024a], the ADA/EASD consensus report [Holt, 2021], the joint ABCD-UKAA summary guideline on hypertension management [Banerjee, 2022], and the KDIGO guideline [KDIGO, 2022]. 
  • The recommended blood pressure targets depending on the person's age and urine albumin:creatinine ratio (ACR) are largely based on the NICE guideline.
  • The ABCD-UKKA guideline states that people with diabetic kidney disease and hypertension are often old, frail, and multimorbid. As a result, lower blood pressure targets may be associated with increased adverse events, including symptomatic postural hypotension, falls, fractures, acute kidney injury (AKI), and hyperkalaemia. It recommends an individualized approach to the management of hypertension in people with diabetic kidney disease, taking into account the person's age, stage of kidney disease, and degree of proteinuria.
  • The ADA/EASD consensus report notes an absence of high-quality data to guide blood pressure targets in people with type 1 diabetes, but cites evidence from other population studies which show that treatment of hypertension to a blood pressure of less than 140/90 mmHg reduces the risk of cardiovascular events and microvascular complications. In addition, a lower target of less than 130/80 mmHg is recommended for people at higher risk of CVD or with evidence of microvascular complications, particularly kidney disease.
  • The recommendation to offer an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-II receptor antagonist as first-line treatment for hypertension in this population group is largely based on the NICE guideline and is supported by the ADA/EASD consensus report. This is also supported by the KDIGO guideline, which recommends use of renin-angiotensin system blocking drugs at the maximum tolerated dose for people with type 1 diabetes if there is concomitant hypertension [KDIGO, 2022]. Furthermore, the ABCD-UKKA guideline supports this approach, and notes that control of hypertension long-term is more important than the use of a specific renin-angiotensin system blocking drug.
  • The information about the possible use of additional antihypertensives is based on the NICE guideline and the KDIGO guideline, which also recommends use of a calcium-channel blocker and/or diuretic if needed to achieve an individualized blood pressure target in people with chronic kidney disease and type 1 diabetes.
  • The recommendation about lifestyle modification is based on the NICE guideline.

Advising about lipid modification

• These recommendations are largely based on the NICE guideline on cardiovascular disease and lipid modification [NICE, 2023d]. In addition, the KDIGO guidelines also recommend use of a moderate- or high-intensity statin as first-line drug treatment for lipid modification in people with chronic kidney disease and type 1 diabetes [KDIGO, 2022].

Diabetic eye disease

• At the initial diagnosis of type 1 diabetes, ensure that all adults are immediately referred to the local diabetic eye screening service.
  • Possible outcomes of screening include reinvitation for routine digital screening in 12–24 months, referral for slit lamp biomicroscopy, referral for digital surveillance, or referral to hospital eye services.
  • Further information on Diabetic eye screening is available on the Diabetes UK website (www.diabetes.org.uk).
• Ensure that an emergency ophthalmology review is arranged if there is: 
  • Sudden loss of vision. 
  • Rubeosis iridis (formation of abnormal blood vessels on the anterior iris). 
  • Pre-retinal or vitreous haemorrhage. 
  • Retinal detachment. See the CKS topic on Retinal detachment for more information.
• Be aware that rapid improvement in blood glucose levels can be associated with transient early worsening of retinopathy.

Diabetic kidney disease

All adults with type 1 diabetes, with or without detected kidney disease, should have annual screening for diabetic kidney disease.

• Arrange for appropriate monitoring tests:
  • Serum creatinine and estimated glomerular filtration rate (eGFR).
  • An 'early morning urine' sample for estimation of the albumin: creatinine ratio (ACR).
• Diagnose chronic kidney disease (CKD) if the eGFR is persistently less than 60 mL/min/1.73 m² and/or the urine ACR is persistently greater than 3 mg/mmol.
  • See the CKS topic on Chronic kidney disease for more information on the diagnosis of CKD.
  • Suspect an alternative (not diabetic) or additional cause for kidney disease if:
    • There is no evidence of progressive retinopathy.
    • Blood pressure is particularly high. See the CKS topics on Chronic kidney disease and Hypertension for more information.
    • There is sudden-onset proteinuria.
    • There is significant haematuria (visible or non-visible). See the CKS topic on Chronic kidney disease for more information on the definition and investigation of haematuria, and the CKS topic on Urological cancers - recognition and referral for more information on management.
    • The person is systemically unwell.
• If a person has confirmed diabetic kidney disease, including moderately increased albuminuria (microalbuminuria, a urine ACR of 3–30 mg/mmol) alone:
  • Consider whether referral to a renal specialist is needed. See the CKS topic on Chronic kidney disease for more information on when to arrange specialist referral.
  • Offer an angiotensin-converting enzyme (ACE) inhibitor if there are no contraindications. If ACE inhibitors are contraindicated or not tolerated, offer an angiotensin-II receptor antagonist (AIIRA) if appropriate.
    • Start with a low dose and titrate up to the maximum tolerated therapeutic dose (within the maximum licensed dose), by doubling the dose every 1–2 weeks.
    • After each upward titration, monitor the person's renal function, serum potassium level, and blood pressure.
    • See the section on Prescribing information in the CKS topic on Hypertension for detailed information on prescribing ACE inhibitors and AIIRAs.
    • See the CKS topic on Chronic kidney disease for more information on the primary care management of CKD.
  • If the person has hypertension, see the section on Managing hypertension for more information.
  • Advise the person to avoid a high protein diet. Consider referring the person to a dietitian or the diabetes specialist team for dietary advice.
  • Offer lipid modification therapy. See the section on Lipid modification for more information.
• Further information on Diabetic nephropathy (kidney disease) is available on the Diabetes UK website (www.diabetes.org.uk).

Diabetic neuropathy

In all people with confirmed type 1 diabetes, consider the possibility of complications from diabetic neuropathy, such as:

• Suspected chronic painful neuropathy — see the CKS topic on Neuropathic pain - drug treatment for more information on management. See the CKS topic on Insulin therapy in type 1 diabetes for more information on acute painful neuropathy, which may occur if there is rapid improvement in blood glucose control.
• Erectile dysfunction — consider prescribing a phosphodiesterase-5 (PDE-5) inhibitor to men with type 1 diabetes with isolated erectile dysfunction, unless contraindicated. See the CKS topic on Erectile dysfunction for more information on assessing and managing erectile dysfunction, including when to refer.
• Suspected gastroparesis and vomiting or diarrhoea due to autonomic neuropathy — consider arranging gastroenterology referral for confirmation of the diagnosis and management, if other causes for symptoms have been excluded.
  • Management options for gastroparesis may include a small-particle-size diet (mashed or pureed food) and/or treatment with a prokinetic drug such as metoclopramide or domperidone.
• Suspected bladder symptoms due to autonomic neuropathy — consider arranging urology referral for confirmation of the diagnosis and management, if other causes for symptoms have been excluded. See the CKS topics on LUTS in men, Urinary tract infection (lower) - men, and Urinary tract infection (lower) - women for more information.
• Suspected excessive sweating due to autonomic neuropathy — see the CKS topic on Hyperhidrosis for more information.
• Further information on Diabetic neuropathy (nerve damage) is available on the Diabetes UK website (www.diabetes.org.uk).

Diabetic foot problems

Ensure that all adults with type 1 diabetes have an assessment of their risk of developing a diabetic foot problem at diagnosis and at least annually following diagnosis, or sooner if any foot problems arise.

• When doing a foot check, remove the shoes, socks, any bandages and dressings (if present), and examine both feet for the following risk factors:
  • Neuropathy — use a 10 g monofilament as part of a foot sensory examination. 
  • Limb ischaemia — measure the ankle brachial pressure index (ABPI) and interpret results carefully because calcified arteries may falsely elevate readings. See the CKS topic on Peripheral arterial disease for more information on measuring ABPI and interpreting results.
  • Skin ulceration.
  • Skin callus.
  • Skin infection and/or inflammation.
  • Joint deformity, including Charcot arthropathy (an acute, localized inflammatory condition that may lead to varying degrees and patterns of bone destruction, joint subluxation, dislocation, and deformity).
  • Gangrene.
• Assess the person's current risk of developing or having an active diabetic foot problem using the following risk stratification:
  • Low risk:
    • No risk factors present except callus alone.
  • Moderate risk:
    • Deformity, or
    • Neuropathy, or
    • Peripheral arterial disease.
  • High risk:
    • Previous ulceration, or
    • Previous amputation, or
    • On renal replacement therapy, or
    • Neuropathy and peripheral arterial disease together, or
    • Neuropathy in combination with callus and/or deformity, or
    • Peripheral arterial disease in combination with callus and/or deformity. 
  • Active diabetic foot problem:
    • Ulceration, or
    • Infection, or
    • Critical limb-threatening ischaemia, or
    • Gangrene, or
    • Suspicion of an acute Charcot arthropathy, or an unexplained hot, swollen foot with a change in colour, with or without pain.
  • Limb-threatening and life-threatening diabetic foot problem:
    • Ulceration with fever or any signs of sepsis. See the CKS topic on Sepsis for more information.
    • Ulceration with limb ischaemia. See the CKS topic on Peripheral arterial disease for more information.
    • Clinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration).
    • Gangrene (with or without ulceration).
• Manage the person's risk of developing a diabetic foot problem.
  • For people who are at low risk:
    • Continue to carry out annual foot checks as part of their diabetes review. See the section on Regular review and monitoring for more information.
    • Emphasize the importance of regular foot care.
    • Advise that they could progress to moderate or high risk.
  • For people at moderate risk — refer to the foot protection service to be seen within 6–8 weeks.
  • For people at high risk — refer to the foot protection service to be seen within 2–4 weeks.
  • For people with a limb-threatening and/or life-threatening diabetic foot problem, refer immediately to acute services such as vascular surgery, and inform the multidisciplinary foot care service, depending on local protocols and pathways.
  • For all other active diabetic foot problems — refer the person within one working day to the multidisciplinary foot care service or foot protection service, depending on local protocols and pathways, for triage within one further working day. 
• Depending on the person's risk of developing a diabetic foot problem, carry out reassessments at the following suggested intervals:
  • Annually — for people who are at low risk, as part of their annual diabetes review.
  • Every 3–6 months — for people who are at moderate risk. 
  • Every 1–2 months — for people who are at high risk, if there is no immediate concern. 
  • Every 1–2 weeks — for people who are at high risk, if there is an immediate concern. 
  • Consider more frequent reassessments for people who are at moderate or high risk, and for people who are unable to check their own feet.
• Provide appropriate information on the risk of developing a diabetic foot problem for all people with type 1 diabetes. This information should be provided at diagnosis, during assessments, and if foot problems arise, and should include:
  • Basic foot care advice and the importance of foot care.
  • Foot emergencies and who to contact.
  • Footwear advice.
  • The person's current individual risk of developing a foot problem.
  • Information about diabetes and the importance of optimal blood glucose control.
• If a person presents with a diabetic foot problem, assess the risk of cardiovascular disease and manage appropriately. See the section on Managing cardiovascular risk for more information.
• Further information on Diabetes and foot problems is available on the Diabetes UK website (www.diabetes.org.uk).

Emotional wellbeing

In all people with type 1 diabetes, consider the possibility of emotional and/or psychological problems:

• Assess and offer management for suspected emotional distress, anxiety, and/or depression, including for people with difficulties with diabetes self-management.
  • Offer and arrange referral to specialist mental health services if clinically appropriate.
  • See the CKS topics on Depression and Generalized anxiety disorder for more information, including when to arrange specialist referral.
• Assess and offer management for suspected disordered eating or eating disorders, including people with the following:
  • Over-concern with body shape and weight.
  • Low body mass index (BMI).
  • Hypoglycaemia. See the section on Suspected hypoglycaemia for more information.
  • Suboptimal overall blood glucose control. See the section on HbA1c measurement and targets for more information.
    • See the CKS topic on Eating disorders for more information, including when to arrange specialist referral.
• Further information on Diabetes and your emotions is available on the Diabetes UK website (www.diabetes.org.uk).

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Type 1 diabetes in adults: diagnosis and management [NICE, 2024a], Chronic kidney disease: assessment and management [NICE, 2021], Diabetic foot problems: prevention and management [NICE, 2019], and Coeliac disease: recognition, assessment and management [NICE, 2015]; the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publications Clinical practice consensus guidelines 2022: Other complications and associated conditions in children and adolescents with type 1 diabetes [Frohlich-Reiterer, 2022], Clinical practice consensus guidelines 2022: Exercise in children and adolescents with diabetes [Adolfsson, 2022], Sick day management in children and adolescents with diabetes [Phelan, 2022], and Nutritional management in children and adolescents with diabetes [Annan, 2022]; the joint Association of British Clinical Diabetologists and UK Kidney Association (ABCD-UKAA) publication Clinical practice guidelines for management of hypertension and renin-angiotensin-aldosterone system blockade in adults with diabetic kidney disease [Banerjee, 2022], the Kidney Disease Improving Global Outcomes (KDIGO) publication KDIGO 2022 Clinical practice guideline for diabetes management in chronic kidney disease [KDIGO, 2022], and the NHS England publication Diabetic eye screening pathway requirements [NHS England, 2025].

Arranging regular review and monitoring

• These recommendations are based on the NICE guidelines on adults with type 1 diabetes [NICE, 2024a] and on coeliac disease [NICE, 2015], the ADA/EASD consensus report [Holt, 2021], and are also extrapolated from the ISPAD clinical practice consensus guidelines on sick day management [Phelan, 2022], on exercise [Adolfsson, 2022], and on other complications and associated conditions [Frohlich-Reiterer, 2022].
  • The ADA/EASD consensus report recommends that an adult with type 1 diabetes should be reviewed at least annually, but the frequency should be individualized depending on the person's circumstances. Additional reviews may be needed if a person is 'recently diagnosed, not meeting their diabetes goals, those who require cardiovascular risk management, and those who would benefit from additional self-management education and psychosocial support', as well as when an insulin regimen is changed or a new device is started.
  • The recommendation to assess emotional and psychological wellbeing is extrapolated from the NICE guideline on adults with type 1 diabetes, which states this allows provision of appropriate support and helps to guide how to pace diabetes education.
  • The NICE guideline on adults with type 1 diabetes recommends to review and amend the individual care plan annually, taking into account changes in the person's wishes, circumstances, and clinical findings. It highlights that potential disability from complications that are not avoided can often be prevented by early detection and active management of complications. It acknowledges that people with diabetes are often unaware of the link between diabetes and periodontitis and may not be having regular oral health reviews, so it stressed the importance of discussing this at annual review.
  • The recommendation to consider screening for other autoimmune disease is based on the NICE guidelines on adults with type 1 diabetes and on coeliac disease, and is also extrapolated from the ISPAD clinical practice consensus guidelines on associated conditions, which note that about 25% of people with type 1 diabetes are diagnosed with another autoimmune disease, which may be asymptomatic or present subclinically [Frohlich-Reiterer, 2022].
  • The recommendation to review the diagnosis of type 1 diabetes depending on clinical judgement is based on the NICE guidelines on adults with type 1 diabetes, which notes that the discriminative value of serum C-peptide to diagnose type 1 diabetes increases, the longer the test is done after the initial diagnosis of diabetes. The recommendation to seek specialist advice if needed if pragmatic, based on what CKS considers to be good clinical practice.

Diabetic eye disease

• These recommendations are based on the NICE guideline for adults with type 1 diabetes [NICE, 2024a], the ADA/EASD consensus report [Holt, 2021], and the NHS England publication on diabetic eye screening [NHS England, 2025].
  • The aim of diabetic eye screening is to reduce the risk of sight loss among people with diabetes by the early detection and treatment of sight-threatening retinopathy. Screening is offered every 12–24 months depending on the outcome of the last test, and can detect eye disease before it affects a person's vision. Outcomes following screening include reinvitation for routine digital screening in 12–24 months, referral for slit lamp biomicroscopy, referral for digital surveillance, or referral to hospital eye services [NHS England, 2025].

Diabetic kidney disease

• These recommendations are based on the NICE guidelines on adults with type 1 diabetes [NICE, 2024a] and on chronic kidney disease [NICE, 2021], the joint ABCD-UKAA clinical practice guidelines on hypertension and diabetic kidney disease [Banerjee, 2022], and the KDIGO clinical practice guideline [KDIGO, 2022].
  • The recommendation about annual screening for diabetic kidney disease is based on the NICE guideline on type 1 diabetes.
  • The recommendations to arrange appropriate monitoring tests and how to diagnose chronic kidney disease (CKD) are based on the NICE guideline on type 1 diabetes and the NICE guideline on CKD.
  • The recommendation about when to suspect an alternative or additional cause for kidney disease is based on the NICE guideline on diabetes. CKS notes that NICE does not give a specific definition of 'particularly high' blood pressure.
  • The recommendation to consider whether referral to a renal specialist is needed is extrapolated from the NICE guideline on diabetes.
  • The recommendations to offer an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-II receptor antagonist (AIIRA) to manage diabetic kidney disease are based on the NICE guideline on CKD, the joint ABCD-UKAA clinical practice guidelines, and the KDIGO clinical practice guideline.
    • The ABCD-UKKA guidelines recommend that most adults with type 1 diabetes mellitus and a urine albumin:creatinine ratio (ACR) persistently greater than 3 mg/mmol should be offered renin-angiotensin system blocking drugs, irrespective of blood pressure, up-titrated to the maximum tolerated dose. It cites evidence that people with proteinuria are at increased risk of progressive diabetic kidney disease and end-stage kidney disease.
    • The KDIGO guideline recommends treatment with an ACE inhibitor or an AIIRA if a person has diabetes, hypertension, and albuminuria, and these medications should be up-titrated to the maximum tolerated dose. This approach is supported by the ABCD-UKKA guidelines, which note that hypertension is a major risk factor for progression of diabetic kidney disease, cardiovascular disease (CVD), and mortality. It stresses that optimal management of hypertension with renin-angiotensin system blocking drugs first-line together with improved blood glucose control can reduce the risk of progressive diabetic kidney disease, and may induce regression of proteinuria, if present.
  • The recommendation to avoid a high protein diet is extrapolated from the NICE guideline on diabetes in adults. CKS notes that the NICE guideline on CKD advises against offering a low-protein diet (dietary protein intake less than 0.6 to 0.8 g/kg/day) to adults with CKD. The recommendations about referral to a dietitian or the diabetes specialist team are pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation about offering lipid modification is based on the KDIGO clinical practice guideline.

Diabetic neuropathy

• These recommendations are based on the NICE guidelines on adults with type 1 diabetes [NICE, 2024a]. They are also pragmatic, based on what CKS considers to be good clinical practice.
  • The NICE guideline notes that there is no strong evidence that any antiemetic drug is effective for vomiting associated with gastroparesis. It notes that some people report benefit from medication such as metoclopramide, erythromycin, or domperidone, but it highlights the risk of adverse effects and potential drug interactions with these treatments. In addition, it states that high doses and long duration of use with domperidone and use of erythromycin for this indication are off-label. Insulin pump therapy may be offered to people with symptomatic gastroparesis [NICE, 2024a].

Diabetic foot problems

• These recommendations are based on the NICE guideline on diabetic foot problems [NICE, 2019] and are supported by the ADA/EASD consensus report [Holt, 2021].
  • The NICE guideline on diabetic foot problems states that a local foot protection service should be led by a podiatrist with specialist training in diabetic foot problems, with access to specialists in diabetes management, biomechanics and orthoses, and wound care. Furthermore, a multidisciplinary foot care service including additional diabetic specialist nurses, vascular surgery, microbiology, and orthopaedic surgery specialists should be available to manage diabetic foot problems that cannot be managed by the foot protection service.
  • Specialist foot services should give advice about skin and nail care, assess biomechanical status including the need for specialist footwear and/or orthoses, and assess the vascular status of the lower limbs [NICE, 2019].
  • The recommendation to assess the risk of CVD if a person presents with a diabetic foot problem is based on the fact there may be an undiagnosed, increased risk of CVD needing further investigation and treatment [NICE, 2019].

Emotional and psychological wellbeing

• These recommendations are based on the NICE guideline on adults with type 1 diabetes [NICE, 2024a], the ADA/EASD consensus report [Holt, 2021], and the ISPAD clinical practice consensus guidelines on nutritional management [Annan, 2022].
  • The recommendations to assess and offer management for suspected emotional and/or psychological problems is based on the NICE guideline and the ADA/EAD consensus report.
    • The ADA/EASD consensus report recommends that, due to the high prevalence and impact of psychosocial problems, emotional distress, and psychological disorders in people with diabetes which can negatively affect diabetes outcomes, screening at least annually and monitoring for these conditions should be a key part of diabetes care. This approach is recommended to promote case-finding, emotional wellbeing, and patient satisfaction with care.
    • The ADA/EASD consensus report states that diabetes-associated emotional distress may result from feeling overwhelmed by the demands of daily self-management of diabetes, fear of hypoglycaemia, concerns about complications, and lack of social support. If prolonged, emotional distress may be associated with depression and increased blood glucose levels.
    • The ADA/EASD consensus report states that 'psychological therapies, including time-limited (online) cognitive behavioural therapy (CBT), mindfulness and interpersonal therapies are effective with regard to a range of psychological outcomes, including diabetes distress and depression'.
  • The recommendation about when to suspect disordered eating is based on the NICE guideline, and is supported by the ADA/EASD consensus report and the ISPAD clinical practice consensus guidelines.
    • The ADA/EASD consensus report notes that eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating, are over-represented in people with type 1 diabetes, particularly in young women.
    • The ISPAD clinical practice consensus guidelines on nutritional management note that repeated episodes of diabetic ketoacidosis (DKA) or worsening blood glucose outcomes may be a sign of disordered eating.

Individual care plan

• At the time of diagnosis, children and young people with type 1 diabetes and/or their family/carers should be offered an integrated package of care provided by a multidisciplinary paediatric diabetes team.
  • To optimize the effectiveness of care and reduce the risk of complications, the diabetes team should include members with appropriate training in clinical, educational, dietetic, lifestyle, mental health, and foot care aspects of diabetes for children and young people.
  • The child or young person may be offered home-based or inpatient management, depending on clinical need and family circumstances and wishes.
    • Initial inpatient management may be offered to children younger than 2 years of age; children and young people with social or emotional factors that would make home-based management inappropriate; and children and young people who live a long distance from hospital-based care.
• A continuing programme of education should be offered.
  • This should include the following core elements:
    • Insulin therapy (including insulin injections, regimens, and dose adjustment) and self-monitoring of blood glucose. See the CKS topic on Insulin therapy in type 1 diabetes for more information.
    • Treatment targets. See the section on HbA1c measurement and targets for more information.
    • Detecting and managing hypoglycaemia (symptoms, avoidance, maintaining awareness, risk factors, and management), hyperglycaemia, and ketosis. See the sections on Suspecting hypoglycaemia and Managing diabetic ketoacidosis, and the CKS topic on Insulin therapy in type 1 diabetes for more information.
    • Management of diabetes during intercurrent illness ('sick-day rules', including monitoring of blood ketones). See the section on Managing intercurrent illness for more information.
    • The effects of diet, physical activity and exercise, and alcohol intake on blood glucose control, and the importance of good oral hygiene and regular oral health reviews for preventing periodontitis. See the section on Lifestyle advice for more information.
    • Complications monitoring and management. See the section on Regular review and monitoring for more information.
    • How to contact the diabetes specialist team, including during working hours and out of hours, if appropriate.
    • The frequency and content of follow-up appointments, including review of HbA1c levels and targets, assessment of any hypoglycaemia episodes, and the next annual review.
  • This should be tailored to the child or young person and/or their family/carers, taking account of issues such as:
    • Emotional well-being.
    • Age and maturity.
    • Cultural considerations.
    • Existing knowledge.
    • Current and future social circumstances.
    • Life goals.

[NICE, 2023c]

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023c], and the International Society for Pediatric and Adolescent Diabetes (ISPAD) publications Clinical Practice Consensus Guidelines 2022: Diabetes education in children and adolescents [Olinder, 2022], Clinical Practice Consensus Guidelines 2022: Nutritional management in children and adolescents with diabetes [Annan, 2022], Clinical Practice Consensus Guidelines 2022: Psychological care of children, adolescents and young adults with diabetes [de Wit, 2022], and Sick day management in children and adolescents with diabetes [Phelan, 2022].

Provision of an individual care plan

• This recommendation is based on the NICE guideline on children and young people [NICE, 2023b] and is also extrapolated from the ISPAD clinical practice consensus guidelines on nutritional management [Annan, 2022] and on psychological care in children [de Wit, 2022].
  • The NICE guideline notes that at the time of diagnosis, home-based care with support from the local paediatric diabetes team (including 24-hour telephone access) is safe and as effective as inpatient initial management, depending on the clinical circumstances of the child or young person.
  • The ISPAD clinical practice consensus guidelines on nutritional management recommend that a specialist dietician with experience in paediatric diabetes is part of the multidisciplinary team and available as soon as possible at diagnosis to develop a consistent relationship with the child or young person and their family/carers. Similarly, the ISPAD clinical practice consensus guidelines on psychological care state that 'professionals with expertise in the mental health of children and adolescents are essential members of interdisciplinary diabetes health care team' [de Wit, 2022].
  • The recommendation about providing psychological support after diagnosis is also based on the fact that a lack of adequate psychosocial support for children and young people with type 1 diabetes has a negative effect on various outcomes including blood glucose management and self-esteem [NICE, 2023b].

Offering an education programme

• This recommendation is based on the NICE guideline on children and young people [NICE, 2023b] and the ISPAD clinical practice consensus guidelines on diabetes education [Olinder, 2022].
  • The NICE guideline committee recognized that people differ in their educational needs and learning styles, and the timing and approach to education delivery should be individualized while covering certain 'core elements'.
  • The ISPAD clinical practice consensus guidelines highlight the challenge to 'deliver diabetes education that optimizes the family's knowledge and understanding of the condition and its treatment, while simultaneously assisting them to adjust to the impact of diabetes management on their everyday lives'. The guidelines recommend that in order to maximize the effectiveness of diabetes treatment and the advances in diabetes management and technology, good quality structured diabetes education should be available to all young people with diabetes and their family/carers. This has a positive effect on blood glucose control and psychosocial outcomes.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023b] and the International Society for Pediatric and Adolescent Diabetes (ISPAD) publication Clinical Practice Consensus Guidelines 2022: Glycemic targets and glucose monitoring for children, adolescents and young people with diabetes [de Bock, 2022].

Frequency of HbA1c measurement

• These recommendations are based on the NICE guideline on diabetes in children [NICE, 2023b].

HbA1c treatment targets

• These recommendations are largely based on the NICE guideline on diabetes in children [NICE, 2023b], together with the ISPAD clinical practice consensus guidelines on blood glucose targets and monitoring [de Bock, 2022].
  • The NICE guideline recommends an HbA1c target level of 48 mmol/mol or lower to minimize the risk of longterm complications in children and young people. It noted a lack of evidence on the optimal HbA1c target for this population group, and acknowledged the need to individualize targets, balancing the lowest achievable HbA1c with the need to minimize the risk of hypoglycaemic episodes. Similarly, the ISPAD clinical practice consensus guidelines on blood glucose targets acknowledge that individualized targets may be appropriate if there are barriers to achieving a target HbA1c of less than 48 mmol/mol, such as access to insulin analogues or advanced technologies, or psychological distress.
  • CKS notes that the ISPAD clinical practice consensus guidelines on blood glucose targets for children and young people recommend a target HbA1c of less than 53 mmol/mol in order to minimize the risk of longterm microvascular and macrovascular complications. The ISPAD guidelines acknowledge that this HbA1c target is higher than the level of 48 mmol/mol set by the NICE guideline, which may be appropriate for healthcare settings offering their paediatric populations continuous glucose monitoring (CGM) and/or automated insulin delivery in combination with specialist diabetes teams and provision of structured diabetes education programmes.

Advice on diet

• Support children and young people with type 1 diabetes and their family/carers to develop a good working knowledge of nutrition, how it affects their diabetes, and to adjust their food choices accordingly.
  • Advise about a healthy, balanced diet, including eating foods with a low glycaemic index (GI), which may improve blood glucose control, reduce the risk of hyperglycaemic episodes, and reduce the risk of future cardiovascular disease (CVD).
  • Offer level 3 carbohydrate-counting education (a meal planning technique for managing blood glucose levels which matches carbohydrate intake to insulin doses and physical activity) to children and young people who are using a multiple daily insulin injection regimen or continuous subcutaneous insulin infusion (insulin pump) therapy.
    • The Diabetes UK (website www.diabetes.org.uk) resources Carbohydrates and diabetes: what you need to know and Eating with diabetes may be helpful.
    • The British Dietetic Association food fact leaflets Type 1 diabetes may be helpful.
  • Explain that children and young people with type 1 diabetes have the same basic nutritional needs as children and young people without diabetes, so their food should provide sufficient energy and nutrients for optimal growth and development.
  • Consider arranging referral to a paediatric dietitian and/or liaise with the paediatric diabetes specialist team to enable the child or young person to make optimal dietary choices and appropriate insulin dose changes to maintain an optimal body mass index (BMI) and blood glucose control.
    • See the CKS topic on Obesity for more information if the person has overweight or obesity.
    • See the CKS topic on Eating disorders for more information if there is a suspected or confirmed disordered eating.
    • See the CKS topic on Insulin therapy in type 1 diabetes for more information on insulin treatment regimens, cultural and religious diets, feasting, and fasting.

Advice on physical activity and exercise

• Advise children and young people with type 1 diabetes about the potential benefits of regular physical activity and exercise as part of a healthy lifestyle.
  • Explain that exercise may lower blood glucose levels, may reduce long-term cardiovascular risk, and can help with weight management. See the CKS topic on Obesity for more information.
• Provide the child or young person and/or family/carers with information about:
  • The role of blood glucose monitoring with changing insulin requirements, carbohydrate intake, and exercise or activity levels. See the CKS topic on Insulin therapy in type 1 diabetes for detailed information about blood glucose monitoring, including before and after exercise.
  • All forms of exercise may be undertaken, provided blood glucose is monitored and appropriate changes are made to diet and carbohydrate intake and insulin doses.
  • The effect of physical activity and exercise on blood glucose levels when insulin levels are adequate, the associated risk of hypoglycaemia, and to have a supply of carbohydrate available to prevent and treat hypoglycaemia.
  • The effect of physical activity and exercise on blood glucose levels when the person is hyperglycaemic or hypoinsulinaemic (risk of worsening hyperglycaemia and ketonaemia). See the section on Suspecting diabetic ketoacidosis for more information.
  • The appropriate adjustments of insulin dosage and/or nutritional intake for periods during and immediately after exercise, and the following 24 hours.
  • Alcohol should be avoided before and during exercise as it may increase the risk of hypoglycaemia, including nocturnal hypoglycaemia after exercise, and impair performance.
  • Further information on Exercise for diabetes and Does exercise lower blood sugar levels? is available on the Diabetes UK website (www.diabetes.org.uk).

Advice on alcohol intake

• Remind young people and/or their family/carers that the legal drinking age in the UK is 18 years.
  • Advise to avoid drinking alcohol on an empty stomach as alcohol will be absorbed faster.
  • Advise to eat a carbohydrate-containing snack (such as a sandwich or crisps) before and after drinking alcohol. Additional insulin is not needed.
  • Advise to measure blood glucose levels regularly, and to maintain blood glucose levels with appropriate carbohydrate intake.
  • Advise that signs of hypoglycaemia may be less obvious following alcohol intake, delayed hypoglycaemia may occur (hours after alcohol consumption), including nocturnal hypoglycaemia, and alcohol may exacerbate or prolong the effect of insulin therapy.
  • Advise that increased alcohol consumption is associated with an increased risk of diabetic ketoacidosis.
    • Further information on Alcohol and diabetes and Type 1 diabetes and drinking is available on the Diabetes UK website (www.diabetes.org.uk).
    • Advise to always wear or carry some form of diabetes identification, as reduced hypoglycaemia awareness may be confused with alcohol intoxication. See the CKS topic on Insulin therapy in type 1 diabetes for more information about hypoglycaemia and safety issues, including different forms of diabetes identification available.
  • See the CKS topic on Alcohol - problem drinking for more information on the recommended weekly alcohol intake for men and women, the risks of excess alcohol, and ways to safely reduce alcohol intake.

Advice on smoking and substance misuse

• Advise about the general health problems associated with smoking, particularly the risks of developing vascular complications.
  • Encourage children and young people with type 1 diabetes not to start smoking.
  • Offer smoking cessation programmes to those who smoke. See the CKS topic on Smoking cessation for more information. Further information on Help with giving up smoking is available on the Diabetes UK website (www.diabetes.org.uk).
• Advise about the general dangers of substance misuse and the possible effects on blood glucose control.
  • Advise that recreational drugs such as cannabis, cocaine, and other stimulant drugs may potentially increase the risk for diabetic ketoacidosis.
  • Further information on Recreational drugs and diabetes is available on the Diabetes UK website (www.diabetes.org.uk).

Oral health

• Advise children and young people with type 1 diabetes and their family/carers that they are at a higher risk of periodontitis than the general population.
  • Advise about the importance of good oral hygiene and regular oral health reviews for preventing periodontitis.
  • Advise that appropriate management of periodontitis can improve blood glucose control and can reduce the risk of hyperglycaemia. See the CKS topic on Gingivitis and periodontitis for more information.
  • Advise the person to attend regular oral health reviews (their oral healthcare or dental team will advise on the frequency, based on their oral health needs).
  • Further information on Diabetes and teeth, gum and mouth problems is available on the Diabetes UK website (www.diabetes.org.uk).

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023b] and Type 1 diabetes in adults: diagnosis and management [NICE, 2024a], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publications Clinical Practice Consensus Guidelines 2022: Nutritional management in children and adolescents with diabetes [Annan, 2022], Clinical practice consensus guidelines 2022: Exercise in children and adolescents with diabetes [Adolfsson, 2022], and Clinical practice consensus guidelines 2022: Microvascular and macrovascular complications in children and adolescents with diabetes [Bjornstad, 2022], and the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021].

Advice on diet

• These recommendations are based on the NICE guideline on type 1 diabetes in children [NICE, 2023b] and the ISPAD clinical practice consensus guidelines on nutritional management [Annan, 2022].
  • The NICE guideline on children noted limited evidence on the optimal diet and nutritional requirements for children and young people with type 1 diabetes, and extrapolated their recommendations from evidence in the adult population. The guideline committee acknowledged that foods with a low glycaemic index can potentially improve blood glucose control, but recognized that appropriate nutritional advice should be given to ensure optimal growth and development of the child or young person.
  • The recommendation to offer carbohydrate-counting education to children and young people using specific insulin regimens is based on the clinical experience of the NICE committee, which noted that dietary advice based on carbohydrate-counting in these children more closely resembled normal physiological processes and showed beneficial effects compared with diet and insulin regimens based on prescribed eating patterns. The ISPAD clinical practice consensus guidelines also state that matching of insulin dose to carbohydrate intake when a person is using an intensive insulin regimen allows greater flexibility in carbohydrate intake and mealtimes, with associated improvements in blood glucose and quality of life.
  • The ISPAD clinical practice consensus guidelines on nutritional management highlight that dietary recommendations are based on healthy eating principles suitable for all young people and families, with the aim of improving diabetes outcomes and reducing cardiovascular risk. In particular, provision of individualized meal plans with mealtime insulin adjustments improves blood glucose outcomes. The guidelines stress that energy intake and essential nutrients should aim to maintain ideal body weight, optimal growth and development and help to prevent acute and chronic complications of type 1 diabetes. Regular monitoring of height, weight, and body mass index (BMI) is therefore required to identify both excessive weight gain and faltering growth in children and young people with type 1 diabetes.

Advice on physical activity and exercise

• These recommendations are based on the NICE guidelines on type 1 diabetes in children [NICE, 2023b] and on adults [NICE, 2024a], and the ISPAD clinical practice consensus guidelines on exercise [Adolfsson, 2022].
  • The recommendation about the potential health benefits of physical activity are based on the NICE guideline on children and the ISPAD clinical practice consensus guidelines, which note that exercise is key for the management and reduction of cardiometabolic risk factors for children and young people with type 1 diabetes. It lists additional physical and mental health benefits of exercise, including increased fitness, muscle mass, and strength; reduced fat mass; increased bone mineral density, and overall improved sense of wellbeing.
  • The recommendation about the role of blood glucose monitoring is based on the NICE guideline on children.
  • The information about the potential risks of hypoglycaemia is based on the NICE guideline on children, is extrapolated from the NICE guideline on adults, and is also based on the ISPAD clinical practice consensus guidelines, which state that there is an increased risk of hypoglycaemia during, shortly after, and up to 24 hours after exercise due to increased insulin sensitivity.
  • The information about the potential risks of hyperglycaemia is based on the NICE guideline on children and is extrapolated from the NICE guideline on adults.
  • The information about the need to amend insulin dosage and/or nutritional intake is based on the NICE guideline on children and is extrapolated from the NICE guideline on adults.
  • The information about the risks of alcohol and physical activity is based on the ISPAD clinical practice consensus guidelines on exercise, and is also extrapolated from the NICE guideline on adults.

Advice on alcohol intake

• These recommendations are based on the NICE guidelines on type 1 diabetes in children [NICE, 2023b] and are extrapolated from the ADA/EASD consensus report [Holt, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.
  • The information about the risks of hypoglycaemia, delayed hypoglycaemia, and the need to eat a carbohydrate-containing snack before and after drinking alcohol is based on the NICE guideline on children.
  • The ADA/EASD consensus report also notes that alcohol inhibits hepatic gluconeogenesis, leading to an increased risk for hypoglycaemia for up to 24 hours after the last alcoholic drink. It also states that alcohol promotes ketosis, and in the context of consumption of sugary alcoholic drinks, this may increase the risk of diabetic ketoacidosis (DKA). In addition, excessive alcohol consumption impairs cognitive function and symptom awareness, potentially resulting in a reduced ability to self-manage diabetes.
  • The recommendation to wear or carry a form of diabetes identification is extrapolated from the ADA/EASD consensus report. It is also pragmatic, based on what CKS considers to be good clinical practice.

Advice on smoking and substance use

• The recommendations on smoking are based on the NICE guidelines on type 1 diabetes in children [NICE, 2023b] and the ISPAD clinical practice consensus guidelines on complications, which note that prevention or stopping smoking will reduce progression of albuminuria and cardiovascular disease [Bjornstad, 2022]. They are also extrapolated from the NICE guideline on adults.
• The recommendations on substance use are based on the NICE guidelines on type 1 diabetes in children [NICE, 2023b] and the ADA/EASD consensus report [Holt, 2021].
  • The ADA/EASD consensus report notes that an association between cannabis use and a more than two-fold increased risk for DKA has been noted in the literature. In addition, use of cocaine and other stimulant drugs increase glucose production and inhibit glucose clearance, which increases the risk for DKA and all-cause mortality.

Advice on oral health

• These recommendations are based on the NICE guideline on children, which highlights the importance of good oral hygiene and regular oral health reviews for preventing periodontitis, as children with type 1 diabetes are at higher risk of this condition than the general population. In addition, non-surgical management of periodontitis can improve blood sugar control and reduce the risk of hyperglycaemia [NICE, 2024a].

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023b], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publications Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state [Glaser, 2022] and Clinical Practice Consensus Guidelines 2022: Definition, epidemiology, and classification of diabetes in children and adolescents [Libman, 2022], and the British Society for Paediatric Endocrinology and Diabetes (BSPED) publication Guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis 2021 [BSPED, 2021].

• The recommendation to arrange emergency hospital admission for suspected diabetic ketoacidosis (DKA) is based on the NICE guideline on children [NICE, 2023b], and the ISPAD guidelines on DKA [Glaser, 2022] and on the definition of diabetes [Libman, 2022].
  • The ISPAD clinical practice guidelines on DKA state that emergency assessment and management of suspected DKA is needed, with frequent monitoring of vital signs, neurological status, and laboratory testing. The goals of treatment are to 'correct dehydration, correct acidosis and reverse ketosis, gradually restore hyperosmolality and blood glucose concentration to near normal, monitor for acute complications, and identify and treat any precipitating event'.
• The recommendation to discuss factors which may have precipitated an episode of DKA is based on the NICE guideline on children [NICE, 2023b] and the BSPED guideline [BSPED, 2021].
• The recommendations to consider the possibility of non-adherence to insulin therapy and to assess the emotional and psychological wellbeing of children are based on the NICE guideline on children [NICE, 2023b].
• The recommendation about management of intercurrent illness and 'sick-day rules' is based on the NICE guideline on children [NICE, 2023b].

Sick-day rules

If a child or young person has an episode of intercurrent illness that does not require hospital admission, advise to follow 'sick-day rules' that should have been provided by the paediatric diabetes specialist team:

• Never stop or omit insulin.
  • The dose of insulin may need to be altered during periods of illness. Seek advice from the diabetes specialist team if there is uncertainty about how to adjust insulin doses. See the CKS topic on Insulin therapy in type 1 diabetes for more information.
• Monitor blood glucose levels more frequently, for example, every 1–2 hours, including through the night.
  • The insulin dose should be titrated according to the blood glucose levels. See the CKS topic on Insulin therapy in type 1 diabetes for more information.
• Consider checking blood ketone levels regularly, for example, every 3–4 hours, including through the night. This may increase to every 1–2 hours, depending on the results.
  • Blood ketones should be checked regardless of blood glucose levels (ketone levels may be elevated even if blood glucose levels are normal).
  • If the blood ketone level is greater than 3 mmol/L, seek urgent medical advice. See the section on Suspecting diabetic ketoacidosis for more information.
• Maintain the person's normal meal pattern, if possible, if appetite is reduced.
  • Advise to replace normal meals with carbohydrate-containing drinks (such as milk, milk shakes, fruit juices, and sugary drinks), if needed.
• Maintain adequate fluid intake to prevent dehydration.
  • If blood glucose levels are normal or high, advise drinking water or carbohydrate-free fluids.
  • If blood glucose levels are low, advise taking carbohydrate-containing drinks as well as fast-acting carbohydrates, if possible. See the CKS topic on Insulin therapy in type 1 diabetes for more information on the management of acute hypoglycaemia.
  • Avoid the use of carbonated drinks.
• Seek urgent medical advice if the child or young person has vomiting, is unable to drink, and/or signs of severe dehydration, as hospital admission and intravenous fluids may be needed.
• While the person is recovering, continue to monitor blood glucose levels frequently until they return to normal.
  • Advise to seek urgent medical advice if blood glucose levels remains uncontrolled. See the CKS topic on Insulin therapy in type 1 diabetes for more information on monitoring blood glucose levels.
• Further information on Diabetes when you're unwell and Hyperglycaemia (hyper) is available on the Diabetes UK website (www.diabetes.org.uk). The joint British Society for Paediatric Endocrinology and Diabetes (BSPED) and the Association of Children's Diabetes Clinicians (ACDC) patient leaflet Patient advice for management of type 1 diabetes mellitus during illness in children and young people under 18 years (sick day rules) may be helpful.

[BSPED, 2021; Phelan, 2022; NICE, 2023b]

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023b], the International Society for Pediatric and Adolescent Diabetes (ISPAD) publications Sick day management in children and adolescents with diabetes [Phelan, 2022] and Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state [Glaser, 2022], the British Society for Paediatric Endocrinology and Diabetes (BSPED) publication Guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis 2021 [BSPED, 2021], and the Association of Children's Diabetes Clinicians (ACDC) joint publication Executive summary. Management of type 1 diabetes during illness in children and young people under 18 years (sick day rules) [Ng, 2021].

Assessing the need for hospital admission or specialist advice

• The recommendations about arranging immediate hospital admission are based on the NICE guideline on children [NICE, 2023b] and the ISPAD publication on sick day management [Phelan, 2022]. They are also pragmatic, based on what CKS considers to be good clinical practice.
• The recommendations about when to consider arranging hospital admission or seeking urgent specialist advice are largely based on the ISPAD publication on sick day management [Phelan, 2022]. They are also pragmatic, based on what CKS considers to be good clinical practice.

Managing intercurrent illness in primary care

• These recommendations are largely based on the ISPAD guidelines on sick day management [Phelan, 2022] and the BSPED guideline [BSPED, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.
  • The ISPAD guidelines on sick day management note that most febrile illnesses increase blood glucose levels due to higher levels of circulating stress hormones which promote glycogenolysis, gluconeogenesis, and insulin resistance. Conversely, decreased food intake, delayed gastric emptying, poor intestinal absorption, and/or overt diarrhoea with more rapid transit time in gastroenteritis, for example, may contribute to the risk of hypoglycaemia during intercurrent illness.
  • The BSPED guideline states that 'children who are alert, not clinically dehydrated, not nauseated or vomiting, do not always require intravenous fluids, even if their ketone levels are high. They usually tolerate oral rehydration and subcutaneous insulin but do require monitoring regularly to ensure that they are improving and their ketone levels are falling'.

Advising about sick-day rules

• These recommendations are largely based on the NICE guideline on children [NICE, 2023b] and the ISPAD guidelines on sick day management [Phelan, 2022]. They are also pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation not to stop insulin is based on the fact that 'even in the fasting state, insulin is required for basal metabolic needs, which may increase during an acute illness, when counter-regulatory or stress hormone levels are elevated' [Phelan, 2022].
  • The ISPAD guidelines on sick day management note that regular home blood ketone monitoring during illness allows earlier identification and treatment of ketosis compared with urine ketone testing, and can reduce diabetes-related emergency department visits and hospitalization. In addition, hydration is a key treatment for ketosis, to avoid water and electrolyte deficits that may progress to acidosis and diabetic ketoacidosis (DKA).
  • The recommendation to avoid carbonated fluids is due to the fact these may alter the distribution of food within the stomach and may contribute to bloating in some people when unwell [Phelan, 2022].

Diabetic eye disease

• Advise children and young people with type 1 diabetes and/or their family/carers that they should have an eye examination by an optometrist every 2 years until the age of 12 years, when they will be eligible for checks under the NHS diabetic eye screening programme.
  • Advise that the programme aims to reduce the risk of sight loss among people with diabetes by the early detection and treatment, if needed, of sight-threatening retinopathy.
• Explain to the child or young person and/or their family/carers that: 
  • Monitoring for diabetic retinopathy begins at 12 years because diabetic retinopathy that needs treatment is extremely rare in children and young people younger than 12 years of age.
  • Background retinopathy is often found through monitoring, and improving blood glucose control will reduce the risk of this progressing to significant diabetic retinopathy.
  • Annual monitoring from 12 years of age is important because if significant diabetic retinopathy is found, early treatment will improve the outcome.

Diabetic kidney disease

From the age of 12 years, children with type 1 diabetes (with or without detected kidney disease) should have annual screening for diabetic kidney disease and hypertension.

• Use the first urine sample of the day ('early morning urine') to measure the albumin:creatinine ratio (ACR). If this is not possible, use a random sample, but be aware that this is associated with an increased risk of false positive results.
  • If the initial ACR is above 3 mg/mmol but below 30 mg/mmol, confirm the result by repeating the test on two further occasions using the first urine samples of the day before arranging further investigations and treatment. See the CKS topic on Chronic kidney disease for more information.
  • If the initial ACR is 30 mg/mmol or more (proteinuria), arrange further investigations and consider specialist referral. See the CKS topic on Chronic kidney disease for more information.
• Explain to the child or young person and/or their family/carers that:
  • Monitoring for moderately increased albuminuria (ACR 3–30 mg/mmol) to detect diabetic kidney disease begins at 12 years of age because diabetic kidney disease is extremely rare in younger children.
  • Using the first urine sample of the day ('early morning urine') to screen for moderately increased albuminuria reduces the risk of false positive results.
  • If moderately increased albuminuria is detected, improving blood glucose control will reduce the risk of this progressing to significant diabetic kidney disease.

Diabetic foot problems

• For children with type 1 diabetes who are less than 12 years of age, give basic foot care advice.
• For children and young people with type 1 diabetes aged between 12–17 years, ensure that the paediatric diabetes specialist team or the transitional care team performs a foot check as part of their annual assessment, and provides information on foot care.
  • Screening for peripheral neuropathy should include assessment of temperature or pinprick sensation, vibration, and ankle reflexes.
  • If a diabetic foot problem is suspected or confirmed, ensure that the child or young person has been referred to an appropriate specialist.

Emotional wellbeing

Be aware that children and young people with type 1 diabetes have a greater risk of emotional and behavioural difficulties than children without diabetes.

• When reviewing a child or young person, consider the possibility of emotional and/or psychological problems.
• Assess and offer management for suspected anxiety, depression, behavioural and conduct disorders, eating disorders, family or relationship difficulties, and/or psychosocial difficulties that can affect management of diabetes, including blood glucose management.
  • Arrange referral or liaise with mental health professionals if needed to support the assessment and management of mental health and behavioural problems, including support for carers.
  • A programme of behavioural intervention therapy or behavioural techniques may be helpful if there are concerns about psychological well-being, including counselling or cognitive behavioural therapy (CBT).
  • See the CKS topics on Conduct disorders in children and young people, Depression in children, Eating disorders, and Generalized anxiety disorder for more information, including when to arrange specialist referral.
• Be aware of the possible negative psychological impact of setting blood glucose targets that may be difficult for a child or young person with type 1 diabetes to achieve and maintain. See the section on HbA1c measurement and targets for more information.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023b], Chronic kidney disease: assessment and management [NICE, 2021], Diabetic foot problems: prevention and management [NICE, 2019], and Coeliac disease: recognition, assessment and management [NICE, 2015]; the International Society for Pediatric and Adolescent Diabetes (ISPAD) publications Clinical practice consensus guidelines 2022: Other complications and associated conditions in children and adolescents with type 1 diabetes [Frohlich-Reiterer, 2022], Clinical practice consensus guidelines 2022: Assessment and management of hypoglycemia in children and adolescents with diabetes [Abraham, 2022], Clinical practice consensus guidelines 2022: Microvascular and macrovascular complications in children and adolescents with diabetes [Bjornstad, 2022], Clinical Practice Consensus Guidelines 2022: Diabetes education in children and adolescents [Olinder, 2022], Clinical Practice Consensus Guidelines 2022: Nutritional management in children and adolescents with diabetes [Annan, 2022], Sick day management in children and adolescents with diabetes [Phelan, 2022], and Clinical Practice Consensus Guidelines 2022: Psychological care of children, adolescents and young adults with diabetes [de Wit, 2022]; and the NHS England guidance Diabetic eye screening pathway requirements [NHS England, 2025].

Opportunistic reviews in primary care

• The recommendation about reviewing blood glucose levels and targets is based on the ISPAD guidelines on microvascular and macrovascular complications, which states that 'children and adolescents with diabetes should receive intensive education and treatment to prevent or delay the onset and progression of vascular complications'. It also notes that reaching blood glucose targets reduces the risk for onset and progression of vascular complications of diabetes [Bjornstad, 2022].
• The recommendation to assess for and manage hypoglycaemia episodes is based on the ISPAD clinical practice consensus guidelines on hypoglycaemia [Abraham, 2022].
• The recommendations about smoking are based on the NICE guideline on children [NICE, 2023b] and the ISPAD guidelines on microvascular and macrovascular complications [Bjornstad, 2022].
• The recommendation about managing intercurrent illness and sick-day rules is based on the NICE guideline on children [NICE, 2023b] and the ISPAD guidelines on sick day management [Phelan, 2022].
• The recommendation about checking the child's growth and physical development is based on the ISPAD guidelines on complications and associated conditions of type 1 diabetes [Frohlich-Reiterer, 2022].

Screening for complications

• The recommendation about regular oral health reviews is based on the NICE guideline on children and young people with type 1 diabetes, which extrapolated from evidence in adults about the benefits of treatment of periodontitis. In addition, the guideline committee's experience was that people are often unaware of the increased risk of periodontitis in this population group and may not be attending regular oral health reviews [NICE, 2023b].
• The recommendation about eye screening is based on the NICE guideline on children and young people with type 1 diabetes [NICE, 2023b], and the ISPAD clinical practice consensus guidelines on complications which recommends that screening for diabetic retinopathy should start at puberty. The ISPAD guidelines state that 'a comprehensive eye examination is also recommended to detect cataracts, major refractive errors, or other ocular disorders at the time of retinopathy screening or earlier if there are any visual disturbances' [Bjornstad, 2022].
  • The information about the frequency and aims of the NHS diabetic eye screening programme is also based on the NHSE eye screening pathway guidance [NHS England, 2025].
• The recommendation about monitoring for diabetic kidney disease is based on the NICE guideline on children and young people with type 1 diabetes [NICE, 2023b], the NICE guideline on chronic kidney disease [NICE, 2021], and the ISPAD clinical practice consensus guidelines on complications [Bjornstad, 2022].
  • The NICE guideline states that annual monitoring in children from 12 years is important because if diabetic kidney disease is found, early treatment will improve outcomes.
  • The ISPAD guidelines on complications states that screening for increased albuminuria in children with type 1 diabetes should begin at puberty and be repeated annually. It recommends using a first morning urine sample for checking the albumin:creatinine ratio (ACR) to confirm persistently increased albuminuria, in order to rule out orthostatic proteinuria causing a false positive result. The guidelines recommend repeating any abnormal test result, as increased albuminuria may be transient due to exercise, menstrual bleeding, urinary tract infections, fever, non-diabetic kidney diseases, and marked hyperglycaemia, for example [Bjornstad, 2022].
  • The recommendation to arrange additional investigations if the initial urine ACR is 30 mg/mmol or more (proteinuria) is based on the NICE guideline on diabetes in children and the ISPAD guidelines on complications, which suggest further tests should include urinalysis, renal tract ultrasound, and an immune work-up. In addition, the ISPAD guidelines on complications recommends optimizing blood glucose control and blood pressure to prevent the onset and progression of albuminuria. The recommendation to consider arranging specialist referral is pragmatic, based on what CKS considers to be good clinical practice.
  • CKS notes that the ISPAD clinical practice consensus guidelines on complications recommend considering screening of estimated glomerular filtration rate (eGFR) in children with type 1 diabetes at puberty. The NICE guideline on chronic kidney disease (CKD) also recommends to consider testing for CKD using eGFR and creatinine in children and young people [NICE, 2021]. CKS notes that testing bloods for eGFR and creatinine is not currently recommended in the NICE guideline on diabetes in children [NICE, 2023b].
• The recommendation about monitoring for hypertension is based on the NICE guideline on children and young people with type 1 diabetes [NICE, 2023b], and the ISPAD clinical practice consensus guidelines on complications [Bjornstad, 2022].
• The recommendation about foot care is largely based on the NICE guideline on diabetic foot problems  [NICE, 2019], and the ISPAD clinical practice consensus guidelines on complications which state that screening for peripheral neuropathy in young people with type 1 diabetes should start at puberty and be repeated annually [Bjornstad, 2022].
• The recommendation about screening for thyroid disease is based on the NICE guideline on children and young people with type 1 diabetes [NICE, 2023b], and is also extrapolated from the ISPAD clinical practice consensus guidelines on other complications and associated conditions, which state that screening for thyroid disease should be arranged soon after diagnosis once the child or young person is clinically stable [Frohlich-Reiterer, 2022].

Assessing emotional and psychological wellbeing

• The recommendation about assessing emotional and psychological wellbeing is based on the NICE guideline on children [NICE, 2023b] and the ISPAD guidelines on psychological care [de Wit, 2022], on nutritional management [Annan, 2022], and on diabetes education [Olinder, 2022].
  • The information that children and young people with type 1 diabetes have a greater risk of emotional and behavioural difficulties than children without diabetes is based on the NICE guideline.
  • The ISPAD clinical practice consensus guidelines on psychological care recommend screening for symptoms of depression, diabetes distress, and disordered eating in children aged 12 years and over at initial diagnosis, periodic intervals, and when there is a change in the disease, treatment(s), or life circumstances. The guidelines stress that the perceived treatment burden, ability to self-manage, level of social and family support, and presence of significant mental health issues should be taken into account when discussing treatment options for children and young people with type 1 diabetes.
  • The recommendation about providing psychological support is based on the fact that a lack of adequate psychosocial support for children and young people with type 1 diabetes has a negative impact on various outcomes including blood glucose management and self-esteem [NICE, 2023b].
  • The NICE guideline also notes that children and young people with type 1 diabetes (in particular, young women) have an increased risk of developing eating disorders, which can impact blood glucose management and potential symptoms of gastroparesis (including vomiting). In addition, the ISPAD guidelines on nutritional management note that repeated episodes of diabetic ketoacidosis (DKA) or worsening blood glucose control may be a sign of disordered eating.
  • Diabetes specialist teams should have access to mental health professionals to support them in psychological assessment and providing psychosocial support [de Wit, 2022; NICE, 2023b].
  • The NICE guideline also notes that specific family-based behavioural interventions may be needed if there are family relationship issues related to the child or young person's diabetes.
  • The ISPAD guidelines on diabetes education support the use of cognitive behavioural therapy (CBT) techniques as part of structured educational programmes, including problem-solving, goal-setting, communication skills, motivational interviewing, family conflict resolution, coping skills, and stress management.
  • The information about the potential negative impact of setting targets for children and young people with type 1 diabetes is based on the NICE guideline and the ISPAD guidelines on psychological care.

Additional complications and associated conditions

• The information about juvenile cataracts and necrobiosis lipoidica is based on the NICE guideline on children [NICE, 2023b].
• The recommendation about coeliac disease is based on the NICE guideline on coeliac disease [NICE, 2015], and is also extrapolated from the ISPAD guidelines on other complications and associated conditions. The ISPAD guidelines note that coeliac disease is often asymptomatic or presents with non-specific symptoms in children and young adults with type 1 diabetes and therefore diagnosis can be challenging. They recommend screening for coeliac disease following diagnosis and then at regular intervals [Frohlich-Reiterer, 2022]. CKS notes that this is a different approach to that recommended in the NICE guideline on coeliac disease.
• The recommendations about other possible autoimmune conditions such as Addison's disease and pernicious anaemia are based on the NICE guideline on children [NICE, 2023b] and the ISPAD guidelines on other complications and associated conditions, which note that about 25% of people with type 1 diabetes are diagnosed with another autoimmune disease, which may be asymptomatic or present subclinically [Frohlich-Reiterer, 2022].

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NICE, 2023b] and the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) consensus report The management of type 1 diabetes in adults [Holt, 2021].

• The NICE guideline states that in young people with type 1 diabetes who are preparing for transition to adult services, clinic attendance rates may be improved by allowing sufficient time for the young person to familiarize themselves with the practicalities of the transition, and giving appropriate information and advice on what to expect following the transition.
• The ADA/EASD consensus report highlights that diabetes self-management education and support should be re-offered when a young person transitions to adult diabetes services, as there may be significant knowledge gaps in a person diagnosed early in life, when education at the time may have been directed to the family and carers rather than the young person directly.