Module 1 Framework for Population Approach in the

Prevention and Control of Diabetes across the Life Course

Age Lifestyle Risk Early Disease Complication Rehabilitation

group advice assessment identification management monitoring care

Antenatal ● A balanced Monitor risk ● Assess all women In women with ● Monitor
diet factors for for the presence GDM fetal growth
● Regular intake gestational of risk factors ● Joint management ● Obstetric
of carbohydrates diabetes: for gestational with experts to complications
● Lower in fat ● BMI more diabetes and attain stringent in women
than 30kg/m2 offer 75 gram glycaemic, blood with GDM
● Plenty of fruits Oral Glucose
and vegetables ● Previous pressure and
macrosomic Tolerance lipid control
● Regular exercise Test (OGTT)
baby ● Advice on
weighting to those with self care
4.5kg or risk factors
● Early
more antenatal-care
● Previous ● Performance of
gestational 75 gram OGTT
diabetes and risk factor
● Family assessment
history of 6-weeks after
diabetes delivery
(first degree ● Consider
relative with regular disease
diabetes) surveillance
in women with
history of GDM

Infancy ● Breast feeding ● Monitor

● Avoid obesity weight gain
● Adequate sleep

Childhood ● Abstain from ● Monitor Work closely with ● Growth and

smoking weight for experts to: development
● Regular exercise height ● improve ● Diabetic
● Healthy eating glycaemic and emergencies
habit risk factor control
● Adequate sleep ● advise on daily
● Avoid excessive living and
intake of sugar psychological
sweetened support to child
beverages and parents
● Make good use ● advise on
of leisure time prevention and
by increasing detection of
physical activities, ketoacidosis
avoid excessive ● Monitor growth
time being spent and development
on watching TV
or playing
computer games

1 HK Reference Framework for Diabetes Care for Adults in Primary Care Settings
 Module 1 Framework for Population Approach in the Prevention and Control of Diabetes across the Life Course

Age Lifestyle Risk Early Disease Complication Rehabilitation

group advice assessment identification management monitoring care

Adulthood ● Abstain from ● Monitor ● Early ● Advise on ● Avoid ● Optimise

smoking BMI identification self-care including hypoglycaemia patient’s
● Smoking ● Monitor using fasting self-monitoring ● Manage coping skills to
cessation for abdominal glucose is diabetic manage daily
suggested for of blood glucose the presence
smokers circumference complications
all subjects as appropriate of diabetes
● Healthy ● Family (e.g.
eating habit history of aged ≥ 45 years ● Control of risk and its
retinopathy,
diabetes ● Early factors including complications.
● Weight diabetic kidney e.g. myocardial
management ● History of identification blood glucose, disease, infarction,
gestational using fasting blood pressure,
● Regular exercise neuropathy and cerebrovascular
diabetes blood glucose
for people of blood lipid and cardiovascular disease, limb
● Presence of all ages with body weight diseases) in amputation,
other risk overweight/ ● Regular collaboration blindness,
factors (e.g. obesity and have with specialists renal failure
hypertension, assessment of
additional risk complications ● Provide support
heart disease, factors for to carer and
stroke and diabetes (as stated and referral to loved ones
smoking) in Module 2) specialist care or ● Adopt a
collaborative care multidisciplinary
as appropriate approach in
rehabilitation

Elderly ● Abstain from ● Monitor ● Screen fasting ● Advise on ● Avoid ● Optimise

smoking BMI blood glucose self-care hypoglycaemia patient’s
● Smoking ● Monitor ● Educate carer ● Manage coping skills to
cessation for abdominal and provide diabetic manage daily
smokers circumference support complications the presence
● Healthy ● Presence of ● Control of risk (e.g. of diabetes
eating habit other risk factors including and its
retinopathy,
factors (e.g. blood glucose, complications.
● Weight diabetic kidney e.g. myocardial
management hypertension, blood pressure disease,
heart disease, and blood lipid infarction,
● Regular exercise neuropathy cerebrovascular
stroke and ● Beware of and
smoking) disease, limb
reduced renal cardiovascular amputation,
and liver function diseases) in blindness,
and increased risk renal failure
collaboration
of drug toxicity
(e.g. metformin) with specialists ● Provide support
and to carer and
hypoglycaemia loved ones
● Adopt a
multidisciplinary
approach in
rehabilitation

HK Reference Framework for Diabetes Care for Adults in Primary Care Settings 2